Priority disorders

Child and adolescent mental disorders can be considered from a number of perspectives. The following disorders are identified as priority areas based on their higher frequency of occurrence, degree of associated impairment, therapeutic possibilities (particularly at primary health care level -PHC) and long-term care consequences.

Early childhood

• Learning disorders. High incidence and prevalence, with serious implications for future productivity. Treatment is limited and school focused; obtaining occupational self-sufficiency is the goal. They may be associated with hyperkinetic disorders.
• Hyperkinetic disorders (ADHD). Presumed high incidence, greatly influenced by media and pharmaceutical awareness campaigns. Highly treatable at relatively low cost when the diagnosis is appropriately made. Long-term consequences relate to reports of poorer occupational attainment and increased co-morbid psychiatric illness and substance use disorders.

Middle childhood

• Tics (Tourette’s syndrome). More recently diagnosed with an incidence and prevalence not previously appreciated. The disorder now appears to be treatable without highly specialized interventions. Untreated, this disorder has high degree of stigmatization and social isolation.

Adolescence

• Depression and associated suicide. Depression is now recognized as a diagnosable disorder in children and adolescents. This in itself is an advance. Refining the diagnosis and recognizing its broad impact is ongoing. The magnitude of the association of depression and aggression with suicide remains open to confirmation on a general population basis but are, nevertheless important clinical issues. It is clear that the combination of depression with substance abuse puts children and adolescents at greater risk for suicide.
• Psychosis. The early identification of psychotic conditions is important for they are not always as obvious as would be thought. Psychoses can result in a host of maladaptive behaviours. The early treatment of psychotic disorders such as schizophrenia not only brings relief to patients, families, and society but improves the prognosis. Toxic psychoses are treatable when recognized with a dramatic reduction in symptoms and often rapid return to functioning.

It should be noted that medical disorders often associated with psychiatric symptoms, such as diabetes and seizure disorders, might be co-occurring with all the disorders noted above.

Substance use disorders are also significant co-morbid conditions that can alter the course of illness, treatment, and outcome, and represent a growth in important issue in the treatment of children and adolescents. Co-morbid substance use disorders or substance abuse can add dramatically to the degree of morbidity and functional incapacity of the individual and may influence the type of care provided.

In addition to the above-noted disorders categorized by age, which could be appropriately managed at the PHC level, the following disorders should be considered for treatment at higher levels of complexity:

• Pervasive Development Disorder. Low incidence with high morbidity and need for intensive rehabilitative efforts involving many sectors including education, rehabilitation, and social services. Poor occupational attainment has a great cost to families and societies dependent on cultural setting and community acceptance. Milder cases may first present as learning delays and less with problems in socialization.
• Attachment disorders. They appear in infancy and have a major long-term impact, but appear to be modifiable with increasingly common early intervention programs. This area of concern focuses attention on the need for programs with a maternal-infant focus.
• Anxiety disorders. A heterogeneous category of disorders with variable diagnosis in even the most sophisticated settings. Interventions are many with varying results. At the extreme phobias and panic disorder can lead to significant social isolation and lack of occupational attainment. When school refusal is included in this diagnostic grouping then the consequences can be seen as having multi-sectorial implications for both diagnosis and treatment.
• Conduct disorder/anti-social personality. The manifestations of conduct disorder may vary across cultures. This diagnosis is most commonly made when associated with anti-social or defiant behaviour, but it can have other manifestations. It should not be made prematurely because once made it is often seen as having such a negative prognosis that it may establish a self-fulfilling prophecy. Treatments are multi-sectoral with quite variable outcomes and require a comprehensive plan for there to be any hope of success
• Substance abuse. While it is often impossible to diagnose children as meeting the criteria for substance dependence, whether it be alcohol or other drugs, the serious manifestations of the abuse of substances is evident. Further, the use of drugs and alcohol clearly alters the diagnosis and treatment of all other disorders that may be co-morbid.
• Eating disorders. These disorders are now seen in developing as well as developed countries and may even manifest themselves in the face of apparent starvation. It is believed that a contributing in the rise of eating disorders is the exposure to Western media and its influence on desirable body characteristics.

Bullying

Bullying has been found to be an important factor associated with children’s mental health. One study – reported in “Peer victimisation during adolescence and its impact on depression in early adulthood” – found that children who had been bullied at age 13 were more than twice as likely to have depression at age 18. A meta-analysis (where several studies are combined) of longitudinal research on bullying and internalised problems (for example, depression and anxiety) reported a “symmetrical bi-directional relationship between peer victimization and internalizing problems”. That is to say, after taking initial levels of depression and anxiety into account, children who were bullied were more likely to report an increase in depression and anxiety over time and conversely, after taking initial levels of being bullied into account, children who had depression or anxiety were more likely to be bullied over time.

In 2011 to 2012 around 1 in 8 children (12%) reported being bullied at school physically, in other ways, or both more than 4 times in the last 6 months. The proportions were similar for boys and girls (13% and 11% respectively) and there had been no change since 2009 to 2010 (11% of all children).

Parental relationships

In 2013, The Children’s Society reported that a child’s relationship with their parents is an important factor associated with overall well-being. Children’s relationships with their parents are particularly prominent and powerful influences on children’s mental health, and disruptions or tumultuous relationships can often lead to behavioural difficulties. Parents are often children’s primary care givers and attachment figures, and quarrels between a child and their mother or father can disrupt children’s lives. Indeed, closeness to mothers and closeness to fathers have both been shown to have independent contributions to children’s happiness, life satisfaction, and psychological distress over and above demographic variables (Amato, 1994).

Just over a quarter (27%) of children reported quarrelling with their mother more than once a week in 2011 to 2012, a decrease from around 31% in 2009 to 2010. This compares with only 19%

who reported quarrelling with their father in 2011 to 2012 – a similar proportion to 2009 to 2010. However, children were also more likely to talk to their mother about things that matter more than once a week. In 2011 to 2012, just over 63% reported talking to their mother about things that matter frequently, whereas only 40% reported talking to their father about things that matter frequently. While there is no difference between the proportions of boys and girls quarrelling frequently with either parent, boys are less likely to talk to their mothers than girls (60% compared with 67%) whereas girls are less likely to talk to their fathers than boys (36% compared with 44%).

There is no evidence to prove a causal link between poor child-parent relationships and mental ill-health; however, there is an association between them. A child with a mental health issue may not be able to articulate their needs and emotions as well as a child with good mental health, and thus they may be more argumentative and disruptive. A poor relationship with parents may exacerbate mental health issues and lead children to exhibit undesirable behaviour or inappropriate emotional responses. The data from Understanding Society shows how difficult child-parent relationships are associated with mental ill-health.

The 4 parental relationship variables in the measurement are: quarrelling with mother, quarrelling with father, talking to mother about things that matter and talking to father about things that matter. Children who quarrelled with their mother or father more than once a week in 2011 to 2012 reported average total difficulties scores of 13.3 and 13.1 respectively. This compares with average scores of 9.5 and 9.8 for those children who reported quarrelling with their mother or their father less than once a week. Figure 2 illustrates the proportions of children with high or very high total difficulties scores according to how frequently they quarrelled with or talked to each of their parents. Children who quarrelled more than once a week with their mother were around 3 times more likely to report a high or very high score (24%) than those who quarrelled less than once a week (8%). Similarly, children who quarrelled with their father more than once a week were more than twice as likely to report a high or very high score (22%) than those who quarrelled less than once a week (9%).

Being able to talk to parents about things that matter may be a “protective” factor for children, helping to dampen any detrimental consequences associated with mental ill-health. In 2011 to 2012, those children who talked to their parents more than once a week reported lower average total difficulties scores (10.1 mother, 9.5 father) than children who talked to their parents about things that matter less than once a week (11.3 mother, 11.0 father). The proportion of children who had high or very high total difficulties scores was higher among those who talked to the motherless than once a week compared with those who talked to their mother more than once a week (15% compared with 11%). There was a similar difference in those reporting high or very high total difficulties scores between those who talked with their father less than once a week and those who talked to their father more than once a week (13% compared with 10%).

The regression analysis showed that quarrelling with either parent was more strongly related to total difficulties than talking with either parent, with a higher frequency of quarrelling associated with a higher score. Quarrelling with mother had the strongest relationship with total difficulties scores of the 4 parental relationship variables, and the second strongest of all the variables in the analysis. Quarrelling with father had the next strongest relationship with higher scores. However, talking more frequently with either parent was associated with a lower total difficulties score and talking frequently to father was more strongly related to lower scores than talking frequently to mother.

Research has suggested that children’s relationships with their mother and fathers can vary according to the gender of the child (Russell & Saebel, 1997). We investigated if the 4 parental relationship variables interacted with sex of the child by running two more regression analyses; one analysis for the “talking to mother or father about things that matter” variables and one for the “quarrelling with mother or father” variables. These analyses revealed no differences between boys or girls in the association between quarrelling with either parent and total difficulties score. However, there were differences between boys and girls for the associations between talking with parents and total difficulties scores. Talking frequently with fathers reduced total difficulties scores for both boys and girls, whereas talking frequently with mothers was only significantly related to lower total difficulties scores for girls.