The epidemiology of child psychiatric disorders is the study of the incidence, prevalence, and distribution of conditions in child and adolescent psychiatry.
Subfields of paediatric psychiatric epidemiology include developmental epidemiology, which focuses on the genetic and environmental causes of child psychiatric disorders. The field of paediatric psychiatric epidemiology finds widely varying rates of childhood psychiatric disorders, depending on study population, diagnostic method, and cultural setting.
Prevalence of Mental Illness
Epidemiological research has shown that between 3% and 18% of children have a psychiatric disorder causing significant functional impairment (reasons for these widely divergent prevalence rates are discussed below) and Costello and colleagues have proposed a median prevalence estimate of 12%. Using a different statistical method, Waddell and colleagues propose a prevalence rate for all mental disorders in children of 14.2%.
Developmental Epidemiology
Developmental epidemiology seeks to “disentangle how the trajectories of symptoms, environment, and individual development intertwine to produce psychopathology”.
Socio-Economic Influences
Mental illness in childhood and adolescence is associated with parental unemployment, low family income, being on family income assistance, lower parental educational level, and single-parent, blended or stepparent families.
Methodological Issues
Epidemiological research has produced widely divergent estimates, depending on the nature of the diagnostic method (e.g. structured clinical interview, unstructured clinical interview, self-report or parent-report questionnaire), but more recent studies using DSM-IV-based structured interviews produce more reliable estimates of clinical “caseness”. Past research has also been limited by inconsistent definitions of clinical disorders, and differing upper and lower age limits of the study population. Changing definitions over time have given rise to spurious evidence of changing prevalence of disorders. Furthermore, almost all epidemiological surveys have been carried out in Europe, North America and Australia, and the cross-cultural validity of DSM criteria have been questioned, so it is not clear to what extent the published data can be generalised to developing countries.
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Adverse childhood experiences (ACEs) encompass various forms of physical and emotional abuse, neglect, and household dysfunction experienced in childhood.
ACEs have been linked to premature death as well as to various health conditions, including those of mental disorders. Toxic stress linked to childhood maltreatment is related to a number of neurological changes in the structure of the brain and its function. The Adverse Childhood Experiences Study, published in 1998, was the first large scale study to look at the relationship between ten categories of adversity in childhood and health outcomes in adulthood. Subsequent research is beginning to identify specific biomarkers associated with different kinds of ACEs.
Long Term Effects
According to the Centre for Youth Wellness website:
“Exposure without a positive buffer, such as a nurturing parent or caregiver, can lead to a Toxic Stress Response in children, which can, in turn, lead to health problems like asthma, poor growth and frequent infections, as well as learning difficulties and behavioral issues. In the long term, exposure to ACEs can also lead to serious health conditions like heart disease, stroke, and cancer later in life.”
Adverse childhood experiences can alter the structural development of neural networks and the biochemistry of neuroendocrine systems (i.e. how the brain regulates the hormonal activity in the body) and may have long-term effects on the body, including speeding up the processes of disease and aging and compromising immune systems.
Adverse childhood experiences are equal to various stresses, and a serious adversity is defined as a trauma. The World Health Organisation (WHO) recognises that prolonged stress in childhood can have life-long implications for the development of many diseases. Moreover, ACEs can disrupt early brain development leading to the possible development of several disorders. WHO has designed a screening questionnaire to be used internationally in order to list adverse effects, and relate them to future developments.
The effects of ACEs goes beyond health and risk taking behaviours with studies reporting that people with high ACEs scores showed less trust in government COVID-19 information and polices.
Health Outcomes in Adulthood
Physical Health
ACEs have been linked to numerous negative health and lifestyle issues into adulthood across multiple countries and regions including the United States, the European Union, South Africa, and Asia. Across all these groups researchers have reported seeing the adoption of higher rates of unhealthy lifestyle behaviour including sexual risk taking, smoking, heavy drinking, and obesity. The associations between these lifestyle issues and ACEs shows a dose response relationship with people having four or more ACEs have significantly more of these lifestyle problems. Physical health problems arise in people with ACEs with a similar dose response relationship. Chronic illnesses such as asthma, arthritis, cardiovascular disease, cancer, diabetes, stroke, and migraines show increased symptom severity in step was exposure to ACEs.
Mental Health
Mental health issues have been well know in the face of childhood trauma. Exposure to ACEs is no different with multiple mental health conditions found to have a dose response relationship with symptom severity and prevalence – including depression, attention-deficit hyperactivity disorder (ADHD), anxiety, suicidality, bipolar disorder and schizophrenia.
Special Populations
Additionally, epigenetic transmission may occur due to stress during pregnancy or during interactions between mother and newborns. Maternal stress, depression, and exposure to partner violence have all been shown to have epigenetic effects on infants.
Implementing Practices
Globally knowledge about the prevalence and consequences of adverse childhood experiences has shifted policy makers and mental health practitioners towards increasing, trauma-informed and resilience-building practices. This work has been over 20 years in the making bringing together research are implemented in communities, education settings, public health departments, social services, faith-based organisations and criminal justice.
Communities
As knowledge about the prevalence and consequences of ACEs increases, more communities seek to integrate trauma-informed and resilience-building practices into their agencies and systems. Indigenous populations show similar patterns of mental and physical health challenges as other minority groups. Interventions have been developed in American Indian tribal communities and have demonstrated that social support and cultural involvement can ameliorate the negative physical health effects of ACEs.
There is a paucity of empirical research documenting the experiences of communities who have attempted to implement information about ACEs and trauma-informed practice into widespread public action. The Matlin et al. (2019) article on Pottstown, Pennsylvania’s process demonstrated the challenges associated with community implementation. The Pottstown Trauma-Informed Community Connection (PTICC) initiative evolved from a series of prior collectives that all had similar goals of creating community resilience in order to prevent and treat ACEs. Over the course of the two-year study, over 230 individuals from nearly 100 organisations attended one training offered by the PTICC, raising the number of engaged public sectors from 2 to 14. Participation in training and events was fairly steady and this was largely due to community networking.
However, the PTICC faced several challenges similar to those predicted by the Building Community Resilience model. These barriers included availability of resources over time, competition for power within the group, and the lack of systemic change needed to support long-term goals. Still, Pottstown has built a trauma-informed community foundation and offers lessons to other communities who have similar goals: start with a dedicated small team, identify community connectors, secure long-term financial backing, and conduct data-informed evaluations throughout.
Other community examples exist, such as Tarpon Springs, Florida which became the first trauma-informed community in 2011. Trauma-informed initiatives in Tarpon Springs include trauma-awareness training for the local housing authority, changes in programs for ex-offenders, and new approaches to educating students with learning difficulties.
Education
ACEs exposure is widespread globally, one study from the National Survey of Children’s Health in the United States reported that approximately 68% of children 0-17 years old had experienced one or more ACEs. The impact of ACEs on children can manifest in difficulties focusing, self regulating, trusting others, and can lead to negative cognitive effects. One study found that a child with 4 or more ACEs was 32 times more likely to be labelled with a behavioural or cognitive problem than a child with no ACEs. Another study by the Area Health Education Centre of Washington State University found that students with at least three ACEs are three times as likely to experience academic failure, six times as likely to have behavioural problems, and five times as likely to have attendance problems. The trauma-informed school movement aims to train teachers and staff to help children self-regulate, and to help families that are having problems that result in children’s normal response to trauma. It also seeks to provide behavioural consequences that will not re-traumatize a child.
Trauma-informed education refers to the specific use of knowledge about trauma and its expression to modify support for children to improve their developmental success. The National Child Traumatic Stress Network (NCTSN) describes a trauma-informed school system as a place where school community members work to provide trauma awareness, knowledge and skills to respond to potentially negative outcomes following traumatic stress. The NCTSN published a study that discussed the ARC (attachment, regulation and competency) model, which other researchers have based their subsequent studies of trauma-informed education practices on. Trauma-sensitive or trauma-informed schooling has become increasingly popular in Washington, Massachusetts, and California in the last 10 years.
Social Services
Social service providers – including welfare systems, housing authorities, homeless shelters, and domestic violence centres – are adopting trauma-informed approaches that help to prevent ACEs or minimize their impact. Utilising tools that screen for trauma can help a social service worker direct their clients to interventions that meet their specific needs. Trauma-informed practices can also help social service providers look at how trauma impacts the whole family.
Trauma-informed approaches can improve child welfare services by:
Openly discussing trauma; and
Addressing parental trauma.
The New Hampshire Division for Children Youth and Families (DCYF) is taking a trauma-informed approach to their foster care services by educating staff about childhood trauma, screening children entering foster care for trauma, using trauma-informed language to mitigate further traumatisation, mentoring birth parents and involving them in collaborative parenting, and training foster parents to be trauma-informed.
Housing authorities are also becoming trauma-informed. Supportive housing can sometimes recreate control and power dynamics associated with clients’ early trauma. This can be reduced through trauma-informed practices, such as training staff to be respectful of clients’ space by scheduling appointments and not letting themselves into clients’ private spaces, and also understanding that an aggressive response may be trauma-related coping strategies. Up to 50% of people with housing insecurity experienced at least four ACEs.
Health Care Services
Screening for or talking about ACEs with parents and children can help to foster healthy physical and psychological development and can help doctors understand the circumstances that children and their parents are facing. By screening for ACEs in children, paediatric doctors and nurses can better understand behavioural problems. Some doctors have questioned whether some behaviours resulting in ADHD diagnoses are in fact reactions to trauma. Children who have experienced four or more ACEs are three times as likely to take ADHD medication when compared with children with less than four ACEs. Screening parents for their ACEs allows doctors to provide the appropriate support to parents who have experienced trauma, helping them to build resilience, foster attachment with their children, and prevent a family cycle of ACEs.
Public Health
Objections to screening for ACEs include the lack of randomised controlled trials that show that such measures can be used to actually improve health outcomes, the scale collapses items and has limited item coverage, there are no standard protocols for how to use the information gathered, and that revisiting negative childhood experiences could be emotionally traumatic. Other obstacles to adoption include that the technique is not taught in medical schools, is not billable, and the nature of the conversation makes some doctors personally uncomfortable. Some public health centres see ACEs as an important way (especially for mothers and children) to target health interventions for individuals during sensitive periods of development early in their life, or even in utero.
Resilience and Resources
Resilience is the ability to adapt or cope in the face of significant adversity and threats such as health problems, stressors experienced in the workplace or home. Resiliency can moderate the relationship of the effects of ACEs and health problem in adulthood. Being able use emotion regulation resources such as cognitive reappraisal and mindfulness people are able to protect themselves from the potential negative effects of stressors, these skills can be taught to people but people living with ACEs score lower on measures of resilience and emotion regulation.
Resilience and access to other resources are protective factors against the effects of exposure to ACEs. Increasing resilience in children can help provide a buffer for those who have been exposed to trauma and have a higher ACE score. People and children who have fostered resiliency have the skills and abilities to embrace behaviours that can foster growth. In childhood, resiliency and attachment security can be fostered from having a caring adult in a child’s life.
Adverse Childhood Experiences Study
The Adverse Childhood Experiences Study (ACE Study) is a research study conducted by the US health maintenance organisation Kaiser Permanente and the Centres for Disease Control and Prevention that was originally published in the American Journal of Preventive Medicine. Participants were recruited to the study between 1995 and 1997 and have since been in long-term follow up for health outcomes. The study has demonstrated an association of ACEs with health and social problems across the lifespan. The study has produced many scientific articles and conference and workshop presentations that examine ACEs.
In the 1980s, the dropout rate of participants at Kaiser Permanente’s obesity clinic in San Diego, California, was about 50%; despite all of the dropouts successfully losing weight under the program. Vincent Felitti, head of Kaiser Permanente’s Department of Preventive Medicine in San Diego, conducted interviews with people who had left the programme, and discovered that a majority of 286 people he interviewed had experienced childhood sexual abuse. The interview findings suggested to Felitti that weight gain might be a coping mechanism for depression, anxiety, and fear.
Felitti and Robert Anda from the Centres for Disease Control and Prevention (CDC) went on to survey childhood trauma experiences of over 17,000 Kaiser Permanente patient volunteers. The 17,337 participants were volunteers from approximately 26,000 consecutive Kaiser Permanente members. About half were female; 74.8% were white; the average age was 57; 75.2% had attended college; all had jobs and good health care, because they were members of the Kaiser health maintenance organisation. Participants were asked about different types of adverse childhood experiences that had been identified in earlier research literature:
Physical abuse.
Sexual abuse.
Emotional abuse.
Physical neglect.
Emotional neglect.
Exposure to domestic violence.
Household substance abuse.
Household mental illness.
Parental separation or divorce.
Incarcerated household member.
Findings
According to the United States’ Substance Abuse and Mental Health Services Administration, the ACE study found that:
Adverse childhood experiences are common.
For example, 28% of study participants reported physical abuse and 21% reported sexual abuse.
Many also reported experiencing a divorce or parental separation, or having a parent with a mental and/or substance use disorder.
Adverse childhood experiences often occur together.
Almost 40% of the original sample reported two or more ACEs and 12.5% experienced four or more.
Because ACEs occur in clusters, many subsequent studies have examined the cumulative effects of ACEs rather than the individual effects of each.
Adverse childhood experiences have a dose-response relationship with many health problems.
As researchers followed participants over time, they discovered that a person’s cumulative ACEs score has a strong, graded relationship to numerous health, social, and behavioural problems throughout their lifespan, including substance use disorders.
Furthermore, many problems related to ACEs tend to be comorbid, or co-occurring.
The ACE Pyramid represents the conceptual framework for the ACE Study, which has uncovered how adverse childhood experiences are strongly related to various risk factors for disease throughout the lifespan, according to the CDC.
About two-thirds of individuals reported at least one adverse childhood experience; 87% of individuals who reported one ACE reported at least one additional ACE. The number of ACEs was strongly associated with adulthood high-risk health behaviours such as smoking, alcohol and drug abuse, promiscuity, and severe obesity, and correlated with ill-health including depression, heart disease, cancer, chronic lung disease and shortened lifespan. Compared to an ACE score of zero, having four adverse childhood experiences was associated with a seven-fold (700%) increase in alcoholism, a doubling of risk of being diagnosed with cancer, and a four-fold increase in emphysema; an ACE score above six was associated with a 30-fold (3000%) increase in attempted suicide.
The ACE study’s results suggest that maltreatment and household dysfunction in childhood contribute to health problems decades later. These include chronic diseases – such as heart disease, cancer, stroke, and diabetes – that are the most common causes of death and disability in the United States. These findings are important because they provided a link between the effects of child maltreatment and negative effects later in life which had not been established as clearly before this study.
Subsequent Surveys
The ACE Study has produced more than 50 articles that look at the prevalence and consequences of ACEs. It has been influential in several areas. Subsequent studies have confirmed the high frequency of adverse childhood experiences.
The original study questions have been used to develop a 10-item screening questionnaire. Numerous subsequent surveys have confirmed that adverse childhood experiences are frequent.
The Behavioural Risk Factor Surveillance System (BRFSS) which is ran by the CDC, is an annual survey conducted in waves by groups of individual state and territory health departments.. An expanded ACE survey instrument was included in several US states found each state. Adverse childhood experiences were even more frequent in studies in urban Philadelphia and in a survey of young mothers (mostly younger than 19). Surveys of adverse childhood experiences have been conducted in multiple EU member countries.
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Parentification is the process of role reversal whereby a child is obliged to act as parent to their own parent or sibling. In extreme cases, the child is used to fill the void of the alienating parent’s emotional life.
Two distinct types of parentification have been identified technically: instrumental parentification and emotional parentification.
Instrumental parentification involves the child completing physical tasks for the family, such as looking after a sick relative, paying bills, interpreting foreign language, or providing assistance to younger siblings that would normally be provided by a parent.
Emotional parentification occurs when a child or adolescent must take on the role of a confidante or mediator for (or between) parents or family members.
Background
Melitta Schmideberg noted in 1948 how emotional deprivation could lead parents to treat their children (unconsciously) as substitute parent figures. “Spousification” and “parental child” (Minuchin) offered alternative concepts exploring the same phenomenon; while the theme of intergenerational continuity in such violations of personal boundaries was further examined. Eric Berne touched on the dangers of parents and children having a symmetrical, rather than asymmetrical relationship, as when an absent spouse is replaced by the eldest child; and Virginia Satir wrote of “the role-function discrepancy…where the son gets into a head-of-the-family role, commonly that of the father”.
Object relations theory highlighted how the child’s false self is called into being when it is forced prematurely to take excessive care of the parental object; and John Bowlby looked at what he called “compulsive caregiving” among the anxiously attached, as a result of a parent inverting the normal relationship and pressuring the child to be an attachment figure for them.
All such aspects of disturbed and inverted parenting patterns have been drawn under the umbrella of the wider phenomenon of parentification – with the result (critics suggest) that on occasion “ironically the concept of parentification has…been as over-burdened as the child it often describes”
Choice of Child
For practical reasons, elder children are generally chosen for the familial “parental” role – very often the first-born children who were put in the anomalous role. However, gender considerations mean that sometimes the eldest boy or eldest girl was selected, even if they are not the oldest child overall, for such reasons as the preference to match the sex of the missing parent.
Thus where there is a disabled child in the family to be cared for, “older siblings, especially girls, are at the greatest risk of parentification”; where a father-figure is missing, it may be the eldest son who is forced to take on his father’s responsibilities, without ever obtaining the autonomy that normally accompanies such adult roles.
Alternatively a widower may put a daughter into the social and emotional role of his deceased wife – “spousification”; or a mother can oblige her daughter to play the caring role, in a betrayal of the child’s normal expectation of love and care
Narcissistic
Narcissistic parentification occurs when a child is forced to take on the parent’s idealised projection, something which encourages a compulsive perfectionism in the child at the expense of their natural development. In a kind of pseudo-identification, the child is induced by any and all means to take on the characteristics of the parental ego ideal – a pattern that has been detected in western culture since Homer’s description of the character of Achilles.
Disadvantages
The almost inevitable byproduct of parentification is losing one’s own childhood. In destructive parentification, the child in question takes on excessive responsibility in the family, without their caretaking being acknowledged and supported by others: by adopting the role of parental care-giver, the child loses their real place in the family unit and is left lonely and unsure. In extreme instances, there may be what has been called a kind of disembodiment, a narcissistic wound that threatens one’s basic self-identity.
In later life, parentified children often experience anxiety over abandonment and loss, and demonstrate difficulty handling rejection and disappointment within interpersonal relationships.
Case Studies
Carl Jung in his late autobiography reports that his mother always spoke to him as an adult, confiding in him what she could not share with her husband. Laurens van der Post commented on the grown-up atmosphere surrounding the young Jung, and considered that “this activation of the pattern of the “old man” within himself…was all a consequence of the extent to which his father and mother failed each other”.
Patrick Casement reports on a patient – Mr T – whose mother was distressed at any and all his feelings, and who therefore protected her from them – mothering her himself.
Literary Examples
The Tale of Genji tells that for “Kaoru’s mother…her son’s visits were her chief pleasure. Sometimes he almost seemed more like a father than a son – a fact which he was aware of and thought rather sad”.
Charles Dickens’ “Angel in the house” characters, particularly Agnes Wickfield in David Copperfield, are parentified children. Agnes is forced to be the parent of her alcoholic father and seems to strive for perfection as a means of reaching the “ego ideal” of her deceased mother (who died upon child-birth). Agnes marries late, has relationship and intimacy problems (she has a hard time expressing her love for David until he reveals his own love for her), and has some self-defeating attitudes; in one scene she blames her own father’s misfortunes on herself. However, she proves to be resilient, resourceful, responsible and even potentially career-driven (she forms her own school). She also manages to marry the protagonist David and the two live happily together for 10 years with children by the end of the novel.
The theme of parentification has also been explored in the Twilight series, with particular but not exclusive reference to the character of Bella Swan.
Bipolar disorder in children, or paediatric bipolar disorder (PBD), is a controversial mental disorder in children and adolescents that is mainly diagnosed in the United States, and is hypothesized to be like bipolar disorder (BD) in adults, thus is proposed as an explanation for extreme changes in mood and behaviour accompanying periods of depressed or irritable moods and periods of elevated moods so called manic or hypomanic episodes.
These shifts are sometimes quick, but usually are gradual. The average age of onset of paediatric bipolar disorder is unclear, but the risk increases with the onset of puberty. Bipolar disorder is rare in childhood. Paediatric bipolar disorder is typically more severe and has a poorer prognosis than bipolar disorder with onset in late-adolescence or adulthood.
The DSM has specified that the criteria for bipolar disorder can be applied to children since 1980. However, the exact criteria for diagnosing paediatric bipolar disorder remains controversial and heavily debated. There are big differences in how commonly it is diagnosed across clinics and in different countries. There has been a rapid increase in research on the topic, but training and clinical practice lag behind.
Identifying bipolar disorder in youth is challenging. Children often exhibit chronic rather than episodic mania periods. Almost always, these chronic problems have causes other than bipolar disorder. The criteria for paediatric bipolar disorder can also often be masked by developmental differences. Comorbid disorders make determining what symptoms are signs of bipolar disorder and which are due to other disorders (e.g. OCD, ADHD, disruptive behaviour problems) difficult, leading to complications in treatment. For example, a common treatment for OCD are serotonin re-uptake inhibitors (SRIs), however, SRIs can lead to mood instability and worsening bipolar disorder.[5] The most common misdiagnosis for ADHD in the USA is paediatric bipolar disorder due to hyperactivity being described as prolonged periods of mania. Empirical research conducted in 2004 found that “bipolar disorder (in preadolescence) was initially misdiagnosed in 12 out of 24 youths” (Mahoney, 2004). This is a dangerous misdiagnosis due to the vastly different treatment forms. Firstly, ADHD does not require mood stabilisers like paediatric bipolar disorder. Secondly, the stimulants given to treat ADHD have been shown to cause psychosis and exacerbate mania in paediatric bipolar disorder (Wendling, 2009). This misuse of medication can lead to mood episodes, suicidality, and hospitalisation.
Brief History
Descriptions of children with symptoms similar to contemporary concepts of mania date back to the 18th century. In 1898, a detailed psychiatric case history was published about a 13-year-old that met Jean-Pierre Falret and Jules Baillarger’s criteria for folie circulaire, which is congruent to the modern conception of bipolar I disorder.
In Emil Kraepelin’s descriptions of bipolar disorder in the 1920s, which he called “manic depressive insanity”, he noted the rare possibility that it could occur in children. In addition to Kraepelin, Adolf Meyer, Karl Abraham, and Melanie Klein were some of the first to document bipolar disorder symptoms in children in the first half of the 20th century. It was not mentioned much in English literature until the 1970s when interest in researching the subject increased. It became more accepted as a diagnosis in children in the 1980s after the DSM-III (1980) specified that the same criteria for diagnosing bipolar disorder in adults could also be applied to children.
Recognition came twenty years after, with epidemiological studies showing that approximately 20% of adults with bipolar disorder already had symptoms in childhood or adolescence. Nevertheless, onset before age 10 was thought to be rare, below 0.5% of the cases. During the second half of the century misdiagnosis with schizophrenia was not rare in the non-adult population due to common co-occurrence of psychosis and mania, this issue diminishing with an increased following of the DSM criteria in the last part of the 20th century.
Epidemiology
The prevalence of bipolar in youth is estimated at 2%.
Diagnosis
Diagnosis is made based on a clinical interview by a psychiatrist or other licensed mental health practitioner. There are no blood tests or brain scans to diagnose bipolar disorder. Obtaining information on family history and the use of questionnaires and checklists are helpful in making an accurate diagnosis. Commonly used assessment tools include the:
In both the American Psychiatric Association’s DSM-5 and the World Health Organisation’s ICD-10, the same criteria used to diagnose bipolar disorder in adults are used to make the diagnosis in children with some adjustments to account for differences in age and developmental stage. For example, the DSM-5 specifies that in children, depressive episodes can manifest as persistently irritable moods.
In diagnosing manic episodes, it is important to compare the changes in mood and behaviour to the child’s normal mood and behaviours at baseline instead of to other children or adults. For example, grandiosity (i.e. unrealistic overestimation of one’s intelligence, talent, or abilities) is normal at varying degrees during childhood and adolescence. Therefore, grandiosity is only considered symptomatic of mania in children when the beliefs are held despite being presented with concrete evidence otherwise or when they lead to a child attempting activities that are clearly dangerous, and most importantly, when the grandiose beliefs are an obvious change from that particular child’s normal self-view in between episodes.
Controversy
The diagnosis of childhood bipolar disorder is controversial, although it is recognised that bipolar disorder typical symptoms are dysfunctional and have negative consequences for minors suffering them. Main discussion is centred on whether what is called bipolar disorder in children refers to the same disorder than when diagnosing adults, and the related question on whether adults’ criteria for diagnosis are useful and accurate when applied to children. More specifically, main discussion over diagnosis in children circles around mania symptomatology and its differences between children and adults.
Diagnostic criteria may not correctly separate children with bipolar disorder from other problems such as ADHD, and emphasize fast mood cycles.
Treatment
Medications can produce important side effects, so interventions have been recommended to be closely monitored and families of patients to be informed of the different possible problems that can arise. Atypical antipsychotics are more effective than mood stabilizers, but have more side effects. Typical antipsychotics may produce weight gains as well as other metabolic problems, including diabetes mellitus type 2 and hyperlipidaemia. Extrapyramidal secondary effects may appear with these medications. These include tardive dyskinesia, a difficult-to-treat movement disorder (dyskinesia) that can appear after long-term use of antipsychotics. Liver and kidney damage are a possibility with mood stabilisers.
Psychological treatment usually includes some combination of education on the disease, group therapy and cognitive behavioural therapy (CBT). Children with bipolar disorder and their families are informed, in ways accordingly to their age and family role, about the different aspects of bipolar disorder and its management including causes, signs and symptoms and treatments. Group therapy aims to improve social skills and manage group conflicts, with role-playing as a critical tool. Finally, cognitive-behavioural training is directed towards the participants having a better understanding and control over their emotions and behaviours.
Lithium or Divalproex is recommended for first-line treatment.
Partial (minimal to moderate) improvement with monotherapy, augment with another of the first-line recommendations.
Stage 2: Monotherapy with an alternative drug, then augmentation.
Stage 3: Possible medication combinations – lithium plus Divalproex, lithium plus atypical, or Divalproex plus atypical.
Stage 4: Combination of 2-3 mood stabilisers.
Stage 5: Alternate monotherapy with oxcarbazepine, ziprasidone, or aripiprazole (all Level D).
Stage 6: For nonresponse or intolerable side effects – clozapine for children or adolescents, or electroconvulsive therapy (ECT) for adolescents only.
BPD I, manic or mixed, with psychosis:
Stage 1: Same as BPD I without psychosis except for first-line treatment warrants a combination of mood stabiliser and an atypical antipsychotic.
Stages 2-4: Varying combinations and augmentations.
Stage 5: Alternate monotherapy (oxcarbazepine) plus an atypical antipsychotic.
Prognosis
Chronic medication is often needed, with relapses of individuals reaching rates over 90% in those not following medication indications and almost to 40% in those complying with medication regimens in some studies. Compared to adults, a juvenile onset has in general a similar or worse course, although age of onset predicts the duration of the episodes more than the prognosis. A risk factor for a worse outcome is the existence of additional (comorbid) pathologies.
Children with bipolar disorder are more likely to suicide than other children.
Dr Alex George explores the wide range of mental health issues children and young people are facing, and finds out how projects funded by Children in Need are making a difference.
Outline
Dr Alex George follows the journeys of young people across the UK who are living with mental health issues. He explores the wide range of difficulties they face and finds out how local charities, including projects funded by Children in Need, are making a difference.
As an A&E doctor and the UK Youth Mental Health Ambassador, Alex has seen at first hand the effects of the pandemic on young people’s mental wellbeing, but he never thought they would affect his own family. But in July 2020, Alex’s 19-year-old brother Llyr, who had been struggling with anxiety during lockdown, took his own life. This poignant film is his response.
Child and Adolescent Mental Health Services (CAMHS) is the name for NHS-provided services in the United Kingdom for children, generally until school-leaving age, who are having difficulties with their emotional well-being or are deemed to have persistent behavioural problems.
CAMHS are organised locally, and the exact services provided may vary, often by local government area.
Brief History
In Europe and the United States child-centred mental health did not become a medical specialty until after World War I. In the United Kingdom children’s and young people’s mental health treatment was for decades the remit of the Child Guidance Movement increasingly working after World War II with local educational authorities and often influenced by psychoanalytic ideas. Provision in NHS hospitals was piecemeal across the country and disconnected from the youth justice system. However opposition to Psychoanalysis with its pioneering research work into childhood and adolescence, which was poorly understood by proponents of the Medical model, caused the service to be abandoned in favour of evidence-based medicine and evidence-based education. This led to the eclipse of the multidisciplinary child guidance approach in the 1990s and a public policy-motivated formal take-over by the NHS.
The development of CAMHS within a four-tiered framework started in 1995. In 1998, 24 CAMHS Innovation Projects started, and the Crime and Disorder Act 1998 established related youth offending teams. In 2000 the NHS Plan Implementation Programme required health and local authorities to jointly produce a local CAMHS strategy.
In November 2008 the independent CAMHS Review was published.
From about 2013 onward major concerns have been expressed about reductions in CAMHS, and apparently increasing demand, and in 2014 the parliamentary Health Select Committee investigated and reported on provision. In 2015 the government published a review, and promised a funding increase of about £250 million per year. However the funds were not ring-fenced and as of 2016 only about half of England’s Clinical commissioning groups had increased local CAMHS funding. CAMHS funding remains a popular topic for political announcements of funding and the current aim is to increase funding to the level that 35% of young people with a disorder are able to receive a specialist service. Different models of service organisation are also advocated as part of this transformation.
In Scotland, between 2007 and 2016 the number of CAMHS psychologists had doubled, reflecting increased demand for the service. However in September 2020, 53.5% of CAMHS patients in Scotland had waited for an appointment longer than the 18 weeks target, and in Glasgow the average waiting time was 26 weeks.
131 new CAMHS beds were commissioned by NHS England in 2018, increasing the existing 1,440 bed base by more than 10%. 56 will be in London, 12 at Bodmin Hospital and 22 at St Mary’s Hospital in Leeds.
Service Framework
In the UK CAMHS are organised around a four tier system:
Tier
Description
1
General advice and treatment for less severe problems by non-mental health specialists working in general services, such as GPs, school nurses, social workers, and voluntary agencies.
2
Usually CAMHS specialists working in community and primary care, such as mental health workers and counsellors working in clinics, schools and youth services.
3
Usually a multi-disciplinary team or service working in a community mental health clinic providing a specialised service for more severe disorders, with team members including psychiatrists, social workers, board certified behaviour analysts, clinical psychologists, psychotherapists and other therapists.
4
Highly specialist services for children and young people with serious problems, such as day units, specialised outpatient teams and in-patient units.
Specialist CAMHS – Tiers 3 and 4
Generally patients cannot self-refer to Tier 3 or 4 services, which are sometimes called specialist CAMHS. Referrals can be made by a wide range of agencies and professionals, including GPs and school nurses.
The aim is to have a team led by a consultant psychiatrist, although other models exist and there is limited evidence of what system works best. It is suggested that there should be a consultant psychiatrist for a total population of 75,000, although in most of the UK this standard is not met.
The Tier 4 service includes hospital care, with about 1,450 hospital beds provided in England for adolescents aged 13 to 18. Typical conditions that sometime require hospital care include depression, psychoses, eating disorders and severe anxiety disorders.
The service may, depending on locality, include:
Art therapy.
Child psychiatry.
Clinical psychology.
Educational psychology.
Family therapy.
Music therapy.
Occupational therapy.
Psychiatric nursing.
Social worker interface.
Speech therapy.
Child psychotherapy.
Forensic CAMHS, working with young offenders or those at risk of offending.
Performance
As of December 2016, some young English people with eating disorders were being sent hundreds of miles away to Scotland because the services they required were not available locally. Not withstanding good care in Scotland it was said that being away from friends and family compromised their recovery. In response the government had adopted a policy of ending such arrangements by 2021, and had allocated a cumulative £150M to improve local availability of care. There are concerns that not enough is being done to support people at risk of taking their own lives. 1,039 children and adolescents in England were admitted to beds away from home in 2017-2018, many had to travel over 100 miles (160 kilometres) from home. Many had complex mental health issues frequently involving a risk of self-harm or suicide, like severe depression, eating disorders, psychosis and personality disorders.
In 2017-2018 at least 539 children assessed as needing Tier 3 child and adolescent mental health services care waited more than a year to start treatment, according to a Health Service Journal survey which elicited reports from 33 out of the 50 mental health trusts.
School social work is a specialised area within the broad profession of social work.
The School Social Work Association of America defines school social workers as:
“trained mental health professionals who can assist with mental health concerns, behavioral concerns, positive behavioral support, academic, and classroom support, consultation with teachers, parents, and administrators as well as provide individual and group counseling/therapy.”
School social workers utilise evidence-based assessments and interventions to support children and adolescents who come from diverse backgrounds, have learning and behavioural difficulties, mental disorders, and other health or social issues to improve their overall well-being, remove barriers, and promote academic success. They also work with crisis intervention, group treatment, child neglect and abuse identification and reporting, integrating services to culturally and economically diverse populations, and working on education policy issues.
Brief History
United Kingdom
Whilst running a poor school in inner London in 1898, Margaret Frere realised that – despite volunteers handing out dinners, clothing, and shoes – poor children remained under fed and badly clothed. She realised that unless the homes were visited and assisted then there was no permanent improvement.
In 1914 London County Council decided to create a school care service that would be modelled on her “Charitable Funds Committees”. Frere had come to believe that a care service should “unite the home with the school education”. The new school care service relied on volunteers but they were initially organised by two women employed by London City Council and Helen Nussey was one of them. Theodora Morton was their boss and head of the new service.
In 1939 there was 158 employed staff and 5,000 volunteers servicing every elementary school in London.
United States
School social work in America began during the school year 1907-1908 and was established simultaneously in New York City, Boston, Chicago and New Haven, Connecticut. At its inception, school social workers were known, among other things, as advocates for new immigrants and welfare workers of equity and fairness for people of lower socioeconomic class’ as well as home visitors. These unheralded and extensive process’ led to the expansion of school social work services with the encouragement of the community.
By 1900 over two-thirds of the states had compulsory attendance laws and by 1918, each state had passed compulsory school attendance laws based on the philosophy of inclusion, making school attendance obligatory by rights, and as a privilege of equal opportunity for those with individual differences (including differences in rate of learning). These pupil personnel workers or attendance workers were replaced by visiting teachers by the 1920s, they were later called as school-based caseworkers. They made different emphases and methods in their work – e.g. Special schools, Psycho-social assessment and referrals and family based intervention.
A 1917 study of truancy in Chicago supported “findings that the need for school attendance officers who understood the social ills of the community” and school social workers were best equipped for that responsibility (Allen-Meares, 1996, p. 25). Mary Richmond, one of the founding figures of social work, devoted an entire chapter to the visiting teacher in her 1922 book on What is Social Casework? The testing movement influenced school social work growth as well. Through the testing movement, educators were gaining knowledge about individual differences, underscoring the need for some children to attend school, children whose social conditions related to their test scores. Lastly during this time, leaders in the field like Sophonisba Breckinridge, expressed concerns of how school and education would relate to future success and happiness, and expressed the need to connect school and home in order to relate to the needs of children.
Later in the 1920s, with the mental hygiene movement school social work was concerned with treating nervous disorders and behavioural problems in difficult children and prevention of social maladjustment, this was the beginning of therapeutic role for school social workers. During the great depression in the 1930s, like school counselling, school social work also declined. Fair Labour Standards Act in 1938 a progressive movement saw social work efforts to be initiated in the schools, and community settlement programs also have its share that led to its growth.
From the 1940-1960 case work and group work in schools had become an established specialty. In 1960, pupil-personnel laws called for a greater emphasis by school social workers on the development of school policies and reforms. School social workers were affected by the governmental reforms and education research. Like school counsellors, social workers were now called upon to address student needs while also addressing the sources of student troubles within the school. The school social worker was considered as an expert by then, who could help schools on varying psychosocial issues.
During the 1970s, school social work gave more emphasis on family, community, collaborative approach with teachers and others school personnel. In 1975, the United States passed the Education of All Handicapped Children Act (EAHC, P.L. 94-142). It gave special importance to the role of School social work services. The legislation was later renamed as the Individuals with Disabilities Education Act in 1990. In the latter part of the 1970s, inflation was rising at an alarming rate and budget cuts threatened the profession of school social work, especially as many social workers were being replaced by other school personnel claiming similar roles. The National Association of Social Work (NASW) published a newsletter to bring attention to the issue and get responses from practitioners. Through this, NASW conducted research and replicated the findings of others’ studies on the roles of school social workers and models of practice, and school social work continued to expand.
In the 1980s, school social workers were included as “qualified personnel” in many pieces of legislation, especially in the Elementary and Secondary School Improvement Amendments of 1988. These led to NASW giving more attention to the profession and more service to meet the needs of the category. NASW’s active participation in the profession eventually led to a school social worker credential with exams in 1992. Since then, there has been a trend of integrative collaborative services. In 1994, school social workers were included in American Education Act. In July 1994 64 school social workers from across the USA met in Edwardsville, Illinois and formed the School Social Work Association of America. They drafted the first constitution and by-laws for the organisation. In June 2009, a second national organisation incorporated, the American Council for School Social Work, after reviewing the direction of the profession and concluding that a stronger, enhanced national voice would benefit the profession.
Germany
School social work in Germany began in the 1970s. The German term for school social work “Schulsozialarbeit”. It dealt with helping students with social skills, interpersonal relations, and personal growth. Initially it was an institutionalized form of both school and youth welfare for providing underprivileged children support regarding healthy socialisation and adjustment in school for rising above the demands of school settings. German school social workers find solution to problems in school environment and personal ones of students. The German Youth Institute provided the first social work training with school social work concentration. Apart from this the changing social and economic paradigms of the 21st century that affects lives of families as wells as of children rises the importance of school social work in German pedagogy.
India
School social work in India was officially recognised by Government of India in the 21st century. From the 1970s, school social workers were prominent in elite schools, adopting the American model of school counselling, based on the client or person centred approach of Carl Rogers and others. The main objective was whole welfare of the child. Central Board of Secondary Education refers to school social workers as Health Wellness Teachers, while the Integrated Child Protection Scheme (ICPS) strictly enforces requirement of a School Social Worker and School Counsellor. The psycho-social service scheme instituted under ICPS in Kerala with the guidance of a child development centre (CDC) have contracted social workers for 800 schools to provide the professional services. The services are limited to only teenage girls, and excludes boys from equal rights to access of the programme.
School Social Work Values
Florence Poole in 1949 described a school social worker as a skilled worker required to determine which needs within the school can be met through school social work service. A school social worker must develop a method of offering the service that will fit with the general organisation and structure of the school, and which could be identified as using social work knowledge and skill. They must define the service and their contribution so that the school personnel can accept it as a service that contributes to the major purpose of the school.
The values that school social work upholds are:
Each pupil is valued as an individual regardless of any unique characteristic.
Each pupil should be allowed to be participate in the learning process.
Individual differences should be recognised; intervention should be aimed at guiding pupils’ goals with educational support to train them to the life to which they look forward.
Each child, regardless of race and socioeconomic characteristics, has a right to equal treatment in the school.
The National Association of Social Workers in the US provides a code of ethics for school social work professionals.
Theoretical Framework and Services
School social work is structured around a range of practice models.
Traditional-Clinical Model
John Alderson was the first to describe the existed traditional-clinical models. Generally the schools followed social change model whose major focus was the dysfunctional conditions of the school; the community school model which urged school social workers to employ community organisation methods; and the social interaction model which de-emphasized a specific methodology and required the worker to intervene with the systems interacting with the target system. These were known as the Traditional models. Students who have disabilities are defined as exceptional children by federal and state legislation, including the Individuals with Disability Education Act (P.L. 94-142), the Rehabilitation Act (Section 504) in the United States of America.
In the clinical model, school social workers work primarily through casework methods supplemented by group methods with students and family members; A greater emphasis is placed on evidence-based practice and promising intervention methods that is supported empirically.
Home-School-Community Relations Model
Later school social workers used an approach that draws on components of the existing multidisciplinary models – Social interaction model, focusing on working with students with social and emotional difficulties and their problems in families(parents) and schools with a flexible and dynamic reciprocal interaction. This model is grounded on systems theory and transactional systems perspective. This model was an answer to organize the methodological diversity inherent in the role, rather than limiting to individual change or systems change.
School-Community-Pupil Relations Model
Leading social worker Lela B. Costin, in 1973 developed this model which focuses on the school, community, and student and the interactions among the three. In this model, school social workers serve as mediators, negotiators, consultants, and advocates for students and school personnel, listening to student grievances. They also set up informal groups for students, teachers, and other school personnel. This model also focuses on evaluation by a school social worker of the characteristics of students, the school, and community conditions and their relational effect on the availability and quality of educational opportunities to specific target groups (students with chemical dependency, disabilities, and so on). They are grounded in social learning theory and systems theory.
Clinical and Environmental Interaction Model
This model is grounded on the ecological systems theory. This was developed by Frey and Dupper (2005) and Germain (2006). The model promotes view of person and environment as a unitary interacting system in which each constantly affects and shapes the other. This model attends the complexities of the person as well as the environment by engaging progressive forces in people and situational assets, and impinging the removal of environmental obstacles for growth and adaptive functioning. This model leads to an effecting dynamic change.
The role of school social workers continues to expand as the knowledge-base and the level of student need grows or the recognition of opportunities to address student need. Two examples of this role expansion include functional behaviour assessment, an efficient, empirically – supported, and amenable approach to undesirable school behaviour that can be accomplished in a classroom collaboration model with teachers (Waller, 2008) and a leadership role in helping schools become foundational in promoting the mental health of children and adolescents in a manner similar to the role that schools already play in promoting physical health. Indeed, the roles played by School Social Workers has grown so substantially as a direct result of student needs, consultation, education, and collaboration with other school personnel (e.g. Waller, 2008) is a practice which is only destined to grow as a means of insufficient resources being used to their greatest advantage.
Functions
A survey published in 1989 by school social work experts categorised five job function dimensions.
Relationships with and services to children and families.
Relationships with and services to teachers and school staff.
Administrative and professional tasks.
Services to other school personnel.
Community services.
Further research on these roles revealed other important areas that are frequently addressed – Consultation and teamwork; needs assessment and programme evaluation; Social work interventions with systems; developmental programs management. A role where school social work falls short is in the range of administering diagnostic psychological tests. School Social Work Association of America identifies general roles like psycho-social assessment, developmental psycho-education, student and family counselling, early intervention for risk behaviours, therapeutic behavioural intervention for academic success, personality development, recreational therapies, yearly assessment, and case management for identifying students in need of help and to promote systematic change within a school system (not to stratify students into groups or of their opportunities), consultation for special issues, crisis intervention and conflict resolution. Social workers deal with stressful situations. Some situations might be more complex than others since every family brings different problems.
Education and Training in the US
American States regulate school social work practice in different ways. Approximately 33 jurisdictions license or certify school social workers. Most require a master’s degree in social work (MSW), but a smaller number of states also license Bachelors of Social Work (holders of the BSW degree). The National Association of Social Workers with 150,000 members also offers a Certified School Social Work Specialist (C-SSWS) Certificate in school social work revised from the 1992 School Social Work Credential Exam. It does not replace any license or certification that individual states require of school social workers.
The Council on Social Work Education (CSWE) is the American accrediting body for social work education at the BSW and MSW levels. It specifies foundational social work program components, but social work specialties areas are defined by the individual accredited MSW programmes. “Social work education is grounded in the liberal arts and contains a coherent, integrated professional foundation in social work practice from which an advanced practice curriculum is built at the graduate level.
Associations and Professional Journals
School social workers work to promote student learning and well-being, address academic and non-academic barriers to learning, develop comprehensive and cohesive academic and social supports, and understand and apply diverse frameworks for evidence-based practice and program development for the educational process to work the fullest extent.
Major associations in North America include the School Social Work Association of America, the American Council for School Social Work, and the Canadian Association of School Social Workers and Attendance Counsellors.
School social work journals have been published across the globe including the School Social Work Journal sponsored by the Illinois Association of School Social Workers, the Journal of School Social Work (JSSW) from Chennai, India and the Canadian Journal of School Psychology from SAGE Publications, Canada.
CBT Toolbox for Children and Adolescents: Over 220 Worksheets & Exercises for Trauma, ADHD, Autism, Anxiety, Depression & Conduct Disorders.
Author(s): Lisa Phifer.
Year: 2017.
Edition: First (1st).
Publisher: PESI Publishing & Media.
Type(s): Spiral-bound, Paperback and Kindle.
Synopsis:
The CBT Toolbox for Children and Adolescents gives you the resources to help the children in your life handle their daily obstacles with ease. Inside this workbook you’ll find hundreds of worksheets, exercises, and activities to help treat:
Trauma.
ADHD.
Autism.
Anxiety.
Depression.
Conduct Disorders.
Written by clinicians and teachers with decades of experience working with kids, these practical and easy-to-use therapy tools are vital to teaching children how to cope with and overcome their deepest struggles. Step-by-step, you’ll see how the best strategies from cognitive behavioural therapy are adapted for children.
Mental Health Matters 
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