Mental Health Disorders

A number of mental health disorders may occur in childhood. Among them are autism, childhood disintegrative disorder, childhood schizophrenia, depression, mania and manic depressive illness, suicidal behavior, conduct disorder, separation anxiety disorder, and somatoform disorders. In addition, gender identity disorder first becomes apparent during childhood, and substance abuse disorders are becoming more prevalent among both children and adolescents. Other important mental health disorders in children include attention deficit disorder, obsessive compulsive disorder, and Tourette's syndrome. Because mental health disorders in children and adolescents tend to be chronic, many families benefit from family therapy and support groups.

Autism

Autism is a disorder in which a young child can't develop normal social relationships, behaves in compulsive and ritualistic ways, and usually fails to develop normal intelligence.

Signs of autism usually appear in the first year of life and always before age 3. The disorder is two to four times more common in boys than in girls. Autism is different from mental retardation or brain injury, although some children with au-tism also have these disorders.

Causes

The cause of autism isn't known. However, autism is not caused by poor parenting. Studies of identical twins indicate that the disorder may be partly genetic, because it tends to occur in both twins if it occurs in one.

Although most cases have no obvious cause, some may be related to a viral infection (for example, congenital rubella or cytomegalic inclusion disease), phenylketonuria (an inherited enzyme deficiency), or the fragile X syndrome (a chromosomal disorder).

Symptoms and Diagnosis

An autistic child prefers to be alone, doesn't form close personal relationships, won't cuddle, avoids eye contact, resists change, becomes excessively attached to familiar objects, and continually repeats certain acts and rituals. The child may begin speaking later than other children, may use language in a peculiar way, or may be unable or unwilling to speak at all.

When spoken to, the child often has difficulty understanding what is said. He may repeat words as they are spoken to him (echolalia) and reverse the normal use of pronouns, particularly using you instead of 1 or me when referring to himself.

Symptoms of autism in a young child lead the doctor to the diagnosis, which is made by close observation. Although no specific tests for autism are available, a doctor may perform certain tests to look for other causes of a brain disorder.

Most autistic children have uneven intellectual performance, so testing their intelligence is difficult. Tests may have to be repeated several times. Autistic children usually do better on performance items (tests of motor and spatial skills) than on verbal items in standard IQ tests.

It is estimated that about 70 percent of children with autism have some degree of mental retardation (an IQ less than 70).

About 20 to 40 percent of autistic children, particularly those with an IQ under 50, start to have seizures before reaching adolescence. Some autistic children have enlarged ventricles (hollow areas) in the brain, which can be seen on computed tomography (CT) scans. In adults with autism, magnetic resonance imaging (MRI) scans may show additional brain abnormalities.

A variant of autism, sometimes called childhood-onset pervasive developmental disorder or atypical autism, can begin later, up to age 12. As with autism that starts in infancy, a child with childhood-onset pervasive developmental disorder doesn't develop normal social relationships and often has bizarre mannerisms and unusual speech patterns.

Such children may also have Tourette's syndrome, obsessive compulsive disorder, or hyperactivity. Because of this, a doctor may find it difficult to distinguish the symptoms of one disorder from those of another.

Prognosis and Treatment

The symptoms of autism generally persist throughout life. Many experts believe the prognosis is strongly determined by how much usable language the child has acquired by age 7. Autistic children with subnormal intelligence for example, those who score below 50 on standard IQ tests-are likely to need full time institutional care as adults.

Autistic children in the near normal or higher IQ range often benefit from psychotherapy and special education. Speech therapy is started early, as is physical and occupational therapy.

Sign language is sometimes used to communicate with mute children, although its benefits are unknown. Behavioral therapy can help severely autistic children learn to manage at home and at school. This therapy is useful when an autistic child tries the patience of even the most loving parents and the most devoted teachers.

Drugs are sometimes helpful, although they can't change the underlying disorder. Haloperidol is used mainly to control severely aggressive and self-destructive behavior.

Fenfluramine, buspirone, risperidone, and the selective serotonin reuptake inhibitors (fluoxetine, paroxetine, and sertraline) are all used to treat the various symptoms and behaviors of autistic children.

Childhood Disintegrative Disorder

In childhood disintegrative disorder, an apparently normal child begins to act younger (regress) after age 3.

In most children, physical and psychologic development occurs in spurts. Sometimes a normal child seems to take a step backward; for example, a toilet-trained child occasionally wets himself accidently.

Childhood disintegrative disorder, however, is a serious disorder and may be responsible when a child over age 3 stops developing normally (shows signs of arrested development) or regresses. Usually no cause can be found, although sometimes the child has a degenerative brain disorder.

Symptoms and Diagnosis

The typical child with childhood disintegrative disorder develops normally until age 3 or 4, learning speech, becoming toilet trained, and displaying appropriate social behavior. After a period of vague illness and mood change, in which the child is irritable and sickly, the child undergoes obvious regression.

He may lose previously acquired language, motor, or social skills, and he may no longer have control over his bladder or bowels. The child gradually deteriorates to a severely retarded level. A doctor makes the diagnosis from the symptoms and searches for an underlying disorder.

Prognosis and Treatment

The prognosis is poor, and a severely retarded child will need lifelong care. However, the child's life span may be normal if he has no underlying disorder. Childhood disintegrative disorder can't be treated or cured.

Childhood Schizophrenia

Childhood schizophrenia is a disorder involving ab-normal behavior and thought, beginning between age 7 and the start of adolescence.

The cause of childhood schizophrenia is unknown. Speculation continues about which chemical abnormalities in the brain are involved and what role heredity plays.

Why some children develop schizophrenia at an early age when most don't show symptoms until late adolescence is also unknown. What is known is that schizophre-nia is not caused by poor parenting.

Symptoms and Diagnosis

Childhood schizophrenia usually appears after age 7. The child becomes withdrawn, loses interest in his usual activities, and develops distorted thinking and perception.

Childhood schizophrenia is similar to the schizophrenia that begins in late adolescence or early adulthood; as with adults, a child with schizophrenia is likely to develop hallucinations, delusions, and paranoia, fearing that others are planning to harm him or are controlling his thoughts.

Children with schizophrenia will also likely have blunted emotions neither their voice nor facial expressions change in response to emotional situations. Events that would normally make them laugh or cry may produce no response.

A doctor bases the diagnosis on the symptoms. No diagnostic tests are available, but the doctor searches for evidence of drug abuse, exposure to toxic substances, and brain injury.

Treatment

Schizophrenia can't be cured, although some symptoms may be controlled with drugs and psychotherapy. Antipsychotic drugs can help correct some of the chemical abnormalities in the brain.

Thiothixene and haloperidol are commonly used, although newer drugs, such as risperidone, may produce greater improvement.

However, children are particularly susceptible to the adverse effects of antipsychotic drugs, such as tremors, slowed movements, and muscle spasms, and the drugs are used with great caution.

A child with schizophrenia may need to be hospitalized temporarily when the symptoms worsen, so that drug doses can be adjusted and he can be kept from harming himself or others. Some children must remain institutionalized.

Depression

Depression is a feeling of intense sadness; it may follow a recent loss or other sad event but is out of proportion to that event and persists beyond an appropriate length of time.

Severe depression is relatively rare among children but common in adolescents.

Nonetheless, some degree of depression can be a problem in school-aged children.

Depression in children and adolescents can be triggered by events or problems such as the following:

• The death of a parent
• A friend moving away
• Difficulty in adjusting to school
• Difficulty making friends
• Drug or alcohol abuse

However, some children become depressed even without profoundly unhappy experiences. Often, family members of such children have experienced depression; studies have found that depression tends to run in families.

Symptoms and Diagnosis

The symptoms of depression in children relate to feelings of overwhelming sadness and worth-lessness. Like adults, depressed children may have suicidal thoughts. A doctor can usually diagnose depression by its symptoms. However, depression is sometimes masked by seemingly contradictory symptoms, such as over activity and aggressive, antisocial behavior.

Treatment

A doctor tries to find out whether family or social stresses may have precipitated the depression and determines whether a physical disorder is the cause.

The doctor may prescribe an antidepressant drug, which works by correcting chemical imbalances in the brain. However, few studies have been conducted to document the effectiveness of antidepressant drugs in children. The drugs prescribed most often are the selective serotonin reuptake inhibitors, such as fluoxetine, sertraline, and paroxetine. Another group of antidepressants, the tricyclic antidepressants such as imipramine, have significant adverse effects and, therefore, are used with extreme caution in children. To find the optimal dose of an antidepressant drug, the doctor monitors any improvement in the child's mental health and observes him for signs of adverse effects.

Treatment of depression in children and adolescents requires more than drug therapy. Individual psychotherapy, group therapy, and family therapy may all be beneficial. Family members and school staff are asked to reduce stress on the child and to make efforts to enhance his self-esteem. A brief hospitalization may be needed in a crisis to prevent a suicide attempt.

Mania and Manic-Depressive Illness

Mania is a mood disorder in which a child is overly elated, excited, and active and thinks and speaks very quickly. A less intense form of mania is called hypomania. In manic depressive illness, periods of mania or hypomania alternate with periods of depression.

Mania and hypomania are rare in children. Manic-depressive illness is very rare before puberty and unknown in early childhood. Some children have marked mood swings, but these swings usually aren't indicative of manic depressive illness.

The symptoms and diagnosis of manic depressive illness in children and adolescents are similar to those in adults. However, the treatment is complex and usually involves a combination of mood stabilizing drugs, such as lithium, carbamazepine, and valproic acid. Children and adolescents with manic depressive illness should be treated by a child psychiatrist.

The author is a professor emeritus of pediatrics in USA.