Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 3: Children and Mental Health
Spanning roughly 20 years, childhood and adolescence are marked by dramatic changes in physical, cognitive, and social-emotional skills and capacities. Mental health in childhood and adolescence is defined by the achievement of expected developmental cognitive, social, and emotional milestones and by secure attachments, satisfying social relationships, and effective coping skills. Mentally healthy children and adolescents enjoy a positive quality of life; function well at home, in school, and in their communities; and are free of disabling symptoms of psychopathology (Hoagwood et al., 1996).
The basic principles for understanding health and illness discussed in the previous chapter apply to children and adolescents, but it is important to underscore the often heard admonition that“children are not little adults.” Even more than is true for adults, children must be seen in the context of their social environments, that is, family, peer group, and their larger physical and cultural surroundings. Childhood mental health is expressed in this context, as children proceed through development.
Development, characterized by periods of transition and reorganization, is the focus of much research on children and adolescents. Studies focus on normal and abnormal development, trying to understand and predict the forces that will keep children and adolescents mentally healthy and maintain them on course to become mentally healthy adults. These studies ask what places some at risk for mental illness and what protects some but not others, despite exposure to the same risk factors.
In addition to studies of normal development and of risk factors, much additional research focuses on mental illness in childhood and adolescence and what can be done to prevent or treat it. The science is challenging because of the ongoing process of development. The normally developing child hardly stays the same long enough to make stable measurements. Adult criteria for illness can be difficult to apply to children and adolescents, when the signs and symptoms of mental disorders are often also the characteristics of normal development. For example, a temper tantrum could be an expected behavior in a young child but not in an adult. At some point, however, it becomes clearer that certain symptoms and behaviors cause great distress and may lead to dysfunction of children, their family, and others in their social environment. At these points, it is helpful to consider serious deviations from expected cognitive, social, and emotional development as“mental disorders.” Specific treatments and services are available for children and adolescents with such mental disorders, but one cannot forget that these disorders emerge in the context of an ongoing developmental process and shifting relationships within the family and community. These developmental factors must be carefully addressed, if one is to maximize the healthy development of children with mental disorders, promote remediation of associated impairments, and enhance their adult outcomes.
The developmental perspective helps us understand how estimated prevalence rates for mental disorders in children and adolescents vary as a function of the degree of impairment that the child experiences in association with specific symptom patterns. For example, the MECA Study (Methodology for Epidemiology of Mental Disorders in Children and Adolescents) estimated that almost 21 percent of U.S. children ages 9 to 17 had a diagnosable mental or addictive disorder associated with at least minimum impairment (see Table 3-1). When diagnostic criteria
Table 3-1. Children and adolescents age 9–17 with mental or addictive disorders, combined MECA sample, 6-month (current) prevalence*
|
(%) |
|
| Anxiety Disorders | 13.0 |
| Mood Disorders | 6.2 |
| Disruptive Disorders | 10.3 |
| Substance Use Disorders | 2.0 |
| Any Disorder | 20.9 |
* Disorders include diagnosis-specific impairment
and CGAS < or = 70 (mild global impairment)
Source: Shaffer et al., 1996a
required the presence of significant functional impairment, estimates dropped to 11 percent. This estimate translates into a total of 4 million youth who suffer from a major mental illness that results in significant impairments at home, at school, and with peers. Finally, when extreme functional impairment is the criterion, the estimates dropped to 5 percent.
Given the process of development, it is not surprising that these disorders in some youth are known to wax and wane, such that some afflicted children improve as development unfolds, perhaps as a result of healthy influences impinging on them. Similarly, other youth, formerly only “at risk,” may develop full-blown forms of disorder, as severe and devastating in their impact on the youth and his or her family as are the analogous conditions that affect adults. Characterizing such disorders as relatively unchangeable underestimates the potential beneficial influences that can redirect a child whose development has gone awry. Likewise, characterizing children with mental disorders as “only” the victims of negative environmental influences that might be fixed if societal factors were just changed runs the risk of underestimating the severity of these conditions and the need for focused, intensive clinical interventions for suffering children and adolescents. Thus, the science of mental health in childhood and adolescence is a complex mix of the study of development and the study of discrete conditions or disorders. Both perspectives are useful. Each alone has its limitations, but together they constitute a more fully informed approach that spans mental health and illness and allows one to design developmentally informed strategies for prevention and treatment.
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