What Are Childhood Mental Disorders?

Mental health in childhood means reaching developmental and emotional milestones, and learning healthy social skills and how to cope when there are problems. Mentally healthy children have a positive quality of life and can function well at home, in school, and in their communities.

Mental disorders among children are described as serious changes in the way children typically learn, behave, or handle their emotions, which cause distress and problems getting through the day.

What are the symptoms of childhood mental disorders?

Symptoms of mental disorders change over time as a child grows, and may include difficulties with how a child plays, learns, speaks, and acts or how the child handles their emotions. Symptoms often start in early childhood, although some disorders may develop during the teenage years. The diagnosis is often made in the school years and sometimes earlier. However, some children with a mental disorder may not be recognized or diagnosed as having one. Healthcare professionals use the guidelines in The American Psychiatric Association’s Diagnostic and Statistical Manual (DSM), to help diagnose mental health disorders in children.

Can childhood mental disorders be treated?

Childhood mental disorders can be treated and managed. There are many treatment options based on the best and most current medical evidence, so parents and doctors should work closely with everyone involved in the child’s treatment — teachers, coaches, therapists, and other family members. Taking advantage of all the resources available will help parents, health professionals, and educators guide the child towards success. Early diagnosis and appropriate services for children and their families can make a difference in the lives of children with mental disorders.

Who is affected?

Childhood mental disorders affect many children and families. Boys and girls of all ages, ethnic/racial backgrounds, and living in all regions of the United States experience mental disorders. Based on the National Research Council and Institute of Medicine report that gathered findings from previous studies, it is estimated that 13 – 20 percent of children living in the United States (up to 1 out of 5 children) experience a mental disorder in a given year.

What is the impact of mental disorders in children?

Mental health is important to overall health. Mental disorders are chronic health conditions—those that go on for a long time and often don’t go away completely—that can continue through the lifespan. Without early diagnosis and treatment, children with mental disorders can have problems at home, in school, and in forming friendships. This can also interfere with their healthy development, and these problems can continue into adulthood.

What you can do

Parents: You know your child best. Talk to your child’s healthcare professional if you have concerns about the way your child behaves at home, in school, or with friends.

Youth: It is just as important to take care of your mental health as it is to take care of your physical health. If you are angry, worried or sad, don’t be afraid to talk about your feelings and reach out to a trusted friend or adult.

Healthcare professionals: Early diagnosis and appropriate treatment based on updated guidelines are very important. There are resources available to help diagnose and treat children’s mental disorders.

Teachers/School administrators: Early identification is important so that children can get the help they need. Work with families and healthcare professionals if you have concerns about the mental health of a child in your school.

Anxiety and Depression in Children

Many children have fears and worries, and will feel sad and hopeless from time to time. Strong fears will appear at different times in development. For example, toddlers are often very distressed about being away from their parents, even if they are safe and cared for. Although fears and worries are typical in children, persistent or extreme forms of fear and sadness feelings could be due to anxiety or depression. Because the symptoms primarily involve thoughts and feelings, they are called internalizing disorders.

Anxiety

When children do not outgrow the fears and worries that are typical in young children, or when there are so many fears and worries that they interfere with school, home, or play activities, the child may be diagnosed with an anxiety disorder. Examples of different types of anxiety disorders include

• Being very afraid when away from parents (separation anxiety)
• Having extreme fear about a specific thing or situation, such as dogs, insects, or going to the doctor (phobias)
• Being very afraid of school and other places where there are people (social anxiety)
• Being very worried about the future and about bad things happening (general anxiety)
• Having repeated episodes of sudden, unexpected, intense fear that come with symptoms like heart pounding, having trouble breathing, or feeling dizzy, shaky, or sweaty (panic disorder)

Anxiety may present as fear or worry, but can also make children irritable and angry. Anxiety symptoms can also include trouble sleeping, as well as physical symptoms like fatigue, headaches, or stomachaches. Some anxious children keep their worries to themselves and, thus, the symptoms can be missed.

Depression

Occasionally being sad or feeling hopeless is a part of every child’s life. However, some children feel sad or uninterested in things that they used to enjoy, or feel helpless or hopeless in situations where they could do something to address the situations. When children feel persistent sadness and hopelessness, they may be diagnosed with depression.

Examples of behaviors often seen when children are depressed include

• Feeling sad, hopeless, or irritable a lot of the time
• Not wanting to do or enjoy doing fun things
• Changes in eating patterns – eating a lot more or a lot less than usual
• Changes in sleep patterns – sleeping a lot more or a lot less than normal
• Changes in energy – being tired and sluggish or tense and restless a lot of the time
• Having a hard time paying attention
• Feeling worthless, useless, or guilty
• Self-injury and self-destructive behavior

Extreme depression can lead a child to think about suicide or plan for suicide. For youth ages 10-24 years, suicide is the leading form of death.

Some children may not talk about helpless and hopeless thoughts, and they may not appear sad. Depression might also cause a child to make trouble or act unmotivated, so others might not notice that the child is depressed or may incorrectly label the child as a trouble-maker or lazy.

Treatment for anxiety and depression

The first step to treatment is to talk with a healthcare provider to get an evaluation. The American Academy of Child and Adolescent Psychiatry (AACAP) recommends that healthcare providers routinely screen children for behavioral and mental health concerns.  Some of the signs and symptoms of anxiety or depression are shared with other conditions, such as trauma. Specific symptoms like having a hard time focusing could be a sign of attention-deficit/hyperactivity disorder (ADHD). It is important to get a careful evaluation to get the best diagnosis and treatment. Consultation with a health provider can help determine if medication should be part of the treatment. A mental health professional can develop a therapy plan that works best for the child and family. Behavior therapy includes child therapy, family therapy, or a combination of both. The school can also be included in the treatment plan. For very young children, involving parents in treatment is key. Cognitive-behavioral therapy is one form of therapy that is used to treat anxiety or depression, particularly in older children. It helps the child change negative thoughts into more positive, effective ways of thinking, leading to more effective behavior. Behavior therapy for anxiety may involve helping children cope with and manage anxiety symptoms while gradually exposing them to their fears so as to help them learn that bad things do not occur.

Treatments can also include a variety of ways to help the child feel less stressed and be healthier like nutritious food, physical activity, sufficient sleep, predictable routines, and social support.

Managing Symptoms: Staying Healthy

Being healthy is important for all children and can be especially important for children with depression or anxiety. In addition to getting the right treatment, leading a healthy lifestyle can play a role in managing symptoms of depression or anxiety. Here are some healthy behaviors that may help:

• Eating a healthful diet centered on fruits, vegetables, whole grains, legumes (for example, beans, peas, and lentils), lean protein sources, and nuts and seeds
• Participating in physical activity for at least 60 minutes each day
• Getting the recommended amount of sleep each night based on age
• Practicing mindfulness or relaxation techniques

Prevention of anxiety and depression

It is not known exactly why some children develop anxiety or depression. Many factors may play a role, including biology and temperament. But it is also known that some children are more likely to develop anxiety or depression when they experience trauma or stress, when they are maltreated, when they are bullied or rejected by other children, or when their own parents have anxiety or depression. Although these factors appear to increase the risk for anxiety or depression, there are ways to decrease the chance that children experience them.

Suicidality and Antidepressant Drugs Per the FDA, antidepressants have been found to increase the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of [antidepressant drug] or any other antidepressant in a child, adolescent, or young adult must balance this risk with the clinical need. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24; there was a reduction in risk with antidepressants compared to placebo in adults aged 65 and older. Depression and certain other psychiatric disorders are themselves associated with increases in the risk of suicide. Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber.

Post-traumatic Stress Disorder (PTSD) in Children

All children may experience very stressful events that affect how they think and feel. Most of the time, children recover quickly and well. However, sometimes children who experience severe stress, such as from an injury, from the death or threatened death of a close family member or friend, or from violence, will be affected long-term. The child could experience this trauma directly or could witness it happening to someone else. When children develop long term symptoms (longer than one month) from such stress, which are upsetting or interfere with their relationships and activities, they may be diagnosed with post-traumatic stress disorder (PTSD).

Examples of PTSD symptoms include

• Reliving the event over and over in thought or in play
• Nightmares and sleep problems
• Becoming very upset when something causes memories of the event
• Lack of positive emotions
• Intense ongoing fear or sadness
• Irritability and angry outbursts
• Constantly looking for possible threats, being easily startled
• Acting helpless, hopeless or withdrawn
• Denying that the event happened or feeling numb
• Avoiding places or people associated with the event

Because children who have experienced traumatic stress may seem restless, fidgety, or have trouble paying attention and staying organized, the symptoms of traumatic stress can be confused with symptoms of attention-deficit/hyperactivity disorder (ADHD).

Examples of events that could cause PTSD include

• Physical, sexual, or emotional maltreatment
• Being a victim or witness to violence or crime
• Serious illness or death of a close family member or friend
• Natural or manmade disasters
• Severe car accidents

The first step to treatment is to talk with a healthcare provider to arrange an evaluation. For a PTSD diagnosis, a specific event must have triggered the symptoms. Because the event was distressing, children may not want to talk about the event, so a health provider who is highly skilled in talking with children and families may be needed. Once the diagnosis is made, the first step is to make the child feel safe by getting support from parents, friends, and school, and by minimizing the chance of another traumatic event to the extent possible. Psychotherapy in which the child can speak, draw, play, or write about the stressful event can be done with the child, the family, or a group. Behavior therapy, specifically cognitive-behavioral therapy, helps children learn to change thoughts and feelings by first changing behavior in order to reduce the fear or worry.  Medication may also be used to decrease symptoms.

Prevention of PTSD

It is not known exactly why some children develop PTSD after experiencing stressful and traumatic events, and others do not. Many factors may play a role, including biology and temperament.  But preventing risks for trauma, like maltreatment, violence, or injuries, or lessening the impact of unavoidable disasters on children, can help protect a child from PTSD.

Obsessive-Compulsive Disorder in Children

Many children occasionally have thoughts that bother them, and they might feel like they have to do something about those thoughts, even if their actions don’t actually make sense. For example, they might worry about having bad luck if they don’t wear a favorite piece of clothing. For some children, the thoughts and the urges to perform certain actions persist, even if they try to ignore them or make them go away. Children may have an obsessive-compulsive disorder (OCD) when unwanted thoughts, and the behaviors they feel they must do because of the thoughts, happen frequently, take up a lot of time (more than an hour a day), interfere with their activities, or make them very upset. The thoughts are called obsessions. The behaviors are called compulsions.

Symptoms

Having OCD means having obsessions, compulsions, or both.

Examples of obsessive or compulsive behaviors include:

• Having unwanted thoughts, impulses, or images that occur over and over and which cause anxiety or distress.
• Having to think about or say something over and over (for example, counting, or repeating words over and over silently or out loud)
• Having to do something over and over (for example, handwashing, placing things in a specific order, or checking the same things over and over, like whether a door is locked)
• Having to do something over and over according to certain rules that must be followed exactly in order to make an obsession go away.

Children do these behaviors because they have the feeling that the behaviors will prevent bad things from happening or will make them feel better. However, the behavior is not typically connected to actual danger of something bad happening, or the behavior is extreme, such as washing hands multiple times per hour.

A common myth is that OCD means being really neat and orderly. Sometimes, OCD behaviors may involve cleaning, but many times someone with OCD is too focused on one thing that must be done over and over, rather than on being organized. Obsessions and compulsions can also change over time.

Treatment for OCD

The first step to treatment is to talk with a healthcare provider to arrange an evaluation. A comprehensive evaluation by a mental health professional will determine if the anxiety or distress involves memories of a traumatic event that actually happened, or if the fears are based on other thoughts or beliefs. The mental health professional should also determine whether someone with OCD has a current or past tic disorder. Anxiety or depression and disruptive behaviors may also occur with OCD.

Treatments can include behavior therapy and medication. Behavior therapy, specifically cognitive-behavioral therapy, helps the child change negative thoughts into more positive, effective ways of thinking, leading to more effective behavior. Behavior therapy for OCD can involve gradually exposing children to their fears in a safe setting; this helps them learn that bad things do not really occur when they don’t do the behavior, which eventually decreases their anxiety. Behavior therapy alone can be effective, but some children are treated with a combination of behavior therapy and medication. Families and schools can help children manage stress by being part of the therapy process and learning how to respond supportively without accidentally making obsessions or compulsions more likely to happen again.

Prevention of OCD

It is not known exactly why some children develop OCD. There is likely to be a biological and neurological component, and some children with OCD also have Tourette syndrome or other tic disorders. There are some studies that suggest that health problems during pregnancy and birth may make OCD more likely, which is one of many important reasons to support the health of women during pregnancy.

Behavior or Conduct Problems in Children

Children sometimes argue, are aggressive, or act angry or defiant around adults. A behavior disorder may be diagnosed when these disruptive behaviors are uncommon for the child’s age at the time, persist over time, or are severe.  Because disruptive behavior disorders involve acting out and showing unwanted behavior towards others they are often called externalizing disorders.

Oppositional Defiant Disorder

When children act out persistently so that it causes serious problems at home, in school, or with peers, they may be diagnosed with Oppositional Defiant Disorder (ODD). ODD usually starts before 8 years of age, but no later than by about 12 years of age. Children with ODD are more likely to act oppositional or defiant around people they know well, such as family members, a regular care provider, or a teacher. Children with ODD show these behaviors more often than other children their age.

Examples of ODD behaviors include

• Often being angry or losing one’s temper
• Often arguing with adults or refusing to comply with adults’ rules or requests
• Often resentful or spiteful
• Deliberately annoying others or becoming annoyed with others
• Often blaming other people for one’s own mistakes or misbehavior

Conduct Disorder

Conduct Disorder (CD) is diagnosed when children show an ongoing pattern of aggression toward others, and serious violations of rules and social norms at home, in school, and with peers. These rule violations may involve breaking the law and result in arrest. Children with CD are more likely to get injured and may have difficulties getting along with peers.

Examples of CD behaviors include

• Breaking serious rules, such as running away, staying out at night when told not to, or skipping school
• Being aggressive in a way that causes harm, such as  bullying, fighting, or being cruel to animals
• Lying, stealing, or damaging other people’s property on purpose

Treatment for disruptive behavior disorders

Starting treatment early is important. Treatment is most effective if it fits the needs of the specific child and family. The first step to treatment is to talk with a healthcare provider. A comprehensive evaluation by a mental health professional may be needed to get the right diagnosis. Some of the signs of behavior problems, such as not following rules in school, could be related to learning problems which may need additional intervention. For younger children, the treatment with the strongest evidence is behavior therapy training for parents, where a therapist helps the parent learn effective ways to strengthen the parent-child relationship and respond to the child’s behavior. For school-age children and teens, an often-used effective treatment is a combination of training and therapy that includes the child, the family, and the school.

Managing Symptoms: Staying Healthy

Being healthy is important for all children and can be especially important for children with behavior or conduct problems. In addition to behavioral therapy and medication, practicing certain healthy lifestyle behaviors may reduce challenging and disruptive behaviors your child might experience. Here are some healthy behaviors that may help:

• Engaging in regular physical activity, including aerobic and vigorous exercise
• Eating a healthful diet centered on fruits, vegetables, whole grains, legumes (for example, beans, peas, and lentils), lean protein sources, and nuts and seeds
• Getting the recommended amount of sleep each night based on age
• Strengthening relationships with family members

Prevention of disruptive behavior disorders

It is not known exactly why some children develop disruptive behavior disorders. Many factors may play a role, including biological and social factors. It is known that children are at greater risk when they are exposed to other types of violence and criminal behavior, when they experience maltreatment or harsh or inconsistent parenting, or when their parents have mental health conditions like substance use disorders, depression, or attention-deficit/hyperactivity disorder (ADHD). The quality of early childhood care also can impact whether a child develops behavior problems. Although these factors appear to increase the risk for disruptive behavior disorders, there are ways to decrease the chance that children experience them.

Behavior Therapy for Behavior or Conduct Problems

What is behavior therapy?

Behavior therapy is effective treatment for behavior or conduct problems that can improve a child’s behavior, self-control, and self-esteem. The goals of behavior therapy are to learn or strengthen positive behaviors and eliminate unwanted or problem behaviors. Behavior therapy can include the parent, the child, or both together. It is most effective in younger children when it is delivered by parents.

When parents become trained in behavior therapy, they learn skills and strategies to help their child succeed at school, at home, and in relationships. Parent behavior therapy means that parents learn how to teach and guide their children and to manage their behavior. Parent training in behavior therapy has been shown to strengthen the relationship between the parent and child, and to decrease children’s negative or problem behaviors. Parent training programs include practicing new skills with the child, either during the therapy or at home.

Behavior therapy training for parents is effective for managing disruptive behavior in young children through age 12. A recent review of treatment in children aged 12 years and under found that the best evidence was for parent behavior therapy, when delivered either as group therapy or individually with child participation.

Finding a therapist

How do families find a therapist who trains parents in behavior therapy?

Psychologists, social workers, and licensed counselors can provide this kind of training to parents. Therapists may be found through professional association directories or through health insurance provider directories. Parents can review the therapist’s online profile or call and ask the therapist to describe their approach to behavior treatment.

What should parents look for?

Families should look for a therapist who focuses on training parents. Some therapists will have training or certification in a program that has been proven to work in children with behavior problems. The following list of questions can be used to find a therapist who uses a proven approach:

Does this therapist

• Teach parents skills and strategies that use positive reinforcement, structure, and consistent discipline to manage their child’s behavior?
• Teach parents positive ways to interact and communicate with their child?
• Assign activities for parents to practice with their child?
• Meet regularly with the family to monitor progress and provide coaching and support?
• Re-evaluate and remain flexible enough to adjust strategies as needed?

What can parents expect?

Parents typically attend eight or more sessions with a therapist. Sessions may involve groups or individual families. The therapist meets regularly with the family to review their progress, provide support, and adjust strategies as needed to ensure improvement. Parents practice with their child during or between sessions.

• The therapist meets regularly with the family to monitor progress and provide support
• Between sessions, parents practice using the skills they’ve learned from the therapist
• After therapy ends, families continue to experience improved behavior and reduced stress.

Improving Access to Children’s Mental Health Care

It can be challenging for some families to get mental health care for their children. Nearly 1 in 5 children have a mental, emotional, or behavioral disorder, such as anxiety or depression, attention-deficit/hyperactivity disorder (ADHD), disruptive behavior disorder, and Tourette syndrome. Children with these disorders benefit from early diagnosis and treatment. Unfortunately, only about 20% of children with mental, emotional, or behavioral disorders receive care from a specialized mental health care provider.

Some families cannot find mental health care because of the lack of providers in their area. Some families may have to travel long distances or be placed on long waiting lists to receive care. Cost, insurance coverage, and the time and effort involved make it harder for parents to get mental health care for their child. CDC works to identify policies and practices that connect more families to mental health care.

Barriers to pediatric mental health specialty care
• Parents may be reluctant to seek professional help
• Cost
• Not enough mental health providers to meet demand
• Lack of access to specialized providers
• Long waiting lists
• Lack of insurance coverage

Pediatric primary care:
9 in 10 children receive regular medical care from a primary care provider, but 1 in 3 pediatricians report that they have sufficient training to diagnose and treat children with mental disorders.

Specialized care providers for mental health
• Child and Adolescent Psychiatrists
• Child Psychologists
• Behavioral Therapists

Improving Access to Mental Health Care through Behavioral Health Integration

Behavioral Health Integration (BHI) is an approach to delivering mental health care that makes it easier for primary care providers to include mental and behavioral health screening, treatment, and specialty care into their practice. It can take different forms, but BHI always involves collaborations between primary care providers and specialized care providers for mental health.

Phone consultation
The primary care provider can receive consultation by phone about a diagnosis and treatment plan from the care provider for mental health.

Practicing together
The primary care practice has a care provider for mental health practicing on-site who is responsible for screening and referrals and may provide therapy. This is often called co-location.

Improving referrals and communication
A care coordinator manages referrals to care providers for mental health and needed social services, and maintains communication between the primary care practice and care providers for mental health.

BHI can result in
• Better outcomes for children and youth
• More efficient and coordinated care
• Higher treatment rates
• Reduced parental stress
• Improved consumer satisfaction