Emotional Behavioral Issues
Research shows that half of all lifetime cases of mental illness begin by age 14.1 Scientists are discovering that changes in the body leading to mental illness may start much earlier, before any symptoms appear.
Through greater understanding of when and how fast specific areas of children's brains develop, we are learning more about the early stages of a wide range of mental illnesses that appear later in life. Helping young children and their parents manage difficulties early in life may prevent the development of disorders. Once mental illness develops, it becomes a regular part of your child's behavior and more difficult to treat. Even though we know how to treat (though not yet cure) many disorders, many children with mental illnesses are not getting treatment.
This fact sheet addresses common questions about diagnosis and treatment options for children with mental illnesses. Disorders affecting children may include anxiety disorders, attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, bipolar disorder, depression, eating disorders, and schizophrenia.
Q. What should I do if I am concerned about mental, behavioral, or emotional symptoms in my child?
A. Talk to your child's doctor or health care provider. Ask questions and learn everything you can about the behavior or symptoms that worry you. If your child is in school ask the teacher if your child has been showing worrisome changes in behavior. Share this with your child's doctor or health care provider. Keep in mind that every child is different. Even normal development, such as when children develop language, motor, and social skills, varies from child to child. Ask if your child needs further evaluation by a specialist with experience in child behavioral problems. Specialists may include psychiatrists, psychologists, social workers, psychiatric nurses, and behavioral therapists. Educators may also help evaluate your child.
If you take your child to a specialist, ask, "Do you have experience treating the problems I see in my child?" Don't be afraid to interview more than one specialist to find the right fit. Continue to learn everything you can about the problem or diagnosis. The more you learn, the better you can work with your child's doctor and make decisions that feel right for you, your child, and your family.
Q. How do I know if my child's problems are serious?
A. Not every problem is serious. In fact, many everyday stresses can cause changes in your child's behavior. For example, the birth of a sibling may cause a child to temporarily act much younger than he or she is. It is important to be able to tell the difference between typical behavior changes and those associated with more serious problems. Pay special attention to behaviors that include:
Problems across a variety of settings, such as at school, at home, or with peers
Changes in appetite or sleep
Social withdrawal, or fearful behavior toward things your child normally is not afraid of
Returning to behaviors more common in younger children, such as bed-wetting, for a long time
Signs of being upset, such as sadness or tearfulness
Signs of self-destructive behavior, such as head-banging, or a tendency to get hurt often
Repeated thoughts of death.
Q. Can symptoms be caused by a death in the family, illness in a parent, family financial problems, divorce, or other events?
A. Yes. Every member of a family is affected by tragedy or extreme stress, even the youngest child. It's normal for stress to cause a child to be upset. Remember this if you see mental, emotional, or behavioral symptoms in your child. If it takes more than one month for your child to get used to a situation, or if your child has severe reactions, talk to your child's doctor.
Check your child's response to stress. Take note if he or she gets better with time or if professional care is needed. Stressful events are challenging, but they give you a chance to teach your child important ways to cope.
Q. How are mental illnesses diagnosed in young children?
A. Just like adults, children with mental illness are diagnosed after a doctor or mental health specialist carefully observes signs and symptoms. Some primary care physicians can diagnose your child themselves, but many will send you to a specialist who can diagnose and treat children.
Before diagnosing a mental illness, the doctor or specialist tries to rule out other possible causes for your child's behavior. The doctor will:
Take a history of any important medical problems
Take a history of the problem - how long you have seen the problem - as well as a history of your child's development
Take a family history of mental disorders
Ask if the child has experienced physical or psychological traumas, such as a natural disaster, or situations that may cause stress, such as a death in the family
Consider reports from parents and other caretakers or teachers.
Very young children often cannot express their thoughts and feelings, so making a diagnosis can be challenging. The signs of a mental illness in a young child may be quite different from those in an older child or adult.
As parents and caregivers know, children are constantly changing and growing. Diagnosis and treatment must be viewed with these changes in mind. While some problems are short-lived and don't need treatment, others are ongoing and may be very serious. In either case, more information will help you understand treatment choices and manage the disorder or problem most effectively.
While diagnosing mental health problems in young children can be challenging, it is important. A diagnosis can be used to guide treatment and link your child's care to research on children with similar problems.
Q. Will my child get better with time?
A. Some children get better with time. But other children need ongoing professional help. Talk to your child's doctor or specialist about problems that are severe, continuous, and affect daily activities. Also, don't delay seeking help. Treatment may produce better results if started early.
Q. Are there treatment options for children?
A. Yes. Once a diagnosis is made, your child's specialist will recommend a specific treatment. It is important to understand the various treatment choices, which often include psychotherapy or medication. Talk about the options with a health care professional who has experience treating the illness observed in your child. Some treatment choices have been studied experimentally, and other treatments are a part of health care practice. In addition, not every community has every type of service or program.
Q. What are psychotropic medications?
A. Psychotropic medications are substances that affect brain chemicals related to mood and behavior. In recent years, research has been conducted to understand the benefits and risks of using psychotropics in children. Still, more needs to be learned about the effects of psychotropics, especially in children under six years of age. While researchers are trying to clarify how early treatment affects a growing body, families and doctors should weigh the benefits and risks of medication. Each child has individual needs, and each child needs to be monitored closely while taking medications.
Q. Are there treatments other than medications?
A. Yes. Psychosocial therapies can be very effective alone and in combination with medications. Psychosocial therapies are also called "talk therapies" or "behavioral therapy," and they help people with mental illness change behavior. Therapies that teach parents and children coping strategies can also be effective.2
Cognitive behavioral therapy (CBT) is a type of psychotherapy that can be used with children. It has been widely studied and is an effective treatment for a number of conditions, such as depression, obsessive-compulsive disorder, and social anxiety. A person in CBT learns to change distorted thinking patterns and unhealthy behavior. Children can receive CBT with or without their parents, as well as in a group setting. CBT can be adapted to fit the needs of each child. It is especially useful when treating anxiety disorders.3
Additionally, therapies for ADHD are numerous and include behavioral parent training and behavioral classroom management. Visit the NIMH Web site for more information about therapies for ADHD.
Some children benefit from a combination of different psychosocial approaches. An example is behavioral parent management training in combination with CBT for the child. In other cases, a combination of medication and psychosocial therapies may be most effective. Psychosocial therapies often take time, effort, and patience. However, sometimes children learn new skills that may have positive long-term benefits.
Q. When is it a good idea to use psychotropic medications in young children?
A. When the benefits of treatment outweigh the risks, psychotropic medications may be prescribed. Some children need medication to manage severe and difficult problems. Without treatment, these children would suffer serious or dangerous consequences. In addition, psychosocial treatments may not always be effective by themselves. In some instances, however, they can be quite effective when combined with medication.
Ask your doctor questions about the risks of starting and continuing your child on these medications. Learn everything you can about the medications prescribed for your child. Learn about possible side effects, some of which may be harmful. Know what a particular treatment is supposed to do. For example, will it change a specific behavior? If you do not see these changes while your child is taking the medication, talk to his or her doctor. Also, discuss the risks of stopping your child's medication with your doctor.
Q. Does medication affect young children differently than older children or adults?
A. Yes. Young children handle medications differently than older children and adults. The brains of young children change and develop rapidly. Studies have found that developing brains can be very sensitive to medications. There are also developmental differences in how children metabolize - how their bodies process - medications. Therefore, doctors should carefully consider the dosage or how much medication to give each child. Much more research is needed to determine the effects and benefits of medications in children of all ages. But keep in mind that serious untreated mental disorders themselves can harm brain development.
Also, it is important to avoid drug interactions. If your child takes medicine for asthma or cold symptoms, talk to your doctor or pharmacist. Drug interactions could cause medications to not work as intended or lead to serious side effects.
Q. How should medication be included in an overall treatment plan?
A. Medication should be used with other treatments. It should not be the only treatment. Consider other services, such as family therapy, family support services, educational classes, and behavior management techniques. If your child's doctor prescribes medication, he or she should evaluate your child regularly to make sure the medication is working. Children need treatment plans tailored to their individual problems and needs.
Q. What medications are used for which kinds of childhood mental disorders?
A. Psychotropic medications include stimulants, antidepressants, anti-anxiety medications, antipsychotics, and mood stabilizers. Dosages approved by the U.S. Food and Drug Administration (FDA) for use in children depend on body weight and age. NIMH's medications booklet describes the types of psychotropic medications and includes a chart that lists the ages for which each medication is FDA-approved. See the FDA Web site for the latest information on medication approvals, warnings, and patient information guides.
Q. What does it mean if a medication is specifically approved for use in children?
A. When the FDA approves a medication, it means the drug manufacturer provided the agency with information showing the medication is safe and effective in a particular group of people. Based on this information, the drug's label lists proper dosage, potential side effects, and approved age. Medications approved for children follow these guidelines.
Many psychotropic medications have not been studied in children, which means they have not been approved by the FDA for use in children. But doctors may prescribe medications as they feel appropriate, even if those uses are not included on the label. This is called "off-label" use. Research shows that off-label use of some medications works well in some children. Other medications need more study in children. In particular, the use of most psychotropic medications has not been adequately studied in preschoolers.
More studies in children are needed before we can fully know the appropriate dosages, how a medication works in children, and what effects a medication might have on learning and development.
Q. Why haven't many medications been tested in children?
A. In the past, medications were seldom studied in children because mental illness was not recognized in childhood. Also, there were ethical concerns about involving children in research. This led to a lack of knowledge about the best treatments for children. In clinical settings today, children with mental or behavioral disorders are being prescribed medications at increasingly early ages. The FDA has been urging that medications be appropriately studied in children, and Congress passed legislation in 1997 offering incentives to drug manufacturers to carry out such testing. These activities have helped increase research on the effects of medications in children.
There still are ethical concerns about testing medications in children. However, strict rules protect participants in research studies. Each study must go through many types of review before, and after it begins.
Q. How do I work with my child's school?
A. If your child is having problems in school, or if a teacher raises concerns, you can work with the school to find a solution. You may ask the school to conduct an evaluation to determine whether your child qualifies for special education services. However, not all children diagnosed with a mental illness qualify for these services.
Start by speaking with your child's teacher, school counselor, school nurse, or the school's parent organization. These professionals can help you get an evaluation started. Also, each state has a Parent Training and Information Center and a Protection and Advocacy Agency that can help you request the evaluation. The evaluation must be conducted by a team of professionals who assess all areas related to the suspected disability using a variety of tools and measures.
Q. What resources are available from the school?
A. Once your child has been evaluated, there are several options for him or her, depending on the specific needs. If special education services are needed, and if your child is eligible under the Individuals with Disabilities Education Act (IDEA), the school district must develop an "individualized education program" specifically for your child within 30 days.
If your child is not eligible for special education services, he or she is still entitled to "free appropriate public education," available to all public school children with disabilities under Section 504 of the Rehabilitation Act of 1973. Your child is entitled to this regardless of the nature or severity of his or her disability.
The U.S. Department of Education's Office for Civil Rights enforces Section 504 in programs and activities that receive Federal education funds. Visit programs for children with disabilities for more information.
Q. What special challenges can school present?
A. Each school year brings a new teacher and new schoolwork. This change can be difficult for some children. Inform the teachers that your child has a mental illness when he or she starts school or moves to a new class. Additional support will help your child adjust to the change.
Q. What else can I do to help my child?
A.Children with mental illness need guidance and understanding from their parents and teachers. This support can help your child achieve his or her full potential and succeed in school. Before a child is diagnosed, frustration, blame, and anger may have built up within a family. Parents and children may need special help to undo these unhealthy interaction patterns. Mental health professionals can counsel the child and family to help everyone develop new skills, attitudes, and ways of relating to each other.
Parents can also help by taking part in parenting skills training. This helps parents learn how to handle difficult situations and behaviors. Training encourages parents to share a pleasant or relaxing activity with their child, to notice and point out what their child does well, and to praise their child's strengths and abilities. Parents may also learn to arrange family situations in more positive ways. Also, parents may benefit from learning stress-management techniques to help them deal with frustration and respond calmly to their child's behavior.
Sometimes, the whole family may need counseling. Therapists can help family members find better ways to handle disruptive behaviors and encourage behavior changes. Finally, support groups help parents and families connect with others who have similar problems and concerns. Groups often meet regularly to share frustrations and successes, to exchange information about recommended specialists and strategies, and to talk with experts.
Q. How can families of children with mental illness get support?
A. Like other serious illnesses, taking care of a child with mental illness is hard on the parents, family, and other caregivers. Caregivers often must tend to the medical needs of their loved ones, and also deal with how it affects their own health. The stress that caregivers are under may lead to missed work or lost free time. It can strain relationships with people who may not understand the situation and lead to physical and mental exhaustion.
Stress from caregiving can make it hard to cope with your child's symptoms. One study shows that if a caregiver is under enormous stress, his or her loved one has more difficulty sticking to the treatment plan.4 It is important to look after your own physical and mental health. You may also find it helpful to join a local support group.
Q. Where can I go for help?
A. If you are unsure where to go for help, ask your family doctor. Others who can help are listed below.
- Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors
- Health maintenance organizations
- Community mental health centers
- Hospital psychiatry departments and outpatient clinics
- Mental health programs at universities or medical schools
- State hospital outpatient clinics
- Family services, social agencies, or clergy
- Peer support groups
- Private clinics and facilities
- Employee assistance programs
- Local medical and/or psychiatric societies.
You can also check the phone book under "mental health," "health," "social services," "hotlines," or "physicians" for phone numbers and addresses. An emergency room doctor can also provide temporary help and can tell you where and how to get further help.