A Bad Rap

Kids with mental health issues have to overcome more than disability

In the United States, one in 10 children and adolescents suffer from mental illness severe enough to cause some level of impairment, according to the U.S. Department of Health and Human Services. Unfortunately, estimates suggest fewer than one in five of these children receive the treatment they need each year.

The situation is dire enough that the Surgeon General labeled it a public crisis in 2001. The call to action included a plea to educate every person involved in the care of children, so they could identify early indicators for potential mental health problems. Much of the instruction involves careful consideration of several elements affecting the mental health of children. A child with a mental disorder must not only deal with the challenge of his or her diagnosis, but also face the developmental process of growing up and defining his or her personal identity. This means environmental factors like friends, family, school and therapy are extremely important, as they all intertwine with a mental health diagnosis to have implications for the child’s future.

Social Complications

Children who battle mental health disorders face a myriad of social complications every professional should consider. These kids often have few friends and are sometimes pegged by teachers and others as being a bad or annoying kid.

“This is such a big problem. Because the truth is, many of these children are annoying to parents, friends and definitely to teachers. Even though you know the issue is biologically based, the fact is, many of these children are destructive,” explained Linda Goldsmith, MA, LCPC, CADC, OTR/L, who has her own counseling practice in Evanston, IL. This issue has personal relevance for her: Her son, now 22, was diagnosed with attention deficit hyperactivity disorder (ADHD) when he was in kindergarten.

The hyperactive-impulsive type of ADHD is a good example of a diagnosis that puts kids at risk socially. Often these children experience problems with peers, parents and teachers because of their intrusive behaviors and tendency to let those behaviors escalate out of control.

“In grade school, kids don’t really want to be associated with the kid getting in trouble for acting out or being disruptive,” Goldsmith said. “These kids are shunned by some groups because they can be in trouble, annoying or bossy. They do find friends, but they typically aren’t the most popular kid in class. That can lead to low self-esteem, which can make their diagnosis an even bigger problem down the road.”

Cathy Whiston, MS, OT/L, has worked in a California day treatment center for emotionally disturbed children for the past 10 years and has seen what support and encouragement can do for these children.

“All of the kids in our program come in with that social baggage. They’ve experienced failures in their school, been called bad, violent, they don’t have friends,” she said. “But if you take a kid out of a class of 30 and you put him in a classroom with only eight kids and three or four team members, you can eliminate a lot of things immediately, just because you can give them the attention they need. We also do a lot of nurturing and set up our activities for success. We believe that no learning takes place in a negative emotional environment.”

Whiston and the other team members work with kids who have diagnoses ranging from mood disorders to post-traumatic stress disorder (PTSD), reactive attachment disorder, anxiety disorder and Asperger’s syndrome. They focus on providing positive feedback to the children whenever they can, while ignoring negative behaviors.

“Occupational therapy is a great net for any of these mental health problems because we foster the positive characteristics and skills of a person,” Whiston said. “That approach is critical to these kids because their whole world is school and friends, and when they’re not being successful, they can really start identifying as a failure. The OT perspective of focusing on what they do well is key.”

Jeanne Schubmehl, OT, agrees that stressing the positive and ignoring the negative is helpful. She works with children who have emotional and behavioral disorders in Springfield, MA.

“We have consequences for bad behavior, but teachers and other workers express those consequences in a matter-of-fact, neutral way,” she said. “Many people just don’t understand mental illness and blame the child for the behavior, as if it’s something totally under the child’s control. But the behavior is a challenge for the child as well, and [the child] takes on that blame and feels like [he is a bad person] or not as good as others.”

Schubmehl said that stressing the positive can be as simple as observing when a child makes a good choice, such as commending a child for kicking a pillow instead of expressing his frustration with another child in a more destructive way.

Knowing What to Look for

Children living with ADHD, bipolar disorder, depression or eating disorders are often misunderstood because they express their symptoms differently than an adult might. Parents and other adults might view the child as simply unmotivated, moody or just trying to get attention. Many parents hope the situation is just a phase that their child will grow out of.

“It’s important to understand, for instance, that depression shows up differently in children and adolescents than it does in adults,” Goldsmith said. “In adolescence it often appears as agitation or irritability, a child getting into a lot of trouble or even a very angry child. For adults it’s more typical to see lower energy and withdrawal.”

Just as in adults, you can find children developing their own coping mechanisms for their disorders and sometimes self-medicating to deal with the symptoms. At times a child or adolescent might be hiding his or her mental health issue behind inappropriate behavior.

“A depressed adolescent might be getting high because it eases the pain. And we can tell from the recent news that gun violence can be traced to depression and other mental health issues,” Goldsmith said.

Disorders can also look somewhat alike in this younger population—for instance anxiety and ADHD often appear the same in children. And it’s often the case that several mental health disorders coexist, so teachers, parents and providers should be on the lookout for any other developing problems. For instance, ADHD can sometimes lead to substance abuse and eating disorders (a side effect of some medications is loss of appetite). As with any child, frequent monitoring is critical and can head off problems before they develop.

Earlier Is Better

While it’s often hard for the lay public to distinguish between regular developmental quirks and a specific mental health diagnosis, referring children for a consultation with the school psychologist or another mental health professional can be beneficial.

Clinical decisions are often based on measures of the intensity, duration and frequency of a behavior in comparison to the norm. Temper tantrums at three years old are a normal expression of frustration; however they would be considered abnormal behavior at 11 years old.

Catching a mental health diagnosis early on can avert some potential troubles down the road, as teens with a history of poor academic outcomes or social problems are at increased risk for developing anxiety and depression, or other problems like aggression, defiance and delinquency.

“The earlier the diagnosis and intervention, the better,” Goldsmith agreed. “A person gets a lot of negative reinforcement by being identified as the class clown or the problem kid. The kids learn that this is the only way to get the attention they need. Both in the home setting and in school, the word no is used a lot. So it builds on itself and leads to bigger problems.”

Those bigger problems can have far more serious consequences than just time-outs or detentions. “By middle school, it may lead to substance abuse, eating disorders, acting out, not thinking before they misbehave and making lots of bad decisions,” Goldsmith continued. “It’s hard to look at the positives. But OTs have the ability to switch out of that negative circle that people get into with these kids. And a good teacher can stop that pattern, too.”

Therapists and other professionals who work with kids with mental health diagnoses can provide tasks and activities that make the kids feel good about themselves, which targets self-esteem and mood issues.

“One thing I remember doing with my son is he loved being the center of attention. So every year, I would ask the teachers to please give him a leadership role,” Goldsmith recalled. “They let him lead the class in an activity, whether it’s cleaning up garbage outside or cleaning up the classroom, which helped him be more constructive.”

A Plan of Action

Parents go through a variety of reactions when their children are diagnosed with mental health issues. In Goldsmith’s case, she was relieved because she knew having the diagnosis would provide her son with the additional support he needed to succeed in school. However, many parents resist diagnosis.

“Many parents don’t want to admit their kid has depression, or an eating disorder, or ADHD. They don’t want him or her labeled,” she said. “And it’s not uncommon, if the child has a diagnosis, for the parents to keep it hidden from the school because they don’t want it to go on any school records. Outward appearance is very important. But I’m always astounded by that, because then the kids don’t get the services they need. The key for parents and teachers is to reframe the view of the child. This is a neurobiological disorder, it does not have to be looked at as negative.”

In these situations, everyone involved with the child needs to collaborate. Once the diagnosis is identified, the school, parents and therapists can move forward together.

“This helps with the follow-through. If parents are in close contact with the teacher, they can find out what systems are working and what can be reinforced at home,” Goldsmith said. “For me, it was helpful to have the OT background because I was used to short-term goals, using my son’s strengths and using visual cues to keep him on track.”

There are other adjustments parents, teachers and health care workers can make, such as monitoring how close the child needs to sit to take in the information, using reminders and providing reward systems. However Schubmehl admits follow-through is one of the difficult parts of working with kids, as the realities of life sometimes prevent everyone from getting on the same page.

“There’s enough blame going around in all of this, so I try to be aware of the stresses of other people,” Schubmehl said. “Teachers and parents can feel like they’re always being told that they’re not doing enough, so I try to recognize what they are doing and what is going well for their child, along with the child’s strengths.”

Sensory Overlap

When Whiston works with her group of 7-11 year olds, she follows a cognitive-behavioral model and leads a lot of sensory-motor activities to address their deficits, their balance and their personal space. The activities include jumping on trampolines, taking walks to observe animals and rolling up in blankets.

“I get to do all the fun stuff in the classroom: ‘brain-gym,’ arts and crafts, social skills, cooking, hands-on science,” she said. “I also spend a lot of time in individual education programs and social skills training—how to introduce yourself, how to compromise.”

There is a lot of overlap between sensory processing disorders and mental illness, so the hands-on activities of occupational therapy address this. Schubmehl uses weighted vests for sensory modulation in the younger kids; however, kids beyond second grade don’t go for that technique because of the stigma of being different. She adapted the idea by making weighted pillows for some age groups.

“Some of the sensory modulation involves imaginative play and this is where the OT background is particularly important,” she said. “You have to allow them to lead the story line—I’ll specifically say, ‘As the fire chief, what should I do next?'”

A significant focus of Schubmehl’s practice is finding occupations children enjoy, and then integrating a blend of physiological psychology principles with occupational therapy and neuroscience. She has adapted the five-stage group model created by Mildred Ross, OTR/L, FAOTA, to work with children’s groups. Ross created the model for sensory stimulation within groups to reduce aggression or agitation.

“The original model is all about body movement and capturing attention, whereas for the kids I need to do things that are calming as well, so they don’t get overexcited,” she said. “I still use a visual-perceptual piece, a motor piece and a cognitive piece for the five-stage group though.”

All of these activities, in conjunction with medication and other therapies as necessary, are effective in treating kids with serious emotional and mental disorders. However, mental illness is a chronic condition that needs continual attention and adjustment.

Keen Observation

Like any person working with kids, professionals dealing with children with mental health diagnoses continually monitor how the child is progressing with his or her treatment and daily living activities. Identifying and treating mental disorders can prevent losing critical developmental years, as well as preventing suicide (the third-leading cause of death in adolescents), school failure or juvenile delinquency.

A child is in a constant state of change as he develops and grows, so it’s important that the people around him frequently assess the child’s situation and progress to fine tune what’s necessary to support the child. Parents, teachers and health care providers must constantly keep in mind what developmental stage and transition the child is going through, to provide a context for the mental issues.

“Observation is so important for this population, but you have to observe in light of the person, their age and the stage that they’re at,” Schubmehl said. “The context around the mental disorder is that this is a child whose days vary. You have to keep in mind what’s going on with them developmentally.”

Sidebar: The Medication Debate

Many parents worry about the safety of their children taking psychotropic medications during their formative years. It’s appropriate for parents and other people interacting with children on psychotropic medications to be mindful of these concerns and closely monitor children for any adverse reactions.

However, many medications successfully control the debilitating symptoms of mental disorders.

“Many of these medications, when properly prescribed from a child psychiatrist instead of a family physician, allow these children to reach their potential to learn, have friends and have a full life,” said Jeanne Schubmehl, OT. “You have to consider what long-term damage might result from having continuous out-of-control behavior without the medication.”

For ADHD, professionals see children on stimulant medications, which are perhaps the most widely studied for children’s use. For children with depression and anxiety disorders, the most widely prescribed medications are selective serotonin reuptake inhibitors (SSRIs). Antipsychotic medications are used to treat children with schizophrenia, bipolar disorder, autism, Tourette’s syndrome and severe conduct disorders.

Some of the older antipsychotic medications have specific indications and dose guidelines for children, according to the National Institute of Mental Health; the newer “atypical” antipsychotics don’t. However, these atypical antipsychotics have fewer side effects and are being used for children despite the shortage of research support. Mood stabilizers like lithium and valproate are used to treat bipolar disorder, and research on their effectiveness is currently underway.

In many cases, psychotherapy is still recommended as the first line of treatment or in conjunction with medications. And the general consensus is that more studies involving children are necessary so we can get more information about the appropriate dosages, how the drugs work in children, and how the drugs affect learning and development.

—Sarah Lebo

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