Issues & Answers

Children and Mental Health

One hundred years ago, infectious diseases and nutritional deficiencies were the major causes of death for children and adolescents. today, the greatest threats to young peoples’ lives are rooted in mental health problems; three-quarters of deaths are from homicide, suicide and accidental injury usually resulting from drug or alcohol abuse. in addition, depression stands as the largest cause of disability among adolescents, fostering problems ranging from learning disabilities and conduct problems in the classroom, to changes in appetite, weight, or sleep habits.

With a mental illness prevalence rate of nearly 12 percent, children across the country face the same stigma and discrimination as adults. Many debilitating adult disorders, such as depression, have their onset in childhood and adolescence. If left untreated or inadequately treated, a lifetime of pain and frustration is likely.

At a time when many people feel overwhelmed by the problems and challenges facing children and adolescents, Columbia Public Health asked three leading mental health researchers to address some of the important concerns surrounding the mental well-being and healthy development of young people.

Stewart L. Adelson, M.D., is assistant clinical professor at Columbia School of Public Health’s (CSPH) Center for Population and Family Health (CPFH), with a joint appointment at the Columbia College of Physicians & Surgeons (P&S), Division of Child and Adolescent Psychiatry. He is also medical director of mental health services for CPFH’s Community Health and Education Program. Adelson is currently working on a chapter about the prevention of adolescent violence, substance abuse, and accidents, for the Building Bright Futures reference book series, published by the Maternal and Child Health Bureau of the U.S. Public Health Service.

Patricia R. Cohen, Ph.D., is a social psychologist-psychiatric epidemiologist with a long-term interest in methodological issues. She is professor of clinical public health (epidemiology) at CSPH and the Department of Psychiatry, P&S, and co-director of the Psychiatric Epidemiology Training Program. She is also on the faculty of the Center for Young Children and Families, at Columbia University’s Teachers College. Her recently published book, Life Values and Adolescent Mental Health, examines the origins and consequences of differences in adolescent life goals.

Myrna M. Weissman, Ph.D., was recently elected a member of the institute of Medicine of the National Academy of Sciences. She is professor of epidemiology in psychiatry at CSPH and P&S, and co-director, Research Training in Child Psychiatry, Division of Child Psychiatry, P&S. Weissman was president of the American Suicide Foundation and is currently president of the American Psychopathologic association. She has been a consultant to the White House and the World Health Organization, and numerous other government and corporate organizations. A recent study by Weissman and her colleagues was featured in a New York Times article on the children of depressed parents.

What makes mental health care for children a public health concern?

Adelson: It’s an issue of prevention, first and foremost. There should be routine screening, like immunization schedules, for the major mental health problems seen in childhood. These include learning disabilities, mental retardation, attention deficit and hyperactivity disorder, and substance abuse as determined by taking a personal or family history.

Weissman: From a public health perspective, if you want to effect prevention, you should not ignore children and adolescents.

Mental health in general has never achieved parity with medical, physical illness. A recent report by the World Bank, called “The Global Burden of Disease Study,” showed that if you compare mental illness with other physical illnesses in countries around the world, mental illnesses are among the most disabling. That finding was measured in terms of disability-adjusted life years, or DALYs, which is the sum of years of life lost due to premature death, and years of life lived with a disability, weighted by the severity of the disability. Depression was found to be the fourth leading cause of disease-burden in 1990, and by 2020 it will be the single leading cause.

What are some of the latest findings in childhood depression?

Cohen: in two recent publications, we looked at the effects of smoking on subsequent depression, and our data suggests that smoking during childhood is linked to subsequent depression. Another study involved children with allergic illnesses—asthma, allergies, and mononucleosis—which we found were predictive of later major depression.

Weissman: in our 10-year study of children of depressed parents, we found a high risk for depression, anxiety disorders and substance use among such children. They’re also likely to develop depression and anxiety disorders sooner than the children of nondepressed parents. When an adolescent exhibits depressive symptoms it’s important to pay attention to them and also to ask about the psychological status of the parents.

Given the growing body of evidence showing that many serious adult mental health disorders have their onset in childhood and adolescence, is mental health care for children receiving the recognition that it deserves?

Weissman: Beyond mental health not achieving parity with physical health, children with mental health problems have been largely ignored. We’ve made considerable progress understanding rates of mental illness and its clinical course in adults, but the information on children and adolescents lags far behind. However, there have been some recent studies by the National institute of Mental Health (NIMH) to rectify this. One that I was involved in found that first onset for schizophrenia, depression, and anxiety disorders peaked during childhood and adolescence.

Adelson: Although many childhood mental health problems can be prevented, and the prevention mitigates illness down the road, there’s a tremendous gap in delivery of mental health services to children. Between 50 percent and 80 percent of children with diagnosable mental health problems don’t get any services due in part to a lack of health insurance coverage and a general failure in health care circles to focus on prevention. in addition, many parents don’t want to take their children to the doctor for mental health problems, in part because it’s stigmatizing and it requires coordinated long-term care.

What other serious shortcomings do you see in efforts to extend effective mental health care to young people?

Cohen: The standard of mental health care for children is much more amorphous than it is for adults. for example, problems in children present clinical difficulties because of issues surrounding dependency status. Service systems often have a tradition of catering more to people responsible for managing childrens’ behavior than they do to the children. Another problem is a shortage of efficacious treatments. Those that work involve families, but it is difficult to enlist families and even harder to do it coercively. It goes against the spirit of what we’re trying to do.

Weissman: By and large there are no guidelines for psychopharmacological treatment of children, partly because the Food and Drug Administration (FDA) has not required the information on children until recently, due to concerns about dose and safety. FDA now requires that if a drug is to be made available to children it needs to be tested on them first. NIMH has followed suit, requiring proof of efficacy for drugs given to children. in the next five years these regulations will have a major impact on drugs and the pharmaceutical industry. We should see more rational prescribing and dosing practices.

What else is being done, or should be done, to bring mental health care for children up to par?

Cohen: We are examining children in different service systems. Mental health, juvenile justice, child welfare and special education systems often see children with quite similar mental health problems. We are only now beginning to see efforts to coordinate and rationalize care across systems.

In addition, we have been following a cohort of about 800 children in upstate New York since 1975, and are now studying their children and the very important transition from adolescence to adulthood, the period of development when the onset of adult disorders often occurs. in younger children we find prospectively that childhood disorders have negative prognostic implications for adult disorders. There is also a marked propensity of problems that don’t meet the full definition of mental illness, including sub-threshold major depression, panic attacks that aren't frequent enough to be panic disorder, and conduct problems, all of which are predictive of adult functional impairment and full-blown disorders.

Adelson: We have found in our own clinical research incredibly large numbers of children disabled by anxiety, learning disorders and attention deficit disorder—which is associated with substance abuse and sociopathy—who have never seen a psychiatrist. in the school-based clinics, social workers and nurse practitioners are evaluating students, trying to refer them for care, educate their families, liaison with hospitals and link them with other community resources in an effort to set-up further screening, assessment and follow-up. Working in the school-based setting has made contact with families easier, because families are more willing to come to school than to a doctor’s office.

Those at the public health policy level need to figure out ways to change the paradigm so that there are incentives to pursue prevention of mental health problems. I often see adolescents who have failed classes, gotten involved with gangs, and experimented with drugs. When I take a history I often find that there has been evidence for years of early, more benign problems. Unfortunately, once the problems have developed in adolescence, its often too late.