IV. MENTAL HEALTH ISSUES

Conceptualizing a domain of "mental health and children" represents an advance in cultural and societal thinking. The various impediments to this view are well known among students of the history of childhood—at least in Western cultures. These include the concept of children as property, and the broader ignorance and denial of children's affective and cognitive development.

More modern concepts of children and childhood provide a foundation for focusing on the mental health of children as a vital concern. One testament to this development is the passage in 1989 of the United Nations Convention on the Rights of the Child . The convention provides a view of children and childhood in which mental-health concerns are central, one that goes beyond the ideas contained in the 1959 Declaration of the Rights of the Child .

The convention makes it clear that mental-health issues(e.g., policies that facilitate prevention, and access to services, among others) are primary implications of children's rights. Children, the convention asserts, are entitled to basic psychological resources. These include mandates to ensure family and social identity, empathic and stable care, protection from exploitation, and rehabilitative treatment when experiencing mental-health problems or being exposed to trauma, such as war and abuse.

This rights-focused orientation to the mental health of children reflects a growing appreciation for the scope, depth, range, and subtlety of children's experience. Indeed, in the field of children's mental health there has been a growing recognition and empirical exploration of the existence and characteristics of child variants and precedents of most major adult mental-health problems. Important examples are those of schizophrenia, post-traumatic stress disorder, and depression.

Schizophrenia

There is evidence that schizophrenia, one of the most devastating mental illnesses with a whole life prevalence rate of about 1 percent, is a developmental disorder, tracing its origin to abnormalities in brain development, which cause subtle and non-specific behavioral changes in childhood and later lead to full blown psychosis, usually in adolescence. Duration of untreated psychosis seems to be a significant predictor of poor outcome (Harrigan et al.), thus making early identification and treatment of first-episode schizophrenia especially important. However, because of the limited specificity and predictive value of the known risk factors for schizophrenia, treatment of asymptomatic subjects with psychotropic drugs is considered unwarranted from a clinical and ethical perspective (Heinssen et al.).

Childhood Experience of Trauma

Trauma—the overwhelming arousal and cognitive dislocation that results from experiencing horrible events—is an important field of study for those who seek to understand mental health in childhood. As with depression, it was once thought that children were incapable of experiencing genuine psychological trauma (Van der Kolk). But research and clinical experience since 1980 have established that trauma and post-traumatic stress disorder play significant roles in the mental health of children.

Children experience trauma in many settings: televised violence, community violence, domestic violence, war, and homelessness. All point to the need to develop a better understanding of the impact of trauma on childhood as part of a larger commitment to understand the mental health issues facing children.

Children may suffer from post-traumatic stress disorder as a consequence of their experiences at home, in school, or in the community. Symptoms in children include sleep disturbances, daydreaming, re-creating trauma in play, extreme startle responses, diminished expectations for the future, and even biochemical changes in their brains that impair social and academic behavior. Trauma can produce significant psychological problems that interfere with learning and appropriate social behavior in school and the family, the bedrocks for mental health in childhood.

The children least prepared to master trauma outside the home are those who experience psychological, physical, or sexual maltreatment at home. Hundreds of thousands of children face the mental health challenge of living with chronic community violence, whether it derives from war or domestic crime. Some 30 percent of the children living in high-crime neighborhoods of Chicago had witnessed a homicide by the time they were fifteen years old, and more than 70 percent had witnessed a serious assault (Garbarino et al.). In refugee camps around the world, children witness and are subject to violence and exploitation.

The experience of community violence takes place within a larger context of risk for these children. They are often poor; often live in families where the father is absent; often contend with their parents' depression or substance abuse; often are raised by parents with little education or few employment prospects; and often are exposed to domestic violence. This constellation of risk by itself creates enormous mental-health challenges for young children. For them, the trauma of community violence is often literally the straw that breaks the camel's back.

Depression in Children

Until the 1970s, many clinicians and scholars expressed doubt that children experience genuine depression. The common view held that children were incapable of experiencing full-blown depression. It is clear that children do experience depression, but do so and express it differently from adults (e.g., in offering less verbalization concerning mood and symptoms). With proper developmentally appropriate rewording, the same diagnostic criteria for major depression that are used in adults can apply to children. Depression becomes increasing common as the child grows and reaches a prevalence rate among adolescents that is comparable to that in adults. It is estimated that up to 9 percent of adolescents meet current criteria for major depressive disorder (MDD) and up to 25 percent had suffered from it by their late teens (Kessler et al.). While depression seems to equally affect boys and girls before puberty, female teenagers have a substantially higher rate of depression than their male peers. As in adults, in youth depression is a major risk factor for suicide, which in 2003 ranked third among the leading caused of death among adolescents.

Some children mask their depression by denying symptoms to avoid humiliation and embarrassment, to protect vulnerable adults who do not appear to be able to tolerate the child's sadness, or to avoid therapeutic intervention that children perceive adversely (e.g., a child may resist the idea of missing recreational activities to attend therapy or may not acknowledge symptoms of depression to avoid causing parental upset or even conflict).

More generally, one of the important breakthroughs in understanding the mental health of children has been the recognition that "what children can tell us depends upon what adults are prepared to hear." That is, children reveal their mental health status in ways that make sense to adults if the adults have the technical skill and psychological availability necessary to receive the child's messages. For adults to be responsive to the mental health issues facing children, they need to understand some basic features of child development, particularly the operation of risk and opportunity.

Risk Factors and Opportunities

Children face a variety of opportunities and risks for mental health and development because of their genetic makeup and because of the social environments they inhabit. Like in other areas of medicine, genetic and environmental factors act in concert in increasing or decreasing the risk for mental disorders. For instance, it has been determined that the risk for antisocial behavior was increased among maltreated boys who also had a genotype resulting in low levels of monoamine oxidase A (MAO), which is an enzyme involved in the metabolism of neurotransmitters (Caspi et al.). The importance of these findings rests on the fact that it was only the coexistence of maltreatment and low MAO expression genotype that conferred an increased risk, whereas either condition in isolation did not. Thus, environment can affect mental health through its impact on the genetically determined makeup of the child. In addition, specific environmental toxins can negatively impact the brain during development. For example, environmental lead poisoning of children may lead to mental retardation and/or behavioral problems. There are also many examples of positive impact of environment during development, such as proper education and non-abusive discipline, which can prevent the emergence of mental disorders even in the presence of an increased genetic risk for these conditions. The complex interaction of risk and protective factors, either environmental or genetic in nature, has profound implications for understanding the mental health of children. The accumulation of risk factors is especially important. For instance, the average IQ scores of four-year-old children were found to be related to the number of psychological and social risk factors present in their lives, including socioeconomic conditions as well as intrafamilial, psychosocial factors (Sameroff et al.). But this research reveals that the relationship is not simply additive. Average IQ for children with none, one, or two of the factors is above 115. With the addition of a third and then a fourth risk factor, the average IQ score drops precipitously to nearly eighty-five, with relatively little further decrement as there is further accumulation of five through eight risk factors. This is important because IQ plays an important role in resilience and coping. Thus, low IQ is a risk factor for children's mental health.

Windows of opportunity (opportunity that arises at particular points in development) for intervention on behalf of the mental health of children appear repeatedly across the life course. What may be a threat at one point may be harmless or even developmentally good for a child at another. Classic analysis of the impact of the Great Depression of the 1930s in the United States reveals that its mental health effects were felt most negatively by young children (Elder). However, some adolescents, particularly girls, benefited from the fact that paternal unemployment often meant special opportunities for enhanced responsibility and status in the family.

Opportunities for development include meaningful relationships in which children find material, emotional, and social encouragement compatible with their needs and capacities at a specific point in their developing lives. For each child, the exact combination of factors depends upon temperament, family resources, potential, skill, and the role of culture in defining the meaning and social significance of specific characteristics or behaviors, within some very broad guidelines of basic human needs that are renegotiated as development proceeds and situations change.

Participation of Children in Mental Health Research

Like in other areas of health, human research has shown to be the most efficient means of acquiring critical knowledge on how to prevent and treat mental illness among children. Direct participation of children in research is considered necessary as research in adults is neither fully relevant nor sufficient due to developmental differences. Thus, treatments of proven efficacy and safety in adults have been found to lack efficacy or to be toxic in children. Child participation in research is subject to special ethical requirements that are in addition to those common to all human research (Code of Federal Regulations). Based on the type of research activity, the concepts of favorable risk/benefit ratio, minimal risk, and minor increase over minimal risk are especially important in determining whether a particular study is ethically acceptable (Vitiello et al.).

Conclusions

The right to mental health is considered an integral part of children's basic rights. Recent years have seen major advances in understanding child development, especially with respect to the interface between neurobiological and psychosocial components and the interaction between genetic endowment and environment. Research on child mental health has emerged as an essential means of developing effective and safe mental health preventive and treatment interventions for children. Participation of children in research raises important ethical issues, thus making child mental health bioethics a particularly lively and rapidly developing area.

james garbarino (1995)

revised by benedetto vitiello

SEE ALSO: Abuse, Interpersonal: Child Abuse; Confidentiality; Emotions; Institutionalization and Deinstitutionalization; Mental Health; Mental Illness; Patients' Rights: Mental Patients' Rights; and other Children subentries

BIBLIOGRAPHY

Caspi, Avshalom; McClay, Joseph; Moffitt, Terrie E.; et al. 2002. "Role of Genotype in the Cycle of Violence in Maltreated Children." Science 297: 851–854.

Elder, Glen H. 1974. Children of the Great Depression: SocialChange in Life Experience. Chicago: University of Chicago Press.

Garbarino, James; Dubrow, Nancy; Kostelny, Kathleen; and Pardo, Carole, eds. 1992. Children in Danger: Coping with the Consequences of Community Violence. San Francisco: Jossey-Bass.

Harrigan, Susy M.; McGorry, Patrick D.; and Hrstev, H. 2003. "Does Treatment Delay in First-Episode Psychosis Really Matter?" Psychological Medicine 33: 97–110.

Heinssen, Robert K.; Perkins, Diana O.; Appelbaum, Paul S.; and Fenton, Wayne S. 2001. "Informed Consent in Early Psychosis Research: National Institute of Mental Health Workshop, November 15, 2000." Schizophrenia Bulletin 27: 571–584.

Kessler, Ronald C.; Avenevoli, Shelli; and Merikangas, Kathleen R. 2001. "Mood Disorders in Children and Adolescents: An Epidemiological Perspective." Biological Psychiatry 49: 1002–1014.

Sameroff, Arnold J.; Seifer, Robert; Barocas, Roger; et al. 1987. "Intelligence Quotient Scores of 4-Year-Old Children: Social-Environmental Risk Factors." Pediatrics 79(3): 343–350.

U.S. 45 Code of Federal Regulations 46 Subpart A: 101–124(1991).

U.S. 45 Code of Federal Regulations 46 Subpart D: 46.401–409(1991).

Van der Kolk, Bessel A., ed. 1987. Psychological Trauma. Washington, D.C.: American Psychiatric Press.

Vitiello, Benedetto; Jensen, Peter S.; and Hoagwood, Kimberly. 1999. "Integrating Science and Ethics in Child and Adolescent Psychiatry Research." Biological Psychiatry 46: 1044–1049.