Recognizing When Children Need Help (page 5)

One of the most difficult tasks for a parent whose child has been exposed to a traumatic event, natural disaster or a death is deciding whether or not additional help from a mental health professional is needed. Parents are generally well versed in the routine doctor visits for physical ailments such as the flu or ear infections, but are sometimes confused about obtaining mental health care. Parents may feel embarrassed or ashamed; think they should handle the problem on their own; feel the situation is hopeless; disagree when others suggest the need for outside help; or dismiss or misunderstand a child’s problem. But just like physical problems, prognosis is better when the mental health problem is identified and treated early.

Although many children show signs of stress in the first few weeks after a trauma, most will return to their usual state of physical and emotional health. However, it is not unusual for the reactions of any individual child to change many times in the days and weeks following a crisis.While some of these reactions are short-lived and resolve on their own, others may linger for months or years after the event has occurred. In addition, some difficulties may not even appear until months or even years after the event. For those children experiencing more difficulty returning to normal, professional help may be necessary.

When to Seek Professional Help

Many physical and emotional signs suggest a possible mental health problem. Problems can range from those of serious concern (for example, when a child or adolescent has lost touch with reality or is in danger of harming him or herself) to those of less concern (for example, when a child or teen experiences a change in eating or sleeping, is irritable or angry or is particularly fearful of something). Further investigation should be considered when a child seems out of step with peers or exhibits changes or problems in any of the following areas:

• Eating/appetite
• Sleeping
• School work
• Activity level
• Mood
• Relationship with family or friends
•  Aggressive behavior
• Return to behavior typical of a younger child
• Developmental milestones such as speech and language

In general, when bringing a child to a mental health professional, symptoms will first be evaluated with respect to their:

• Intensity
• Duration
• Age-appropriateness
• Level of interference with daily life: in school, at home, with peers

Mental Health Problems of Concern

All children exposed to the intense fear and helplessness associated with trauma or death of a loved one may be susceptible to posttraumatic stress disorder (PTSD), anxiety disorders and/or depression. Each of these diagnoses will be discussed in detail below.

Posttraumatic Stress Disorder in Children

All children experience stressful events, but some children experience or witness unusual, sudden and frightening traumatic events. Examples of such events are child abuse, community violence, natural disasters like Hurricane Katrina and the events of September 11th.These events may involve the actual or threatened death or serious injury to the children themselves or to someone they know.

What are the symptoms of PTSD?

Children’s PTSD symptoms fall into the following categories:

Re-experiencing

• Moments when a child seems to replay the event in his/her mind
• Intrusion of recurrent memories of the event or repetitive play about the even
• Nightmares

Arousal

• Disorganized and agitated behavior
• Irritability or anger
• Nervousness about everyone and everything around him or her (e.g., when people get too close)
• Jumpy when hearing loud noises

Avoidance

• Avoidance of thoughts, feelings or places that remind the child of what happened
• Numbing or lack of emotions

Other behaviors

• Regression to earlier behavior, such as clinging, bed-wetting or thumb sucking
• Difficulty sleeping or concentrating
• Detachment from others or social withdrawal
• Excessive use of alcohol or other substances to self-medicate

Who is likely to have PTSD?

Following a traumatic event such as the attack on the World Trade Center or a natural disaster such asHurricane Katrina, children and teens most at risk for PTSD are those who:

• Directly witnessed the event(s)
• Suffered direct personal consequences (such as the death of a parent, or injury to self)
• Had other mental health or learning problems prior to the event
• Lack a strong social network

What causes PTSD?

Not everyone who goes through the same experience responds in the same way. People are born with different biological tendencies in how they respond to stress— some are more adaptable, others more cautious. Reactions and recovery also are affected by the length and intensity of the traumatic event.

Can PTSD be prevented?

Parental support influences how well the child will cope in the aftermath of the event. Parents and professionals can help children by:

• Providing a strong physical presence
• Modeling and managing their own expression of feelings
• Establishing routines with flexibility
• Accepting children’s regressed behaviors while encouraging and supporting a return to age appropriate activity
• Helping children use familiar coping strategies
• Helping children share in maintaining their safety
• Allowing children to tell their story in words, play or pictures to acknowledge and normalize their experience
• Discussing what to do or what has been done to prevent the event from recurring
• Maintaining a stable and familiar environment

Common Questions and Answers

“Do children who are bereaved after a disaster suffer from PTSD?”

Grief responses may include some of the same symptoms we see in individuals with PTSD, such as sadness, withdrawal,
intrusive thoughts or avoidance of people and places that serve as reminders.While grief responses are usually worked through with time, PTSD may be part of the reaction for individuals who continue to experience these symptoms for one month or longer.

“What is the most common age for a child to develop PTSD?”

Children who have been exposed to a traumatic event may be at risk for PTSD at any age. PTSD is more difficult to diagnose in very young children who have less developed language and therefore cannot describe their internal thoughts and feelings well or understand the meaning of intrusive thoughts or nightmares.

“When does PTSD start and how long does it last?”

PTSD can develop years after an event. Responses and reactions following a disaster may last for weeks or months but often show a relatively rapid decrease after the direct impact subsides. Some children may not develop PTSD until a year or more after the event, which is known as the “sleeper effect”. However, PTSD is very responsive to intervention and symptoms can decrease over time.

How is PTSD Treated?

Cognitive behavioral therapy (CBT) has been shown to be effective for children with PTSD. Cognitive training helps children restructure their thoughts and feelings so they can live without feeling threatened. Behavioral interventions include learning to face fears so children no longer avoid people and places that remind them of the event. Relaxation techniques are used in combination with the child being carefully guided in telling the story about the event.These strategies teach children how to handle their fears and stress effectively. Training parents to help the child with new coping strategies and teaching adults how to use their own coping strategies are also often included. For more information on types of treatments and where to get help, see Chapter 14.

Anxiety Disorders in Children

Anxiety is a normal, natural emotion experienced by all human beings. However, some people, even children, worry to a degree that interferes with their daily lives. The anxiety can be about separation from parents, worry about a catastrophe happening, having a panic attack, being trapped if something goes wrong or being judged. A child may be so worried about getting a perfect score that he studies without respite; a child may be so afraid about not having the right answer that she never raises her hand; or a child may avoid social events because he is afraid that someone might not like him.

What are the symptoms of an anxiety disorder?

There are five major types of childhood anxiety disorder: separation anxiety disorder, generalized anxiety disorder, social phobia, obsessive compulsive disorder and panic disorder with or without agoraphobia. Children’s symptoms of anxiety are seen in these different ways:

Physical Feelings

• Headache, stomachache and/or muscle tension
• Panic attack symptoms such as shortness of breath, pounding or rapid heart beat, tingling and numbing sensations, hot or cold flushes and terror in certain situations

Thoughts

• Fear of being away from home or from primary caretaker
• Fear of something terrible happening to oneself or primary caretakers
• Excessive and uncontrollable worry about many things, such as the future, being on time for appointments, health, school performance, crime, change in routines and family matters
• Fear of being negatively evaluated, rejected, humiliated or embarrassed in front of others
• Fear of giving oral reports, participating in gym class, starting or joining in conversations, eating in public places or talking to unfamiliar people
• Nightmares

Behaviors

• Avoidance of situations or things causing worry such as social gatherings, school or animals
• Reluctance or resistance to sleeping alone
• Crying, tantrums, clinging in situations where worried
• Repetitive behaviors such as hand washing

Who is likely to have an anxiety disorder?

An estimated 5 to 20 percent of all children have been diagnosed with an anxiety disorder, making it the most common child mental health problem based on internal thoughts and feelings. An anxiety disorder can happen seemingly without warning or can be present for a long time without anyone realizing what it is.The earlier the onset, the more susceptible the child is to multiple types of anxiety and to depression about the anxiety. Teens with an anxiety disorder may also be at risk for developing major depression.

What causes an anxiety disorder?

Anxiety disorders result from a combination of family and biological influences. Studies suggest that some children who are temperamentally (even at birth) shown to be shy or tentative in unfamiliar situations may be more prone to anxiety. Anxiety may be caused by a chemical imbalance or problems with specific brain mechanisms. Anxiety disorders tend to run in families, but the complex relationship between genes, biological systems and anxiety is not well understood. Moreover, evidence suggests that anxiety and phobic reactions can be learned, either through direct experience or observations of others.

Depression in Children

All kids have a “blue mood” at some time.When the mood does not lift, however, the child may be depressed. Depressed children may have the usual symptoms of adult depression—they feel helpless, hopeless and worthless—but often they show other behaviors that may signal depression.

What are the symptoms of depression?

There are two basic types of depression: major depression, which lasts at least two weeks, and a milder, but chronic
condition called dysthymia, in which the child’s temperament or personality seems to be characterized by a long-standing depressed mood. In general, children with a depressive disorder will show some or all of the following symptoms:

• Depressed mood (that can be expressed as feelings of sadness and emptiness, tearfulness or irritability)
• Decreased interest or pleasure in activities
• Difficulty concentrating and paying attention
• Anger
• Fatigue or lack of energy
• Feeling hopeless
• Low self-esteem
• Sleep problems
• Appetite problems (e.g., increase or decrease)
• Significant weight gain or loss
• Social withdrawal (may be expressed as boredom)
• Restlessness or slowing down
• Thoughts of death

Who is likely to have childhood depression?

Anyone at any age, even two and three year-olds can be depressed. One to 2 percent of children aged five to 11 are diagnosed with depression and that number jumps to 8 percent for 12 to 18 year olds (twice as many girls as boys). Children with  depression may have another disorder as well; for example, at least half also have an anxiety disorder. Children who think about or attempt suicide are usually diagnosed with depression.

What causes childhood depression?

We all experience upsetting events in our lives. No one knows why some children get depressed while others faced with the same circumstances may be sad but are able to move on. Although life events can affect a child’s mood, trigger depression or make it more difficult to manage stress, usually there is a preexisting physiological vulnerability to depression. Most likely the depressive reaction is the result of the imbalance of the chemicals in the brain responsible for producing positive mood; this imbalance seems to be inherited. Research consistently shows that depression runs in families; children whose parents have a depressive disorder are 50 percent more likely to become depressed themselves.

Common Questions and Answers

“How can my child be depressed if he’s running around and having a good time?”

Depression in children often looks different than it does in adults. It is rare for young children to appear sad for long periods of time.They are more likely to be irritable, to complain of being bored and are difficult to please.

“Where does my child’s depression come from? She gets everything she wants.”

Unfortunately we do not know the cause of childhood depression. For some children depression seems to be a biological response that is not under their control and can be triggered by stress. Being “spoiled” does not cause depression.

“Will medication make children change their personality?”

No.Taking medication for depression can be compared to taking medicine for a horrible headache. Medication does not change who you are, but it takes away the headache. Similarly, the medication for depression relieves the child of the burdensome feelings, letting him or her to pursue and enjoy activities.

“Isn’t there anything else to help depression besides medication?”

Medication or CBT seem to be equally effective, and a parent, child and professional may choose one or both.
However, if a child is suicidal or has difficulty with basic everyday functions, medication should be considered. For most kids,
most kids, medications alone are not enough. A supportive, understanding, caring environment is also needed.

How is Depression Treated?

Getting help is vitally important. Keeping strong feelingsof sadness, helplessness, loneliness and pain inside can make things worse.When problems fester, treatment is often more difficult. Children and teens who talk about suicide or death should be taken seriously; they are not necessarily just looking for attention and therefore a mental health professional should be  consulted. Depression is treated in a number of ways, and in fact, it is one of the most easily and successfully treated mental illnesses. Research has shown CBT and medication to be helpful. Cognitive therapy that helps children learn how to monitor potentially troubling situations and feelings, how to counteract negative thinking and how to develop ways to handle sad feelings has also been shown to be effective.

About the NYU Child Study Center

The New York University Child Study Center is dedicated to increasing the awareness of child and adolescent psychiatric disorders and improving the research necessary to advance the prevention, identification, and treatment of these disorders on a national scale. The Center offers expert psychiatric services for children, adolescents, young adults, and families with emphasis on early diagnosis and intervention. The Center's mission is to bridge the gap between science and practice, integrating the finest research with patient care and state-of-the-art training utilizing the resources of the New York University School of Medicine. The Child Study Center was founded in 1997 and established as the Department of Child and Adolescent Psychiatry within the NYU School of Medicine in 2006. For more information, please call us at (212) 263-6622 or visit us at http://www.aboutourkids.org/.