Dr. Carol MacKinnon-Lewis

Introduction to Children’s Mental Health

History – What is Mental Health/Mental Illness?

Mental health challenges and other co-occurring disorders will provide the context for much of this course.

Many of the values and principles associated with family-centered care are not unique to the mental health area.

We’ll see a similarity is perspectives, but differences in the terminology used.

We’ll look at:

• Mental health vs. Mental Illness

• A number of perspectives

• Mental disorder

• Mental illnesses

It’s important to have an overall understanding of the range of disorders.

An overall theme is the importance of understanding context.

Context is not just culture. It could be changes that have taken place over time in the concept of mental health.

Continually ask yourself about the role of contexts.

World Health Organization Definition

The World Health Organization explains that scholars from various cultures define mental health differently.

Concepts of mental health include:

• Subjective well-being – How do I feel?

• Perceived self-efficacy – Do I feel in control of my life?

• Inter-generational dependence

• Self actualization of one’s intellectual and emotional potential

From a cross-cultural perspective, it’s nearly impossible to define mental health.

It’s generally agreed that mental health is broader than a lack of mental disorders.

You may not have a mental disorder, but still may not be mentally healthy either.

There may be an absence of discrete, diagnosable mental disorder.

You may feel you’re not in control of your life.

Other Definitions

The successful performance resulted in:

• Productive activities

• Fulfilling relationships with others

• Ability to adapt to change and cope with adversity

It’s not the absence of adversity, but the ability to adapt to change and cope with it.

Mental health (Fallon House): the successful performance of mental function.

Mental health: a relatively enduring state of being in which a person is reasonably satisfied with self as a reflection of their zest for living.

Elements of mental health may be identifiable, but the term itself isn’t easily defined.

The definition is rooted in value judgments, which may vary across cultures.

Mental health shouldn’t be seen as the absence of illness.

For instance, when individuals feel they are:

• Coping

• Fairly in control of their lives

• Able to face challenges

• Taking care of responsibility

World Federation of Mental Health

Elaboration of WFMH’s Definition

Mental Disorders

Mental disorders have been viewed as diseases with underlying biological and neurological causes and impairments.

We now have improved technologies for studying brain functioning.

We label overt, observable behaviors.

Contrary View

Mental disorders:

• Social constructs

• We look at behaviors

• Labeled based on social and culture perspectives

Two Very Divergent Views

Diseases with underlying biological and neurological causes

Social constructions / Our interpretations of behaviors

Is there a difference?

What do you think?

Is this reasonable?

Can there be a combination?

There are certain criteria that meet the conditions of being a disease with the underlying and neurological causes.

Others are viewed as judgments based on the behavior.

Mental Disorders

Importance of Context

Bio-psychological Model

Viewing behavior without an understanding for the context in which the behavior occurs is dangerous.

Behaviors labeled as dysfunctional or pathological may be understandable when viewed in the proper context.

BIOLOGICAL

01

PSYCHOLOGICAL

02SOCIAL

03

CULTURAL

04

Movement to a Therapeutic State

Horwitz conducts research on depression.

There’s been a movement to classify depression as a disease with biochemical roots and to treat it with medication.

Horwitz believes that a therapeutic intervention is required to treat this.

This is an example of a condition that at times meets the definition of a disease, and at times doesn’t.

We have gray areas.

Dr. Allan V. Horwitz

There’s has been a huge cultural transformation in the construction of mental illness in a short period of time.

Behaviors that violate rules or norms are interpreted as symptoms of mental disorder.

Dr. Allan V. Horwitz

There’s been a huge cultural transformation in the construction of mental illness in a short period of time.

Behaviors that violate rules or norms are interpreted as symptoms of mental disorder.

Influences in Transformation

Why is this Background Important?

This isn’t a simple field.

Helping people / Intellectually challenging

The factors that play a role include:

• Bio

• Psychosocial

• Cultural

• Economic

• Political

1. Prevalence or frequency of the problem

2. Magnitude

3. Privacy

Stay away from using the word, “cause”, because there’s different meanings connected to it.

Many factors may contribute to a problem, but a problem that leads to lots of other negative outcomes is more serious.

Seriousness of the Problem

Three Main FactorsHow do we determine the seriousness of this problem?

Prevalence of the Problem

Three Months One Year LifetimeThree Months Six Months One Year Lifetime

The DSM can be used to define something as a case.

Some people have take the created and translated them into:

• Measurement instruments

• Instruction

• Diagnostic interviews

To determine prevalence in children’s mental health, we use diagnostic interviews.

If a diagnosis is present, we define somebody as a case.

It’s very common for a 14-year old to report different symptoms than a parent.

The child may report more internalizing symptoms.

The prevalence rate will be much higher if we say it’s a case.

We have to:

• Identify sample

• Solicit participation

• Conduct diagnostic interviews

The best research comes from pulling together the findings of separate studies in different communities.

Community surveys: to identify random probability samples in a community.

Six Months

Research on Prevalence

Approximately ¼ of youth have diagnosable mental disorders within a six-month period.

Close to 20% meet the criteria for having a serious emotional disturbance.

According to the criteria, our priority should be on kids who have a diagnosis that significantly interferes with their functioning.

Serious emotional disturbance: the diagnosis of a condition that interferes with the functioning of a child.

For information on the trends in prevalence in disabilities from the CDC, click here.

Examples Common Diagnoses

Internalizing Problems Externalizing Problems

• Are not always manifested

• The emotions we feel

• More difficult to observe and measure

One of the most common diagnoses is anxiety disorder, including phobias and depression.

• Behaviors are observable

• Often interfere with social relationships

• In frequent motion

Conduct disorders, anti-social behavior, delinquent behavior, and physical altercations are externalizing problems..

Comorbidity of Diagnoses

A high level of comorbidity means that individuals have more than one diagnosis.

Comorbidity is not uncommon, and tends to result in more severe impairment.

Psychiatric problems tend to co-occur with other problems, like developmental disabilities.

Sometimes they lead to substance abuse and poor interpersonal relationships.

Intervention must take this all into account, also when establishing service systems.

A high degree of correlation with poor school functioning, speaks to the importance of close partnerships in treatment with schools.

Age of Onset, Magnitude, and Primacy

Adult disorder:

½ had an age of onset 14 or younger

¾ had an age of onset 24 or younger

Kid disorders:

19% have a serious emotional disturbance

25% are at risk of not becoming productive adults.

Research suggest that the age of onset for mental disorders continues to decrease.

Ronald Kessler

The National Comorbidity Study:

• Individuals 16 years and older

• Asked for every disorder found

• Asked when it first began

That represents a major loss from a production and societal standpoint.

The suffering and stress caused to the individuals and families have a major effect.

Suicide is one of the highest causes of death in young people, making the magnitude severe.

Lee Schorr

• Coined the term rotten adolescent outcomes

• The syndrome includes substance abuse and school failure

From a standpoint of prevalence, magnitude, and primacy, these are all very significant problems.

Increased Focus on Effects of Trauma

We’ve become more aware of the large numbers of people exposed to trauma.

We have adolescents who’ve moved in and out of the worst foster homes, and ones who’ve been abused.

The effects of trauma may be manifested in different disorders.

Most of us are exposed to significant traumas.

However, some of us have the coping skills or our environments have the resources to allow us to better deal with it.

Exposure to Trauma

We’re becoming more aware of the impact of trauma, due to natural disasters.

The most commonly referenced trauma-related disorder is post-traumatic stress disorder (PTSD).

This interferes with people’s functioning.

Jane Costello

Study Conducted:

• 1,420 youngsters sampled

• 25% exposed to high-magnitude traumatic event by age 16

• 6% exposed to one such event in the last 3 months

Research by Fairbank reports that children exposed to trauma have almost doubled the

rates of psychiatric disorder of those who haven’t been exposed.

Effects of Psychological Trauma

If the trauma is a lower magnitude event, it doesn’t have the same impact.

The impact is a function of:

• Their resilience to protect the factors

• The degree of support

• The skills they have

The impact isn’t as great if you have good coping skills, and people who can help.

Resilience is a significant part of this whole equation.

More Effects of Psychological Trauma

ACES was a study with a large sample that looked at adults in their 40s, 50s, 60s, and beyond.

They gathered data on their:

• Physical health

• Psychological functioning

• Exposure to adverse childhood experiences

They found that there were long-lasting physical and emotional effects in adults of significant impact exposure to trauma as youths.

We rarely ask about context before conducting intake interviewing.

We’ve had very little that was targeted to help individuals deal with exposure to trauma.

Adverse Childhood Experiences Study (ACES)

Implications for Policy

There’s been a lack of a coherent policy to address the seriousness of the problem.

The problems have been dismissed as being too infrequent or just a stage that kids go through.

In the beginning of the 20th century, juvenile courts death with these problems.

After WWII, many young adults weren’t qualified to serve in the military because of mental health problems.

There’s been a greater focus on mental health.

There’s been a lack of coherent policy, but there’s a greater recognition now of the seriousness.

Involvement in Multiple Systems

These systems have to accept responsibility and work together in order to develop effective policies and services that’ll lead to positive outcomes.

Children with Mental Health

Education

Child Welfare

Juvenile Justice

Substance Abuse

Developmental Service

Unclaimed Children

Jane Knitzer wrote the book, Unclaimed Children.

She maintained that each of the systems passed their responsibility on to other the systems.

As a result, kids were left without the services they needed.

Progress

There’s been progress made.

In 1984, The National Institute of Mental Health initiated CASSP.

The policy’s focus was to shift attention to children with serious emotional disturbances.

It was also to develop services based on a set of values.

CASSP

In 1993, the Substance Abuse and Mental Health Services Administration started a children’s mental health initiative to further support systems of care development.

Additional Progress

Significant changes have occurred throughout the years.

Awareness of children’s mental health problems

Co-occurrence with other challenges

The role of families and youth

Movement towards more strength-based care

The expansion of evidence-based interventions

Efforts to develop a culturally competent system, that takes into

account context.

Next Week

Next Week’s Topics

• Characteristics of effective systems

• What it means to be an effective system

• What does it look like?

You have reached the end of the presentation.