By Courtney Cutright

Diane Kelly said the phone calls come somewhat frequently. The flustered parent of a child, whose pediatrician has just made a psychiatric referral, calls Mental Health America of the Roanoke Valley for guidance.

“The first thing I tell them is, ‘Don’t freak out. If your child had a broken leg, they would be referred to an orthopedic surgeon,’” said Kelly, executive director of MHARV.

A psychiatrist is a spet, Kelly explains further, another health professional with specific training to assess the child’s mental health.

The National Alliance on Mental Illness reports that mental illness affects about one in 10 children in the U.S. and half of all lifetime cases of mental illness are diagnosed by the time a child reaches 14 years of age. The earlier mental illnesses are identified and treated effectively, the better the outcomes for children.

Parents and other primary caregivers are the front lines when it comes to recognizing indicators of mental illness. Red flags may include: a sudden drop in school performance, aggressive behavior, threats to self or others, mood swings, withdrawing socially, extreme sadness or anxiety, changes in sleeping or eating patterns, and alcohol or drug abuse.

Dr. Lyn Day, a Roanoke County psychologist, said parents should be concerned if a generally cooperative child suddenly becomes aggressive.

Parents “should really be concerned about those types of behaviors,” Day said.

She said the majority of the children who visit her private practice have been diagnosed with either an Autism Spectrum Disorder, anxiety, or depression. Autism spectrum disorders, which may not commonly be considered mental health issues, fit into the category because the disorders are neurological in nature.

Other common mental health disorders affecting children include: attention deficit hyperactivity, bipolar, oppositional defiant, and obsessive compulsive. Childhood onset schizophrenia is far less common.

Attention deficit hyperactivity disorder

Attention Deficit Hyperactivity Disorder, or ADHD, is a neurobiological disability that affects approximately one of every 20 children, and it is more common in boys than girls. A child with ADHD tends to have trouble staying focused to complete tasks. At home, parents may witness a child’s inattention to details, short attention spans, carelessness, disorganization, extreme fidgeting, talking excessively, and constant interrupting.

“When parents need to be concerned, I think, is when the child has significant academic troubles because of difficulty with inattentiveness and sitting still,” Day said.

There are specifics tests to determine whether a child has ADHD, but to be formally

diagnosed, the symptoms of inattention, impulsivity, hyperactivity, and low tolerance of frustration must be present for at least six months and be observed in two or more settings. It is important to communicate with your child’s teacher about any concerns you have and, if needed, to request an evaluation for special education services.

Day points out that there are many treatments for ADHD that do not involve medication. Her personal take is not to recommend medication unless the child’s self-esteem is significantly impacted by the ADHD symptoms.

Children with ADHD have a somewhat high rate of co-occurring disorders. NAMI reports that over half have at least one other major childhood disorder, including 40 percent with Oppositional Defiant Disorder, 25 percent with Conduct Disorder, 30 percent with anxiety disorders, and 67 percent with depression.

Depression and anxiety

Clinical depression in children is frequently undiagnosed or misdiagnosed because children do not exhibit the same external symptoms adults do. When it comes to depression in children the common symptom is not sadness, but rather irritability and aggressiveness. In addition, parents should be on the lookout for extreme combativeness; sullenness; complaints about imagined body pains, such as headaches or stomachaches that cannot be explained by medical evaluations; drop in school performance, inability to have fun; and lethargy.

Day, who has been in private practice for more than 30 years, said she also sees many clients whose families are struggling with a significant change, such as a divorce or the death of a loved one. She said it is important to make sure children are still seeing friends and maintaining interests and hobbies, which indicates they are absorbing the stress and do not need help dealing with it.

The most common mental illnesses among children are anxiety disorders. Normal events and expectations produce intense dread and worry for children with anxiety disorders. These disorders take three forms in children. Separation anxiety, or the childhood version of panic disorder, occurs when a child experiences intense anxiety about being separated from his or her parents. Overanxious disorder is likened to a childhood version of generalized anxiety disorder, which is characterized by excessive worry. Lastly, avoidant disorder, which resembles social phobia, is centered on acute shyness and discomfort in social situations.

A key warning sign of anxiety disorders is missing school. The parent of a child with an anxiety disorder faces a unique challenge because accommodating the behavior could result in school failure but stopping the behavior could cause the child to continually fall apart.

“The fact of the matter is, children have to go to school,” said Rev. Melissa Hays-Smith, a licensed clinical social worker and registered play therapist at Family Service of Roanoke Valley. “It’s good for them to go to school. When a parent gives in and allows them to stay home … that kind of affirms that the child should be afraid.”

Hays-Smith said it is okay for parents to sympathize with the child, but it is important to follow it with reassurance about the anxiety-causing situation.

Behavior-related disorders

As a parent, it may be difficult or even impossible to rationalize with a child who shows the symptoms of a mental illness.

“The thing about kids is the same symptoms can mean different things,” Hays-Smith said.

She cautioned that is very important not to make gross assumptions about what the symptoms signify. Leave it to trained mental health professionals to diagnose your child. A parent’s role is to heed the warning signs and seek help.

“If something is starting to get in the way of a normal everyday life, it is worth addressing,” Hays-Smith said.

Two of the behavior-related mental health disorders affecting children are Oppositional Defiant Disorder and Conduct Disorder. Oppositional Defiant Order, or ODD, is characterized by defiant behavior and refusal to cooperate with adults. A child with ODD might be belligerent, inflexible, resentful, and spiteful. Conduct Disorder, or CD, is characterized by intentional behaviors, such as aggression, cruelty toward people and animals, destruction, deceit, and lack of remorse. Children with either of these mental disorders tend to exhibit socially unacceptable behaviors, which may shock or embarrass parents and result in frequent suspensions from school.

These disorders are more prevalent in boys than girls. Children who come from unstable home environments, such as poverty, abuse, or neglect, may be more vulnerable, but children from stable homes are not excluded. Children as young as age three can show symptoms.

“No behavior is them just being mean, or just being disobedient,” Hays-Smith said. “I believe it means something. As adults, we have to figure out what it means.”

Hays-Smith said the best setting to uncover the causes — especially in children ages 10 and under — is play therapy. She is one of about a dozen registered play therapists in the Roanoke Valley, though many other counselors in the area also offer it.

“If you’ve got somebody that’s going to try to do talk therapy with a child, you’re in trouble,” Hays-Smith said.

She advocates for play therapy instead because a child is still developing and so is his or her brain. As a result, most children are not equipped to have a deep discussion about their feelings. Play therapy allows children to express themselves in a safe environment by doing what is easy and natural for them: playing. A session may involve time in an established play room, where a variety of toys and games can be found. Or a session may focus on a creative activity, such as art, music, or sand tray therapy.

Play therapy “is more than just one thing,” Hays-Smith said. “It is very serious work. It doesn’t look that way, and the kids like to come.”

Other mental illnesses affecting children

            There are three other categories of mental illnesses affecting children: obsessive-compulsive disorder, bipolar, and childhood onset schizophrenia.

Obsessive-compulsive disorder involves the recurrence of obsessions that children attempt to ward off with compulsions. The obsessions tend to be intrusive, anxiety producing thoughts and impulses, such as fear of germs, fixation on lucky numbers, need for symmetry and exactness, fear of catastrophic danger, and sexual thoughts and impulses. Compulsions are rigidly patterned irrational behaviors, such as ritual hand washing, repetitive counting, and continuous checking and questioning that are attempts to counter the obsessions.

This disorder affects more than a million children and adolescents, with boys twice as likely to be affected. The peak age of onset is 10, although symptoms can start as young as age three or four. Half of adults with OCD report their condition began before the age of 15.

            Bipolar is a mood disorder characterized by swings from manic highs to depressive lows.  A child who is silly and full of energy one moment will suddenly become angry or defiant. Parents report mood shifts that move from angel to devil at home, with upbeat moods switching to explosive rages in the blink of an eye. Children with bipolar usually control rage in front of classmates.

Scientific evidence about this disorder is still developing, but notable observations include a link to family history of the disorder and the early-onset of symptoms in children. The onset of bipolar disorder may mirror the symptoms of ADHD, ODD, CD, or depression, so a careful diagnosis is critical. Prescribing a stimulant or antidepressant may trigger manic and psychotic episodes.

Childhood-onset schizophrenia is very rare, affecting 1 in about 40,000 children under age 15. This mental illness is a chronic brain disorder characterized by delusions, hallucinations, apathy, withdrawal, and lack of motivation. This disorder is rarely seen in children younger than age 5, and the age of onset is one way it can be distinguished from Autism Spectrum Disorders.

The residual stage of childhood-onset schizophrenia is also characterized by anxiety and disruption in social situations, school failure, inability to make friends, showing no emotion, rarely speaking, inappropriate emotional expression, and little or no contact. Delusions and hallucinations occur in the active stage and  cause children with this disorder to be confused about what is real.

Stigma attached to mental illness

Day acknowledges there sometimes is a stigma attached to mental illness, especially in light of media reports of violent acts committed by individuals with mental illnesses. But she points out there is not a greater incident rate of violence among mentally ill children versus those who are not mentally ill.

Sometimes the parents of a child with a neurological-based illness that causes psychiatric symptoms have a hard time accepting the diagnosis.

“Parents get nervous about mental illness,” Day said. “It is a really tough thing for parents to deal with.”

The symptoms of mental illness are somewhat invisible, as compared to an illness with physical symptoms.

“With cancer, we either have a chance or we don’t,” Day said. “Our child’s behavior isn’t erratic. Our child’s personality isn’t drastically affected by medical illness. Mental illness almost always is accompanied by illogical, emotional, and behavioral problems.”

The bottom line

If you are worried about your son or daughter’s mental health, follow your gut instinct. Consult with your pediatrician or family doctor, and have your child evaluated by a licensed mental health professional.

“All parents have concerns about our children’s mental health [including] first time parents who don’t know what’s normal and what’s not,” said Day.

Parents have a tendency to want things to go away, but Kelly emphasizes the importance of early intervention to avoid losing ground during a child’s critical developmental years.

“Sometimes things aren’t just a phase,” Kelly said.

Research shows that early identification and effective intervention can minimize the long-term effects of mental illness, while concurrently allowing children to be successful in school, to develop socially, and to fully experience all that childhood has to offer.