Mental health disorders in children and young people: scope, cause and prevention

OBJECTIVE: To review the scope and characteristics of mental health disorders in children and young people in Australia; detail some emerging concepts of the causal pathways of mental health disorders in children and young people; and discuss aspects of the prevention of mental health disorders and the promotion of mental health in children and young people. METHOD: An integrated review of selected literature. RESULTS: (i) While as many as one in five Australian children aged from four to 17 have significant mental health problems there remains a need for prevalence estimates in subsections of the population, notably children and young people of Aboriginal and Torres Strait Islander descent; (ii) appropriate studies of gene-environment interaction will require better measurement and developmental exposition of those risk exposures that are known to be on the causal pathway to mental health disorder; and (iii) universal, selective and indicated prevention trials and evaluations directed at anxiety, depression and conduct disorder are needed. CONCLUSION: Preventive intervention and promotion in mental health must entail effective collaboration at national, state and local levels between health, welfare and education sectors. These sectors must be informed by high quality epidemiology and a knowledge of the causal pathways of mental health disorders. Such intervention must also improve the movement of scientific knowledge to political policy on one hand and to praxis on the other. This will require a clear and persistent vision of the urgency, costs and consequences of mental health disorders in children and young people coupled with effective leadership and political resolve.     

Children with psychiatric disorders who are frequent attenders to primary care

Child psychiatric disorder has been found to be linked to enhanced primary care attendance. We studied the somatic and psychological associations of psychiatric disorder amongst frequent (four or more consultations a year) primary care attending school children. We compared 32 children aged 7–12 years with a psychiatric disorder with 77 non-disordered (also frequently attending) children. Psychiatric disorder was not associated with type of presenting complaint at the surgery nor with chronic physical illness. However disordered children were more likely to be described by their mothers as handicapped by existing physical problems, in poor health, with low energy levels and likely to experience physical symptoms under stress. Problems in social relationships and educational difficulties were reported in more disordered children; more of them came from broken homes and had mothers who reported other psycho-social and health stresses and showed characteristic health beliefs. The findings indicate that knowledge about the child's general physical well-being and relationships and about maternal mental health may assist in the primary care identification and management of psychiatric disorders of frequently attending school children. Accepted: 17 September 1998     

Health-related quality of life in methylphenidate-treated children with attention-deficit-hyperactivity disorder: results from a Taiwanese sample

OBJECTIVE: Attention-deficit-hyperactivity disorder (ADHD) is the most common neuropsychiatric disorder of childhood. The purpose of the present study was to assess the health-related quality of life (HRQL) in methylphenidate-treated school-age children with ADHD as compared with healthy children in a Taiwanese population. METHODS: Subjects were 6-15 years of age with ADHD who were currently receiving methylphenidate treatment (total n=119). Subjects were compared to 129 healthy children recruited from the community. Child Health Questionnaire Parent Form-50 (CHQ-PF-50), a functional health status measure of HRQL was arranged for parents to complete. Disease-related variables were analysed to determine their relationship and predictive power with HRQL of children. RESULTS: The HRQL of methylphenidate-treated children with ADHD was rated worse than that of community children in all the psychosocial subscales and the Psychosocial Summary Score of CHQ-PF-50. In addition, the problems of ADHD children interfered with family activities and family cohesion significantly. Moreover, improvement of ADHD core symptoms after medication treatment predicted higher psychosocial functioning. This effect was independent of children's current age, age receiving diagnosis, age starting and duration of medication treatment but was not independent of ADHD comorbidity. CONCLUSION: This study may serve as one of the cross-cultural validations of ADHD as a common concern for children and families worldwide. After methylphenidate treatment, parents of Taiwanese children with ADHD still reported them to have poorer health outcomes than control children across almost all domains of HRQL. Improvement of HRQL should be integrated in the overall treatment plan for children with ADHD.     

Health functioning impairments associated with posttraumatic stress disorder, anxiety disorders, and depression

Although anxiety disorders have been associated with impairments in self-reported health functioning, the relative effect of various anxiety disorders has not been studied. We compared health functioning of patients with a principal diagnosis of posttraumatic stress disorder (PTSD), panic disorder (PD), generalized anxiety disorder (GAD), and major depressive disorder (MDD). Patients with PTSD and MDD were equally impaired on overall mental health functioning, and both were significantly worse than patients with PD and GAD. PTSD was associated with significantly worse physical health functioning relative to PD, GAD, and MDD. Hierarchical regression showed that the association of PTSD with physical health functioning was unique and was not caused by the effects of age, depression, or comorbid anxiety disorders. Both PTSD and comorbid anxiety accounted for unique variance in mental functioning. These results highlight the association of PTSD with impaired physical and mental functioning and suggest that effective treatment of PTSD may affect overall health.     

Deterioration in the health-related quality of life of persons with multiple sclerosis: the possible warning signs

Baseline data from a population-based study examining the health-related quality of life (HRQL) of MS patients about to begin disease modifying therapy was used to determine the factors associated with the HRQL of Saskatchewan adults with relapsing-remitting MS. Participants completed a self-report questionnaire regarding demographic and socioeconomic status, fatigue, comorbid medical conditions, disability level (EDSS), number of attacks in past 6 months, illness intrusiveness (Illness Intrusiveness Ratings Scale), depression (Beck Depression Inventory), and HRQL (SF-36 Health Status Survey). Multiple linear regression models were used to identify the factors associated with the physical and mental health summary scores of the SF-36. We found poorer physical HRQL in those who are female; older; not working; have musculoskeletal or respiratory problems; greater fatigue, higher disability scores, and more MS attacks. High illness intrusiveness; digestive system problems; genitourinary problems; and headaches were associated with poorer mental HRQL. Interestingly, we found an interaction between sex and age in mental HRQL, with worse mental health in older men but better mental health in older women. These findings may assist health care providers in identifying patients who may be at risk for decline in their HRQL, permitting appropriate and timely interventions.     

Family health and characteristics in chronic fatigue syndrome, juvenile rheumatoid arthritis, and emotional disorders of childhood

OBJECTIVE: To compare family health and characteristics in children with chronic fatigue syndrome (CFS), in juvenile rheumatoid arthritis (JRA), and emotional disorders. METHOD: Parents of 28 children and adolescents aged 11 to 18 years with CFS, 30 with JRA, and 27 with emotional disorders (i.e., anxiety and/or depressive disorders) were recruited from specialty clinical settings and completed interviews and questionnaires assessing family health problems, parental mental distress, illness attitudes, and family burden of illness. RESULTS: Parents of children with CFS were significantly more likely than those of children with JRA to report a history of CFS-like illness, high levels of mental distress, and a tendency to experience functional impairment in response to physical symptoms. Families of children with CFS were characterized by significantly greater emotional involvement and reported greater family burden related to the child's illness in comparison with families of children with JRA. CONCLUSIONS: CFS in childhood and adolescence is associated with higher levels of parental CFS-like illness, mental distress, emotional involvement, and family illness burden than those observed in association with JRA, a chronic pediatric physical illness.     

Quality of life and disability in patients with obsessive-compulsive disorder.

The aim of this study is to describe the situation of Spanish obsessive-compulsive disorder (OCD) patients and compare it to that of the general population and other patient groups. METHODS: Thirty-six OCD patients on maintenance treatment were evaluated using the Y-BOCS, SF-36, and DAS-S. Their SF-36 scores were compared to Spanish norms and to those obtained from U.S. OCD patients, schizophrenic outpatients, depressed outpatients, heroin dependents, patients on hemodialysis, and kidney transplant recipients. RESULTS: Sixty-one percent of the patients had severe or extremely severe symptoms. Their quality of life was worse when compared with the Spanish norms in all SF-36 areas, but especially with respect to mental health. In contrast to U.S. OCD patients, social functioning is more impaired in the Spanish OCD patients. OCD patients reported the same quality of life as schizophrenics in the areas of mental health, but better in the areas of physical health. Compared with heroin dependents and depressed patients, their quality of life was worse. On mental health scales, OCD patients scored worse than somatic patients. CONCLUSIONS: OCD in the Spanish population was shown to be associated with worse quality of life than for any other patient group (including physical groups), except schizophrenics.     

Quality of life in patients with panic disorder.

In this study we assessed the quality of life of patients with panic disorder, with particular attention to the influence of anxiety and depression comorbidity on quality of life. Findings were compared with established general population norms as well as norms for patients with chronic medical conditions and major depression. The Medical Outcomes Study Short-Form Health Survey (SF-36) was administered to panic disorder patients entering clinical trials or treatment in an outpatient anxiety disorders program. Subjects were 73 consecutive patients with a primary diagnosis of panic disorder without current substance abuse or contributory medical illness. Their quality of life scores were compared with population mean estimates using single-sample t-tests, and the influence of comorbidity was examined with between-group comparisons. All SF-36 mental and physical health subscale scores were worse in patients with panic disorder than in the general population. This was true regardless of the presence of comorbid anxiety or mood disorders, although the presence of the comorbid conditions worsened select areas of functioning according to subscale analyses. SF-36 scores in panic patients were at approximately the same level as patients with major depression and tended to be worse in specific areas than patients with select medical conditions. This study provides evidence of the pervasive negative effects of panic disorder on both mental and physical health.     

Mental and physical health of out of school children in a South African township

BACKGROUND: Poor school attendance has negative consequences for the individual and society. We investigated physical and mental health correlates of school attendance amongst black children in Cape Town, South Africa. METHODS: We undertook a cross-sectional community study of children, aged 6-16 years, living in Khayelitsha township. Multistage sampling produced a sample of 499 children. They, and/or their parents, were interviewed using a Xhosa translation of the Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3). Prevalence of mental and physical health problems of school attenders were compared with those of non-attenders. RESULTS: 23.6 % of children were not attending school. Young children from unserviced areas were at particular risk. Male school attenders suffered higher levels of chronic illness than non-attenders. No differences in the prevalences of psychiatric disorders were found. CONCLUSIONS: There is no significant excess of physical or mental health problems in out of school children. Poverty plays an important role in failure to attend school.     

Linking clinical variables to health-related quality of life in Parkinson's disease

OBJECTIVE: Identify the point-in-time relationship between Parkinson's disease (PD) signs and symptoms and measures of health-related quality of life (HRQL). BACKGROUND: Clinical measures used in PD assessments traditionally emphasize physical signs and symptoms. We hypothesized that these measures would be strongly associated with the physical function dimensions of HRQL that reflect mental symptoms. DESIGN/METHODS: A cross-sectional study of 193 neurology clinic PD patients employed self-administered in-clinic and take-home questionnaires and in-person clinical examinations and interviews. RESULTS: The variance explained by PD physical signs and symptoms was substantial for physical function, but only modest for all other HRQL dimensions. Mental symptoms explained a larger proportion of variance than physical symptoms for 12 of the 14 HRQL measures. CONCLUSION: PD patients' well-being, general health perceptions, health satisfaction and overall HRQL are strongly influenced by mental health symptoms and more weakly influenced by physical symptoms. Clinical evaluation of PD patients should include mental health and self-reported HRQL assessment.     

Discriminative validity of a parent version of the Young Mania Rating Scale

OBJECTIVE: To examine the usefulness of a parent report version of the Young Mania Rating Scale (P-YMRS) in distinguishing bipolar disorder from other mental health conditions in children and adolescents. METHOD: Parents of 117 youths aged 5 to 17 years presenting to an outpatient research center completed an adapted Young Mania Rating Scale (P-YMRS). Eligible subjects underwent a diagnostic evaluation including a semistructured instrument (Schedule for Affective Disorders and Schizophrenia for School-Age Children) and also a clinical evaluation by a child and adolescent psychiatrist in more than 75% of the subjects. RESULTS: Factor analyses of the P-YMRS suggested one dimension, with a total score showing acceptable internal consistency (alpha =.75). Logistic regressions discriminated bipolar mood disorder versus unipolar disorder, versus disruptive behavior disorder, and versus any other diagnosis. Classification rates exceeded 78%, and receiver operating characteristics analyses showed good diagnostic efficiency, with areas under the curve greater than 0.82. CONCLUSIONS: The P-YMRS may be used to derive clinically meaningful information about mood disorders in youths.     

Psychopathology and substance abuse in parents of young children with attention-deficit/hyperactivity disorder

OBJECTIVE: To compare the prevalence of psychological disorders in parents of young children with and without attention-deficit/hyperactivity disorder (ADHD) and comorbid disruptive behavior disorders (DBD). METHOD: Subjects included 98 three- to seven-year-old children with DSM-IV ADHD (68 with ADHD and comorbid oppositional defiant or conduct disorder [ADHD+ODD/CD]) and 116 non-ADHD comparison children recruited in 1995-96 during the first wave of a longitudinal study. Biological mothers were administered interviews to assess ADHD and DBD in their children and mood, anxiety, and substance use disorders in themselves. In addition, they were queried about symptoms of childhood ADHD and DBD, and antisocial personality disorder in themselves and their children's biological fathers. RESULTS: Child ADHD was associated with increased rates of maternal and paternal childhood ADHD relative to comparison children. Child ADHD+ODD/CD was associated with maternal mood disorders, anxiety disorders, and stimulant/cocaine dependence, and paternal childhood DBD. Mothers of children with ADHD+ODD/CD also reported increased drinking problems in their children's fathers. CONCLUSIONS: These findings indicate that many young children with ADHD, particularly those with comorbid ODD/CD, require comprehensive services to address both their ADHD and the mental health needs of their parents.     

Who gets treated? Factors associated with referral in children with psychiatric disorders

There is evidence from several industrialized countries that only a small proportion of children with psychiatric disorders receive specialist treatment. It is unclear, however, why some disturbed children are brought for treatment while others are not. To examine this issue in one community, children aged 7 through 11 were screened for behavioral problems using the Child Behavior Checklist (CBCL); 89 treated and 126 nontreated children, all of whom scored in the clinical range (above the 90th percentile) on the CBCL, were compared on measures of psychopathology, environmental factors and adaptive functioning. All the children were assessed using the Diagnostic Interview Schedule for Children. There was no difference between the groups in the proportions receiving a psychiatric diagnosis, or in the proportions with more than one psychiatric disorder. The nontreated disturbed children were as likely as the treated ones to have attention deficit disorders, anxiety, and oppositional disorders, and to be failing in school. The treated children had more cases of conduct disorder and depressive disorders, and were more likely to be poor, male and black. Teachers reported twice as many behavioral problems in treated as in untreated children, suggesting that adults' discomfort with children's behavior may have been a more potent precipitator of referral than the children's failure to perform well at school. The findings suggest that many nontreated children may be no less impaired than those who receive treatment, and that other factors than severity of psychopathology may dictate which disturbed children receive mental health services.     

The mental health of young people in Australia: key findings from the child and adolescent component of the national survey of mental health and well-being

OBJECTIVE: To identify the prevalence of three mental disorders (Depressive Disorder, Conduct Disorder and Attention-Deficit/Hyperactivity Disorder), the prevalence of mental health problems, the health-related quality of life of those with problems, and patterns of service utilisation of those with and without mental health problems, among 4-17-year-olds in Australia. To identify rates of health-risk behaviours among adolescents with mental health problems. METHOD: The mental disorders were assessed using the parent-version of the Diagnostic Interview Schedule for Children Version IV. Parents completed the Child Behaviour Checklist to identify mental health problems and standard questionnaires to assess health-related quality of life and service use. The Youth Risk Behaviour Questionnaire completed by adolescents was employed to identify health-risk behaviours. RESULTS: Fourteen percent of children and adolescents were identified as having mental health problems. Many of those with mental health problems had problems in other areas of their lives and were at increased risk for suicidal behaviour. Only 25% of those with mental health problems had attended a professional service during the six months prior to the survey. CONCLUSION: Child and adolescent mental health problems are an important public health problem in Australia. The appropriate balance between funding provided for clinical interventions focusing on individual children and families and funding for interventions that focus on populations, requires careful study. The latter are an essential component of any strategy to reduce mental health problems as the high prevalence of problems makes it unlikely that individual care will ever be available for all those needing help. Clinical and population health interventions must take into account the comorbid problems experienced by children with mental disorders.     

Mental-physical comorbidity in Te Rau Hinengaro: the New Zealand Mental Health Survey

OBJECTIVE: To estimate the prevalence of chronic physical conditions, and the risk factors for those conditions, among those with 12 month mental disorder; to estimate the prevalence of 12 month mental disorder among those with chronic physical conditions. METHOD: A nationally representative face-to-face household survey was carried out in October 2003 to December 2004 with 12,992 participants aged 16 years and over, achieving a response rate of 73.3%. Mental disorders were measured with the World Mental Health version of the Composite International Diagnostic Interview (CIDI 3.0). Physical conditions were self-reported. All associations are reported adjusted for age and sex. RESULTS: People with (any) mental disorder, relative to those without mental disorder, had higher prevalences of several chronic physical conditions (chronic pain, cardiovascular disease, high blood pressure and respiratory conditions) and chronic condition risk factors (smoking, overweight/obesity, hazardous alcohol use). Around a quarter of people with chronic physical conditions had a comorbid mental disorder compared with 15% of the population without chronic conditions. Significant relationships occurred between some mental disorders and obesity, cardiovascular disease and diabetes for females, but not for males. CONCLUSIONS: This paper provides evidence of substantial comorbidity between mental disorders and chronic physical conditions in New Zealand. This should be borne in mind by clinicians working in both mental health and medical services.     

Validation of a Portuguese version of a generic health quality-of-life questionnaire for children with neurological and neuropsychiatric disorders, including epilepsy

PURPOSE: To validate a Portuguese version of a generic HRQL instrument already used for children with epilepsy. To analyze differences of scores among children with epilepsy and co-morbidities in contrast to other neurological and neuropsychiatric diagnosis, especially Attention Deficit and Hyperactivity Disorder (ADHD). METHODS: A total of 194 children (64 with epilepsy, 94 with ADHD and 38 with other neurological or neuropsychiatric diagnosis) were consecutively seen in a neuropaediatric ambulatory unit. Parents or caregivers responded to a Portuguese version of ICIS (Impact of Childhood Illness Scale). The questionnaire was analyzed for internal consistency and face validity. Clinical and socio-demographic variables were also analyzed. RESULTS: Internal consistency, analyzed by Cronbach's alpha showed good results for total and combined scores and all sections of ICIS, except for the section "impact of illness and its treatment". The diagnostic categories differed in several ICIS sections, with the worst scores for children with epilepsy and co-morbidities. Children who only had epilepsy had a worse score on the section about treatment impact compared with children with ADHD, but better scores in relation to disease impact in development and parents/family. In the epilepsy group, HRQL scores were worst for symptomatic epilepsy, whilst seizure control and socioeconomic factors affected each section of the instrument in different ways. CONCLUSIONS: ICIS Portuguese version has good psychometric properties. It is a useful tool for analyzing HRQL in children with epilepsy and other neurodevelopmental and psychiatric disorders. Epilepsy and psychiatric co-morbidity seems to have an additive impact on a child's HRQL. This result is clinically important since epilepsy management must include not only seizure control but also mental health support.     

Epidemiology of mental disorders in children and adolescents

This article provides a review of the magnitude of mental disorders in children and adolescents from recent community surveys across the world. Although there is substantial variation in the results depending upon the methodological characteristics of the studies, the findings converge in demonstrating that approximately one fourth of youth experience a mental disorder during the past year, and about one third across their lifetimes. Anxiety disorders are the most frequent conditions in children, followed by behavior disorders, mood disorders, and substance use disorders. Fewer than half of youth with current mental disorders receive mental health specialty treatment. However, those with the most severe disorders tend to receive mental health services. Current issues that are now being identified in the field of child psychiatric epidemiology include: refinement of classification and assessment, inclusion of young children in epidemiologic surveys, integration of child and adult psychiatric epidemiology, and evaluation of both mental and physical disorders in children.     

Seizure frequency and the health-related quality of life of adults with epilepsy.

OBJECTIVE: To compare the health-related quality of life (HRQL) of a nonsurgical sample of adults with epilepsy with that of age- and gender-equivalent norms, and to analyze the relative importance of seizure frequency, time since last seizure, gender, and comorbidity on HRQL in the epilepsy sample. METHODS: Data were obtained from 139 adults with epilepsy from three US centers and published norms on the Medical Outcomes Study Short-Form 36 (SF-36). Patients were classified according to number of seizures over the prior 4 weeks (zero, one to five, six or more). Bivariate and multivariate modeling was used. RESULTS: HRQL scores for seizure-free patients were similar to the general population. Significant differences between seizure frequency groups were found for seven domains and the physical and mental component summary scales of the SF-36 (p<0.001). No differences were found in bodily pain. The largest differences were in physical role and social functioning, and general health (p<0.001). In the multivariate model, seizure frequency was a significant inverse predictor of HRQL across all domains (p<0.01 to 0.001). Men reported poorer physical function than women (p<0.05), and patients with a comorbid condition had poorer HRQL in the areas of pain (p<0.05) and general health perception (p<0.01). Time since last seizure was not related uniquely to HRQL. CONCLUSIONS: Seizure-free adults can have HRQL levels comparable with those of the general population. As seizure frequency increases, patients report more impaired HRQL, regardless of time since last seizure, gender, and comorbid status. Potential for difficulties in HRQL should be considered in clinical assessment and in evaluating treatment outcomes.     

Use of mental health care and substance abuse treatment among adults with co-occurring disorders

OBJECTIVES: This study investigated patterns of use of mental health care and substance abuse treatment for a nationally representative sample of adults with co-occurring mental health problems and a substance use disorder and compared these patterns with those of persons with either a mental health problem or a substance use disorder. METHODS: Data were from the 2001 and 2002 National Surveys on Drug Use and Health. The study examined rates of substance use disorders and mental health problems among adults aged 18 years and older, rates of substance use disorders among adults with mental health problems, and rates of mental health problems among adults with substance use disorders. Next, rates of substance abuse treatment and mental health care use were calculated among five groups that were formed on the basis of the presence of a substance use disorder, mental health problems, or both in the past year. RESULTS: A total of 2,851 respondents had a substance use disorder only, 1,633 had a substance use disorder with one or more mental health symptoms and without serious mental illness, 1,872 had a substance use disorder with serious mental illness, 13,759 had one or more mental health symptoms only, and 7,530 had a serious mental illness only. A substantial proportion of adults with comorbid mental health problems and a substance use disorder did not receive any treatment (46 percent of those with serious mental illness and 65 percent of those with one or more mental health symptoms). Co-occurring substance use disorder was not associated with increased use of mental health care. The likelihood of receiving any substance abuse treatment increased with the presence and severity of mental health problems. Across all five groups, use of mental health care was more common than use of substance abuse treatment. Less than one-third of patients with comorbid mental health problems and a substance use disorder who used mental health care also received substance abuse treatment. CONCLUSIONS: The large proportion of untreated individuals with mental and substance use disorders reinforces existing concerns about barriers to beneficial treatment. Low rates of use of substance abuse treatment among patients who have comorbid mental health problems and a substance use disorder and use mental health care suggest that recommendations that substance use disorders be treated before, or concurrently with, mental disorders have not been widely adopted.     

Prospective assessment of treatment use by patients with personality disorders

OBJECTIVE: This study examined the utilization of mental health treatments over a three-year period among patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorders compared with patients with major depressive disorder and no personality disorder. METHODS: A prospective, longitudinal study design was used to measure treatment use for 633 individuals aged 18 to 45 years during a three-year period. RESULTS: Patients with borderline personality disorder were significantly more likely than those with major depressive disorder to use most types of treatment. Furthermore, all patients continued using high-intensity, low-duration treatments throughout the study period, whereas individual psychotherapy attendance declined significantly after one year. CONCLUSIONS: Although our data showed that patients with borderline personality disorder used more mental health services than those with major depressive disorder, many questions remain about the adequacy of the treatment received by all patients with personality disorders.