http://www.nimh.nih.gov/health/publications/treatment-of-children-with-mental-disorders/summary.shtml

Treatment of Children with Mental Disorders

There has been public concern over reports that very young children are being prescribed psychotropic medications. The studies to date are incomplete, and much more needs to be learned about young children who are treated with medications for all kinds of illnesses. In the field of mental health, new studies are needed to tell us what the best treatments are for children with emotional and behavioral disturbances.

Children are in a state of rapid change and growth during their developmental years. Diagnosis and treatment of mental disorders must be viewed with these changes in mind. While some problems are short-lived and don’t need treatment, others are persistent and very serious, and parents should seek professional help for their children.

Not long ago, it was thought that many brain disorders such as anxiety disorders, depression, and bipolar disorder began only after childhood. We now know they can begin in early childhood. An estimated 1 in 10 children and adolescents in the United States suffers from mental illness severe enough to cause some level of impairment. Fewer than one in five of these ill children receives treatment. Perhaps the most studied, diagnosed, and treated childhood-onset mental disorder is attention deficit hyperactivity disorder (ADHD), but even with this disorder there is a need for further research in very young children.

This booklet contains answers to frequently asked questions regarding the treatment of children with mental disorders

Long Term Consequences of Abuse

Bullied Kids More Likely to Become Psychotic Preteens 

http://www.medscape.com/viewarticle/702560?src=mpnews&spon=12&uac=101660BT

May 8, 2009 — Children who are bullied are more likely to develop psychotic symptoms in early adolescence — and there is a dose effect, with repeated bullying associated with greater risk.

In the first prospective study to examine the relationship between childhood bullying and psychotic symptoms in early adolescence, investigators at the University of Warwick, in Coventry, the United Kingdom, found the risk for psychotic symptoms nearly doubled among children who were victims of bullying at age 8 or 10 years, independent of other psychiatric illness, family adversity, or the child's IQ, and increased nearly 4-fold when victimization was chronic or severe.

Study coauthor Dieter Wolke, PhD, told Medscape Psychiatry the findings have clear clinical implications.

"If children present with physical or mental health problems, also explore their peer relationships. Being victimized, in particular chronically or severely, can make you ill," Dr. Wolke, told Medscape Psychiatry.

The study is published in the May issue of Archives of General Psychiatry.

Significant Dose Effect

The researchers studied 6437 individuals in early adolescence (average age, 12.9 years) who were part of the Avon Longitudinal Study of Parents and Children (ALSPAC). Parents had completed regular mailed questionnaires about their child's health and development since birth, and the children underwent yearly physical and psychological assessments from the age of 7 years.

At each visit, trained interviewers rated the children on whether they had experienced psychotic symptoms, including hallucinations, delusions, or thought disorders, during the previous 6 months.

Children, parents, and teachers also reported on whether the child had experienced peer victimization, defined as negative actions by 1 of more other students with the intention to hurt.

The researchers categorized 46.2% of participants as victims and 53.8% as not victimized at either age 8 or 10 years. Dr. Wolke pointed out that this includes being victimized at any time in childhood, not just during the year in question.

At age 12.9, 13.7% of subjects had broad psychosislike symptoms with 1 or more symptoms suspected or definitely present; 11.5% had intermediate symptoms with 1 or more symptoms suspected or present at times other than going to sleep, waking from sleep, fever, or after substance use; and 5.6% had 1 or more symptoms definitely present.

The odds ratio for psychotic symptoms was 1.94 among victims of bullying at ages 8 and/or 10 years and jumped to 4.60 for repeated or severe victimization.

Victims Often Less Socially Skilled

Dr. Wolke said it is doubtful that being a target of peer victimization was the result rather than the cause of an underlying predisposition to psychotic symptoms.

"This is the issue of reverse causality," Dr. Wolke said. "We are fairly certain that this is not the case, as victimization reported by mothers from 4 years onward also related to psychotic symptoms. Also, it is not possible to measure psychotic symptoms before 8 years — believing in Santa Claus or fairies is not a delusion but part of appropriate development until that age."

"However," Dr. Wolke added, "we know victims show a reaction to bullying more often — by crying for example — are less socially skilled, and have no or few friends who can protect them. Thus, while the children may not have had psychotic symptoms, they may be socially awkward and were more likely to become targets. However, monozygotic twin studies that are discordant for bullying show that the victimized twin is more likely to develop depression and behavioral symptoms."

The researchers suggest further research is needed to sort out whether repeated victimization experiences alter cognitive and affective processing or reprogram stress response or whether psychotic symptoms are more likely due to genetic predisposition.

"Social victimization by peers is a severe stress. It may lead to reprogramming of the hypothalamic pituitary adrenal axis or a different cognitive style, both found in those with psychosis. It may be more severe in those with genetic susceptibility. However, these are speculations that require more research,” Dr. Wolke said.

"A major implication is that chronic or severe peer victimization has nontrivial, adverse, long-term consequences. Reduction of peer victimization and of the resulting stress caused to victims could be a worthwhile target for prevention and early intervention efforts for common mental health problems and psychosis," the authors conclude.

Cause and Effect Not Demonstrated

David Fassler, MD, from the University of Vermont College of Medicine, in Burlington, told Medscape Psychiatry that bullying is a common experience for many young people. 

"Surveys indicate that over half of all children are bullied at some time during their school years, and at least 10% are bullied on a regular basis,” Dr. Fassler said.

According to Dr. Fassler, previous research suggests bullying may increase the risk of developing psychiatric disorders such as schizophrenia or depression later in life. In this regard, the results of the current study are consistent with previous reports and demonstrate that children who are bullied during childhood are more likely to show "psychoticlike" symptoms by early adolescence. 

"Due to the design of the study, the authors can't actually prove that these symptoms are a direct result of the bullying. However, they do demonstrate a significant association," said Dr. Fassler. He warned that the results of this study should be interpreted with caution due to a number of methodological issues. 

"For example, the authors experienced a significant dropout rate over the course of the study. They were ultimately able to follow less than half their original sample. In addition, they didn't have access to baseline data on 'psychoticlike' symptoms for the children. However, despite these limitations, the article represents a useful addition to the literature on bullying.

"Hopefully, subsequent studies will help us identify kids who are particularly vulnerable, so we can intervene as early as possible to minimize the risk of lasting emotional consequences," Dr. Fassler said.

The UK Medical Research Council, the Wellcome Trust, and the University of Bristol provide core support for ALSPAC. This study was funded by a grant from the Wellcome Trust. The authors report no conflicts of interest.

Arch Gen Psychiatry. 2009;66: 527-536. Abstract

http://www.nimh.nih.gov/health/topics/depression/depression-in-children-and-adolescents.shtml

Depression in Children and Adolescents

Only in the past two decades has depression in children been taken very seriously. The depressed child may pretend to be sick, refuse to go to school, cling to a parent, or worry that the parent may die. Older children may sulk, get into trouble at school, be negative, grouchy, and feel misunderstood.

http://www.nih.gov/news/health/feb2008/nimh-26.htm

Teens with Treatment-resistant Depression More Likely to Get Better with Switch to Combination Therapy

Teens with difficult-to-treat depression [http://www.nimh.nih.gov/health/topics/depression/depression-in-children-and-adolescents.shtml] who do not respond to a first antidepressant medication are more likely to get well if they switch to another antidepressant medication and add psychotherapy rather than just switching to another antidepressant, according to a large, multi-site trial funded by the National Institutes of Health's National Institute of Mental Health (NIMH). The results of the Treatment of SSRI-resistant Depression in Adolescents (TORDIA) trial were published February 27, 2008, in the Journal of the American Medical Association (JAMA).

Psychological Impact Of Child Abuse

http://www.sciencedaily.com/releases/2009/05/090521112831.htm

ScienceDaily (May 24, 2009)— According to a new Mayo Clinic study, a history of child abuse significantly impacts the wide range of challenges facing depressed inpatients. Included are an increase in suicide attempts, prevalence of substance use disorder, and a higher incidence rate of personality disorder.

Additionally, these victims also had an earlier onset of mental illness and an increase in psychiatric hospitalizations for psychiatric issues. The study was presented at the American Psychiatric Association 2009 Annual Meeting in San Francisco.

The impact of child abuse already is known to increase the risk of suicide, however the literature about other characteristics of depressed victims of child abuse is scarce. Although the findings of the Mayo study do not confirm causality, the information stresses the importance of more aggressive approaches from the public health perspective to prevent child abuse. "A history of child abuse makes most psychiatric illnesses worse," according to Magdalena Romanowicz, M.D., lead author of the study. "We found that it significantly impacts the wide range of characteristics of depressed inpatients including increased risk of suicide attempt, substance abuse, as well as earlier onset of mental illness and more psychiatric hospitalizations. This new information serves as a reminder of the importance of child abuse prevention from a public health perspective."

Dr. Romanowicz says plans are under way to further examine the association between child abuse and metal illness in a larger study of patients.

Other authors of this Mayo Clinic study include: Gen Shinozaki, M.D.; Victoria Passov, M.D.; Simon Kung, M.D.; Renato Alarcon, M.D.; and David Mrazek, M.D.