Child and adolescent mental health – a guide for healthcare professionals
June 2006
Type of problems faced
Many children will suffer symptoms of some of these problems to a certain extent. For example, most children will feel low, moody or sad at some point; this does not mean that they suffer from depression. To be classified as a disorder, symptoms must be sufficiently severe to, in most cases, impair a child’s normal functioning and cause distress.[Notes 2 and 9]. The categories broadly follow those used by the ONS in its 2004 survey, Mental health of children and young people in Great Britain, 2004, which are based on the World Health Organisation International Classification of Diseases (ICD). [Note 2] (See appendix 1 on page 55 for a list of categories covered by the ICD) The Royal College of Psychiatrists, the charities Mind and the Mental Health Foundation, and Williams & Kerfoot (ed) Child and adolescent mental health services (2005) [Note 13]. all provide more information about different types of child and adolescent mental health problems.
Emotional disorders
Emotional disorders are the most common mental health problems in children, and include anxieties, phobias and depression.
Anxieties and phobias are related to fear, which can be generalised, or specific to a situation or object; for example school or separation from a parent. For a problem to be classified as a disorder, behaviour needs to present as an exaggeration of normal developmental trends. [Note 14] Parents can take action to help allay children’s anxieties, for example, by reassuring and supporting them, and talking about worries. If the child is unable to cope with everyday life, more specialist treatment may be necessary to deal with the cause of the anxiety and overcome the problem. [Note 9]
Depression: it is estimated that 1 per cent of children and 3 per cent of adolescents suffer from depression in any one year. [Note 15]. Symptoms include sadness, irritability and loss of interest in activities. Associated features include changes in appetite, sleep disturbance and tiredness, difficulty concentrating, feelings of guilt, worthlessness, and suicidal thoughts. Depression can be treated through talking treatments, although it should be noted that these treatments are currently of limited availability in Child and Adolescent Mental Health Services (CAMHS). [Note 16] (See 'Strategies for improving care' section for further explanation of CAMHS.)
Antidepressant drugs can also be used, but must be combined with talking treatments. [Notes 9 and 17]. (See box below for an explanation of talking treatments.) The National Institute for Health and Clinical Excellence (NICE) recommends that children suffering from moderate to severe depression should only be given antidepressants in combination with psychological therapy. Children with mild depression should not be offered antidepressants. [Note 18].
There is evidence that diet may have an impact on depression. Research studies have shown that a deficiency in omega-3 fatty acids is associated with symptoms of depression, and supplementation has led to dramatic improvements in some clinical trials. Similarly, an association has been shown between low levels of vitamins and minerals and depression. Studies have found that vitamin and mineral supplementation in combination with existing treatment led to more improved outcomes in depression than the treatment alone. It should be noted that while the evidence base of an association between diet and mental health is growing, more research is needed. [Note 19]. More information about the effect of food on mental health can be found at www.foodandmood.org, a project supported by Mind. Further information about diet and exercise in relation to children can be found in the BMA report, Preventing childhood obesity (2005). [Note 20].
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Self-harm and suicide
Self-harm and suicide can be a symptom of underlying unhappiness or emotional disorder. Self-harm can include self-cutting, burning, hair-pulling or self-poisoning. It may be linked to suicidal thoughts, and is a way of coping with problems, a means of taking control, or a form of release from painful feelings.[Notes 17 and,9] NICE has produced clinical guidance on treating those who self-harm. [Note 21]. Research suggests that the incidence of self-harm is increasing among young people. A survey of school children in England in 2002 found that 6.9 per cent of young people had committed an act of self-harm, and it was more common in girls (11.2 %) than boys (3.2 %). [Note 22]. The average age of onset of self-harm is 12 years. [Note 23]. A two-year national inquiry carried out by the Camelot Foundation and Mental Health Foundation found that self-harm is an issue that is poorly understood, even among professionals and school staff, and treatment is often inappropriate; for example focusing on the self-harm rather than the underlying causes. The report of the inquiry, Truth hurts (2006), calls for more comprehensive and targeted research into the issue, and sets out an agenda for change. [Note 23].
Suicide rates are very low in children, but start to increase from the age of 11. [Note 24]. Boys and young men aged 15-24 are most at risk, but there has been a decrease in the number of suicides in this group in the last few years. [Note 25]. Attempted suicide is more frequent: as many as 2-3 per cent of girls attempt suicide at some point in their teenage years.[Note 17]. Depression, serious mental health problems and the misuse of drugs are all factors related to suicide attempts. Young people who have already tried to kill themselves, or know someone who has tried to kill themselves are also at greater risk of attempting suicide. [Note 9]
Eating disorders
During adolescence, young people’s bodies are changing, and they can become more susceptible to external influence such as peer pressure and the media. This can lead to greater awareness of physical appearance. Some young people find it hard to cope with the experience of growing up. These factors can lead to concerns about weight, which in some cases can become problematic. Eating disorders include anorexia nervosa, where the person eats very little, effectively starving themselves, and bulimia nervosa which involves binging on food followed by induced vomiting or use of laxatives. The average age of onset of anorexia is 15, and of bulimia, 18. [Note 17].
Both conditions can cause severe weight loss, which can lead to other medical conditions including osteoporosis and cardiovascular problems. [Note 27]. If left untreated, the disorders can result in death, either from the weight loss or from suicide. NICE has produced clinical guidelines on treating those with eating disorders. [Note 28]. The BMA publication, Eating disorders, body image and the media (2000), provides greater detail about both conditions, and discusses the role of modern society in the onset of these disorders.
Conduct disorders
All children will occasionally be badly behaved and disobedient. If bad behaviour continues for several months (six months, according to the ICD 10) [Note 14] or beyond the normal age period for misbehaviour, or if it is out of the ordinary and seriously breaks accepted rules, there may be a more acute problem, known as a conduct disorder. Conduct disorders affect a child’s development and ability to lead a normal life, and can cause them distress. Typical behaviour includes unusually frequent and severe temper tantrums beyond the age that this is normally seen, severe and persistent disobedience, defiant provocative behaviour, excessive levels of fighting and bullying, cruelty to others or animals, running away from home and some criminal behaviour. [Notes 9,2 and 14]. According to the 2004 ONS survey, children with conduct disorders were more likely to be boys (69 %) and 55 per cent were aged 11-16. [Note 2].
Hyperkinetic disorders
Hyperkinetic disorder is the official term in the UK for describing children who are consistently over-active and inattentive. Attention-deficit hyperactivity disorder (ADHD) and attention deficit disorder (ADD) are also commonly used terms. [Note 9]
Signs of hyperkinetic disorder include restlessness and over-activity, inattentiveness and difficulty concentrating, acting impulsively, and disruptive and destructive behaviour. Many young children occasionally behave in this way. But to be diagnosed with hyperkinetic disorder, a child must display both impaired attention and over-activity in more than one situation, such as at home and at school. [Note 14]. Children with hyperkinetic disorder may find it difficult to interact with other children, and their inability to concentrate and restlessness at school impacts on their education, and can be extremely disruptive to other pupils. Their behaviour can also put significant strains on family life. These problems can persist into adult life; approximately two fifths of children with hyperkinetic disorder will still have some symptoms at age 18. [Note11]. Most children do however settle down by the time they reach their mid-teens, especially if they receive appropriate treatment. [Note 9].
Medication, such as methylphenidate, can help treat hyperkinetic disorder, reducing the hyperactivity, and improving concentration. Although this is only a temporary effect, significant improvements in behaviour are reported in children prescribed these medications. [Note 9]. There is however concern about the prescribing of drugs to young children, and the British National Formulary advises that methylphenidate is not given to children under six years. Medication should only be used in association with other psychological therapies. [Note 17]. The ONS survey found that 43 per cent of children with hyperkinetic disorder were taking some form of medication, most commonly methylphenidate. [Note 2]. The Royal College of Psychiatrists provides further information on the use of medication to treat hyperkinetic disorder. [Note 9]. NICE is currently reviewing its guidance on the use of these medications, [Note 29] and is working on guidance for treating those with ADHD, which is due in February 2008. [Note 30]. There is evidence suggesting that diet can impact on the behaviour of some children, which sometimes improves on a diet low in sugar, artificial colourings and carbonated drinks. [Notes 9 and 17]. Research trials have shown a link between deficiencies in essential fatty acids and ADHD; lower levels of essential fatty acids in the body correlated with symptoms of ADHD. Supplementation with omega-3 was shown to lead to a decrease in symptoms in some studies. Similar relationships have been found between iron, zinc and magnesium deficiencies and ADHD symptoms. Again, more research into the effects of diet on mental health is needed. [Note 19] See the 'Type of problems faced' section for more information on the link between diet and mental health.
Autistic spectrum disorders
The term ‘autistic spectrum disorder’ (ASD) describes a range of lifelong developmental disorders, which can come under the definition of learning disabilities, and are characterised by difficulties in social interaction, communication and imagination. They may appear indifferent or aloof, insensitive to others’ needs and have difficulty cooperating with other people. They may have language problems, both understanding and speaking, as well as non-verbal communication. They can have problems with interpersonal play and imaginative activities, preferring instead familiar routines, resisting change.
There is a spectrum or range of disorders, from those with severe learning disabilities, some of whom may never speak, to those with average or above average intelligence, such as sufferers of Asperger syndrome. Some may be particularly talented in a specific area, such as drawing or mathematics. [Notes 9 and 31].
For more information, go to the National Autistic Society at www.autism.org.uk.
Psychotic disorders
Psychotic disorders cover a range of conditions where a person suffers from symptoms such as delusions and hallucinations. These include schizophrenia and bipolar affective disorder (commonly known as manic depression). The causes of psychotic illnesses are not properly understood; they can sometimes be genetic and in schizophrenia and bipolar affective disorder, abnormalities in the chemistry of the brain are thought to be involved. The use of mind-altering substances, such as drugs, alcohol, glue and aerosols, can also lead to, and be a symptom of psychotic disorders. For more discussion on the links between substance misuse and mental health, See 'Type of problems faced' . The incidence of psychotic illnesses increases in early adulthood. Treatment varies depending on the condition. Medication, sometimes taken over a long period, is usually an important part of treatment. Patients may need to be hospitalised, and talking treatments and support are often also useful. [Notes 9 and 11]
For more information, go to the Royal College of Psychiatrists at www.rcpsych.ac.uk and the Mental Health Foundation at www.mhf.org.uk.
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There are many more mental health disorders, but this report is not intended to include all of them. Examples include tic disorders, stammering and pica (persistent eating of non-nutritional substances, eg soil, paint). The Royal College of Psychiatrists and the Mental Health Foundation both provide information on these and other mental health disorders.
Co-morbidity
The ONS survey found that one in five of children diagnosed with a disorder had more than one disorder, the most common combinations being conduct and emotional disorder and conduct and hyperkinetic disorder. The majority (72 %) of children with multiple disorders were male, reflecting the high proportion of children with conduct disorder in this group. Children suffering from more than one disorder were at greater risk of suffering more serious problems. Sixty-three per cent of those with multiple disorders were behind in their intellectual development, compared to 49 per cent of those with a single disorder, and children with multiple disorders accounted for approximately one third of those using specialist mental health services. [Note 2]
Alcohol and substance misuse
Alcohol and substance misuse can sometimes be linked to mental health problems, and a significant proportion of young people take alcohol and drugs. The use of alcohol and drugs can both exacerbate and trigger mental health problems: those with mental health problems may be at greater risk of misusing drugs, and the misuse of drugs can cause mental health problems. For example, alcohol can be attractive to those suffering from depression because it increases confidence and may produce a feeling of wellbeing, drowning out problems in the short-term. It is, however, also a depressive, and can worsen the symptoms of depression, such as increasing risk of suicidal thoughts and behaviour. [Note 32]. A survey of 11-15 year olds in England in 2004 found that while the prevalence of drinking among young people had not changed greatly in recent years (23 % had drunk in the previous week in 2004; 25 % in 2003), the amount consumed by those who do drink has increased: 10.7 units per week in 2004, compared to 5.3 units in 1990 and 9.9 units in 1998. [Note 33].
Young people may be particularly at risk of problems resulting from substance misuse as their brains are still developing. [Note 32]. For example, some research suggests that young people who use a significant amount of cannabis are more likely to have mental health problems, and develop mental illnesses later in life. [Note 34]. In 2004, 11 per cent of 11-15 year olds had taken cannabis in the last year. Prevalence increased with age, with 26 per cent of 15 year olds having taken it. The survey also found that 4 per cent of 11-15 year olds had taken Class A drugs in the previous year, a figure that has remained constant since 2001. [Note 33] Some CAMHS work with drug dependency teams, but this is not universal. [Note 35]. Given the correlations between mental health problems and substance misuse, and the effectiveness of multi-agency working in addressing mental health problems among young people (see 'Multiagency working' section), more widespread collaboration between these services would be appropriate. More information about the links between mental health problems and alcohol and drug use can be found at SANE, Mind and the Royal College of Psychiatrists. The BMA report Adolescent health (2003) discusses alcohol and drug use by young people and the consequences, including mental health problems. [Note 24].