When our babies are born, we worry about their growth and physical health. But as our children age, we also need to worry about their mental health. Daily care of a person’s mental health is important, but also important is recognizing mental disorders in our children. A mental disorder is a serious change in the way children learn, behave, or handle their emotions causing distress. A child with a mental disorder may struggle or show distress getting through their day. Mental disorders include anxiety, depression, bipolar disorder, schizophrenia, personality disorders, eating disorders, substance abuse disorders and behavior disorders. Attention Deficit Hyperactivity Disorder can also be classified as a mental disorder due to symptomology including emotional dysregulation and behavior problems.
Over 17% of all children will be diagnosed with a mental disorder. Most frequently diagnosed are ADHD, anxiety, depression, and substance abuse. We will be focusing on depression and anxiety but also touch on eating disorders and substance abuse.
Depression is a mental health disorder where a person suffers from persistent feelings of sadness or hopelessness. Depression will cause a person to lose interest in enjoyable activities. Depression affects 3.2% of all children aged 3 through 17 years. The incidence of depression increases as children enter the teen years. Overall, we are also seeing a rise in depression rates in our youth with a 69% increase from 2009-2017.
Symptoms or signs of depression include
• Changes in mood including ongoing irritability or anger
• Feeling hopeless
• Feeling guilty
• Frequent conflict with family and friends
• Changes in behavior
• Changes in relationships
• Loss of interest in activities
• Sleep issues including a hard time sleeping or sleeping too much
• Appetite changes including increased or decreased appetite
• Changes in weight or eating patterns
• Problems with memory and concentration
• Decreasing interest in school, drop in grades or effort
• Changes in appearance such as a lack of focus on hygiene
• Increase in risky behaviors
• Substance abuse
• Thoughts of suicide
Some people with depression have a seasonal pattern to their symptoms, with more symptoms occurring during winter months. This is called Seasonal Affective Disorder. It generally is not diagnosed in younger children but is possible. Living in a northern latitude with shorter daylight hours during winter is a risk factor.
A person with depression may also other conditions such as anxiety or behavior problems. Over 75% of people with depression will also have anxiety, and over 50% will have a diagnosed behavior problem.
Anxiety is a mental disorder in which a person frequently or constantly has feelings of apprehension and fear. Over 7% of children aged 3 to 17 years will be diagnosed with anxiety. Overall, the number of youth diagnosed with anxiety has increased over 20% from 2009-2017.
Anxiety is a general term but is actually a group of disorders. The most common are Generalized Anxiety, Social Anxiety Aisorder, Panic disorder, Phobias, Post-Traumatic Stress Disorder, Obsessive-Compulsive Disorder, and Separation Anxiety Disorder (including school phobia or refusal). These can be seen at all ages, but Panic disorder is very rare in younger children and not usually diagnosed until after age 15.
Anxiety can appear as a stronger response to a situation than expected, an unrealistic anxiety (the event will never actually happen), or feelings that last long after the problem is resolved. A person with anxiety may also have physical symptoms. It may affect their daily life or be sporadic. They may struggle with school, home, friends and/or social activities. Their worries will feel impossible to manage. They may avoid situations or experiences even ones that they enjoy. Sometimes the feelings of anxiety will come up due to a particular situation or it can come up unexpectedly without trigger. Some people, especially with generalize anxiety, may have symptoms constantly without an identifiable source for their anxiety.
Symptoms of anxiety include
• Recurring fears or worries
• Changes in behavior
• Feeling tense
• Avoiding enjoyable activities
• School avoidance or refusal
• Decreasing interest in school, grades dropping
• Trouble sleeping or concentrating
• Increase in risky behaviors
• Substance abuse
• Chronic physical complaints such as headaches, digestive issues, or chronic pain
• Physical symptoms of anxiety including:
o Foggy brain
o Butterflies in stomach
o Dissociated feeling
o Racing heart
o Lump in throat
o Stomach pain
o Frequent urination
o Tingly or numb feeling
o Feeling like you can’t breathe
o Panic attacks
A Panic attack may come on suddenly, even during sleep, and can be related to an event or without warning. A panic attack generally last 5-10 minutes and can be scary for children (and their parents). During a panic attack they may feel
• Chest pain
• Shortness of breath or feeling they can’t breathe
• Trembling or shaking
• Feeling detached or not real
• Numbness or tingling
• Chills or hot flashes
Like depression, you can also be diagnosed with other mental health disorders if you have anxiety. For example, 33% of people diagnosed with anxiety may be diagnosed with depression and 38% of people with anxiety will also have a behavior disorder.
Depression and anxiety will be the main focus today despite children having other mental disorders including Eating Disorders, Substance Abuse disorders, and Self-harm behaviors. Though these are thought of as different disorders, they are often result of a person coping with a mental health disorder such as anxiety and depression. Over 97% of those with an eating disorder and 93% of those with a substance abuse disorder are also diagnosed with depression. And 56% of those with an eating disorder and 20% of those with substance abuse disorder will have an anxiety disorder diagnosis.
Eating disorders affect 3-13% of children many of whom are never diagnosed. Women are diagnosed at three time the rate of men. Rates of eating disorders in teens aged 15-24 have doubled in the last decade. Children under the age of 12 have seen a 120% increase in eating disorder diagnoses in the past decade!
Eating and feeding disorders include anorexia, bulimia and binge-eating disorder. Eating disorders include these feeding problems:
• orthorexia (the need to cut out all “unhealthy foods” and a strong focus on healthy or pure foods)
• compulsive exercise
• diabulimia” (the neglect of diabetes management to lose weight)
• pica (the eating of non-food substances)
• Avoidant Restrictive Food Intake Disorder (AFRID which is extreme pickiness or fear of choking or vomiting due to eating).
Eating disorders are not diagnosed in 70% of the people who suffer from them, as there is a stigma around the diagnosis and treatment. But of the people who do seek treatment, 80% will complete treatment and improve significantly. Treatment is essential for a full return to health both physical and mental health. Anorexia is actually the deadliest mental illness and is the 3rd most chronic illness in teens after asthma and obesity.
A person with an eating disorder may be preoccupied with their weight, weight loss, food and nutrition. They may be uncomfortable eating around others or have food rituals. They may skip meals or reduce portions significantly. They may eat large quantities in a short amount of time and hide their eating habits. They may purge by vomiting or exercise. You may notice
• weight changes (both increases or decreases) or frequent fluctuations in weight
• stomach pain
• menstrual irregularities
• feeling cold all the time or when others are not
• sleep problems
• cuts or calluses on top of fingers
• dental cavities or erosion
• dry skin and nails
• swelling of salivary glands,
• fine hair on their body
• muscle weakness
• cold hands and feet
• swollen hands and feet
• poor wound healing
• difficulty concentrating
Substance abuse disorders affect 14% of the population. Substance abuse disorder is the inability to control the use of legal or illegal drugs or medications and the inability to stop using substances even if it causes harm. A teen who may have a substance abuse disorder may need to use the drug daily or even several times a day. They may have intense urges for the drug which may preoccupy their thoughts. They may need more of the drug overtime to get the same high and they may have withdrawal symptoms if they don’t take the drug. They may spend money they can’t afford to secure the drug and may steal in order to pay for drugs. They may cut back on social activities to use the drug. They may start performing worse in school and their grades may drop. Signs your teen may be using include problems at school, physical health issues, neglected appearance, changes in behavior, and money issues.
Self-harm is considered a separate diagnosis but often is in conjunction with anxiety or depression. Self-harm is not just cutting but can include burning, scratching, or hitting. Self-harm is NOT for attention. Self-harm is a coping mechanism that children use to help them through strong emotions or to distract themselves from strong emotions. They may want regain control over their body or feel “real”. They may want to punish themselves or counter feelings of numbness or emptiness. A person who self-harms may want to turn emotional pain in to physical pain or to feel “euphoria” that can occur due to the release of adrenaline and stress hormones by their body.
Often children try to hide their self-harming behavior either on hard to see areas of their body (such as abdomen or inner thighs) or by wearing clothing to cover the cut, burn, scratch or bruise. Self-harm can be but usually is not a suicide attempt, and the extent of self-harm does not equal their emotional distress.
THIS IS NOT JUST A TEEN ISSUE. The average age of children we see engaging in self-harming behaviors is 12 meaning we see it frequently in younger children! If you suspect or know your child is self-harming, the goal is to address what the underlying issue may be, such as anxiety or depression.
Mental disorders do not have a known singular cause. There are environmental and situational factors that can increase the risk of having a mental disorder. Genetics also plays a strong role not just with anxiety and depression but particularly in substance abuse disorders and eating disorders. The genetic life-time risk of each is
• Depression: 40%
• Anxiety: 26%
• Eating Disorders: 40-60%
• Substance Abuse Disorders: 40-60%
There are a few common environmental factors identified in teens and children that increase the risk of anxiety and depression. These include
• Busy schedules
• Pressure to succeed
• Social media use
• Underdeveloped coping skills
• Relationship difficulties both friendship and/or romantic
• Feel of uncertainty
• Feeling the world is scary or threatening
• Children or teens who identify as LGBTQ+
WHEN TO GET HELP
It is hard to know when the right time to talk to your child about getting help or to know if they even need help. It can be challenging to tell what is normal behavior and what isn’t normal adolescent behavior.
A few signs that it is time to get help include:
• Anxiety symptoms that occur more hours of the day, more days of the week than not
• Anxiety symptoms lasting more than 3-6 months
• Depression symptoms lasting more than a few weeks
• Symptoms that prevent your child from attending school or social events
• Symptoms that increase over time
• Any sign of eating disorder, self-harm, or substance abuse
• Any “red flag” comments or behaviors (see below)
• Suicide threats or suicide plans
Suicide is the 2nd most common death of children and young adults aged 10-24. Over 17% of this age group has thought about suicide, 14% have made a plan and 7% have made an attempt.
Anxiety and depression are two risk factors for suicide. Other risk factors include
• Previous attempt
• Family history
• Family conflicts
• Abuse including physical, sexual, and emotional
• Violence in the home or community
• Lack of family connectedness
• Parents who have untreated mental health disorders
• Changes in their life including a loved one’s death and homelessness
• History of foster care and adoption
• Psychiatric illness including schizophrenia
• Use of alcohol or other mind-altering substances
• History of behavior problems including impulsivity or aggressive behavior
• Easy access to guns or other lethal methods
• History of being bullied or cyberbullied
• Recent suicide in community
o This is especially increased in children aged 12-13 years
• LGBTQ+ children and teens
o Increased if there was a negative reaction from family to coming out
o Increased if there is rejection by family when coming out
o Further increased in children who are transgendered or gender non-conforming
Red flags include
• Direct statements threatening to hurt or kill themselves
• Verbal cues
o Statements of hopelessness
o Rage, anger or wanting revenge
o Statements of feeling trapped
• Indirect verbal cues including statements such as
o I wish I did not exist
o This nightmare will be over when I die
o Nothing matters
o Everyone would be better off without me
• Decreasing self esteem
• Indicating they feel like a burden
• Feelings of isolation
• Statements of above on social media
• Increased alcohol or drug use
• Withdrawal from others
• Dramatic mood changes
• Giving things away suddenly
• Looking for or researching ways to kill themselves with guns, pills, or weapons
• A sudden or unusual increase in talking or writing about death, dying or suicide
If your child expresses any red flag statements to you or friends, has any red flag behaviors, has suicidal ideation or a plan to commit suicide, you must seek help immediately. The National Suicide Prevention Lifeline can be reached at 800-273-8255 or HERE. Suicidal ideation requires immediately evaluation and is considered an emergency. You should bring your child to the ER or call 911 if you cannot safely get your child to the ER.
WHY SEEK HELP
Only 60% of children with anxiety and 80% of children with depression and 3% of those with an eating disorder will seek help. Do not let your child’s symptoms snowball or become chronic issues without treatment. Untreated anxiety and depression impact their physical as well as their mental health.
Chronic anxiety can lead to depression, substance abuse, suicide, school or learning problems, and chronic health problems such as headaches, chronic pain, digestive issues, and an increase risk of heart disease. It may also result in a weakened immune system.
Chronic depression can result in substance abuse, suicide, sleep problems, heart disease, weight gain or weight loss, a weakened immune system, and physical pain. It may also increase your sensitivity to pain. A person who does not treat their chronic depression can have work or school issues, issues with relationships. They may not respond as well to treatments for physical illnesses.
MENTAL HEALTH RESOURCES
Half of us is a resource with more information about mental health disorders. It also has links for getting support and helping a friend you are worried about.
This teen mental health website has information about mental health and how to find support. They also have free magazine downloads and links to YouTube video resources
National Eating Disorder Association
This organization provides support and services for individuals with an eating disorder.
National Institute on Drug Abuse for Teens
This site has information for teens who are battling substance abuse disorder or may have family or friends they are worried about. There is also a link to treatment centers.
The Born This Way Foundation has mental health resources for LGBTQIA+ youth including information on drugs, alcohol, self-harm, crisis resources, bullying, depression, grief management, and therapy.
The Samaritans provide crisis support and work to prevent suicide. You can call, text, or chat in over 240 languages. It is available 24 hours a day, 7 days a week.
Treatment is essential for treating your child’s anxiety or depression, protecting their future health, and helping them learn to cope with strong feelings and emotions. Next week we will explore the role of COVID-19 on our children’s mental health and the following week we will discuss how to help your child if they are showing signs of anxiety, depression, or other mental health disorders.
Children’s Health Care of Newburyport, Massachusetts, and Haverhill, Massachusetts is a pediatric healthcare practice providing care for families across the North Shore, Merrimack Valley, southern New Hampshire, and the Seacoast regions. The Children’s Health Care team includes pediatricians and pediatric nurse practitioners who provide comprehensive pediatric health care for children, including newborns, toddlers, school-aged children, adolescents, and young adults. Our child-centered and family-focused approach covers preventative and urgent care, immunizations, and specialist referrals. Our services include an on-site pediatric nutritionist, special needs care coordinator, and social workers. We also have walk-in appointments available at all of our locations for acute sick visits. Please visit chcmass.com where you will find information about our pediatric doctors, nurse practitioners, as well as our hours and services.
Disclaimer: this health information is for educational purposes only. You, the reader, assume full responsibility for how you choose to use it.