Psychological Disorders in Children

I have witnessed my daughter going into ‘fits of rage’ at the young age of five-years-old. She was banging down my bedroom door, kicking, screaming, and yelling obscenities, while I was crying on the other side. I had the door locked and watched as she kicked and pounded on the door; it moved with every hit. I was frightened; I was thinking “What happened to my little girl?” I remember this night whenever I hear about children experiencing ‘fits of rage’. What happens when she becomes older?

Psychological Disorders

According to Nevid and Rathus, Psychology and the Challenges of Life, (2005, p.257), “Psychological disorders are more common that people tend to think; many go undetected and untreated.” Co-morbid diagnosis exist widely in children and adolescents; typically starting with a diagnosis of attention deficit hyperactivity disorder and resulting in co-morbid mental illnesses with a need for pharmaceutical medication. I will explain a few of the mental illnesses common in childhood to young adult; how these illnesses can evolve from one disorder to another; and my story of mental illness in my family.

Attention Deficit Hyperactivity Disorder

“The most common childhood psychological disorder, attention-deficit hyperactivity disorder, or more commonly referred to as ADHD,” (Psychcentral.com, 2010, para.7) is typically noticed by another adult, such as a teacher. My daughter was around five-years-old when I was first told to have her checked for attention deficit hyperactivity disorder. According to R. Woliver (2009, p.42), “ADHD results from deficiencies in the brain’s dopamine neurotransmitter systems, which help the brains cells communicate.” When a connection is missing, symptoms occur that can be noticed by others. The most common symptoms of ADHD noticed in children are disorganization, hyperactivity or hypoactivity (decreased activity of the body), forgetfulness, memory problems, negative conduct behaviors, and lack of concentration.

“Impairments due to the symptoms of ADHD must also have been observed in at least two different, such as school, at work, in the community, at social events, or at home” (Psychcentral.com, 2010, para.2). My daughter was displaying trouble with peers both at home and at school, unable to concentrate in class and at home, and she forgot her schoolwork at home and homework at school. So she met the criteria and was diagnosed with attention deficit disorder. I was told medication would help and so the family pediatrician prescribed Concerta (a new medication for ADHD treatment).

What I was not told was “treatment for ADHD has two important components: medication and psychotherapy interventions (for both the child and parents)” (Psychcentral.com, 2010, para.1). When my daughter’s behaviors worsened, I searched for therapy assistance. “Some people turn to psychotherapy instead of medication, as it is an approach that does not rely on taking stimulant medications” (Psychcentral.com, 2010, para.4). More options are available today than 10 years ago. I brought my daughter to a ‘regular family therapist’ not knowing there was a difference in therapy techniques.

Interpersonal Therapy

According to the National Institute for Mental Health,

Interpersonal therapy (IPT) is most often used on a one-on-one basis to treat depression or dysthymia (a more persistent but less severe form of depression); IPT helps identify how a person interacts with other people. When a behavior is causing problems, IPT guides the person to change the behavior (NIMH website, 2010, para.16).

The medication did not seem to help and the therapy sessions were nothing but a ‘talk session’ to discover why she was acting out the way she was. She was young; children do not know or understand why children act a certain way and they do not want to change it if it is working for them. Nothing seemed to help, it only got worse and before I knew it, my now nine-year-old daughter was diagnosed with depression.

Figure 1: Many children with Co-morbid disorders hide the core issues with depression like symptoms or rageful behavior.

Depression

Children and teens can also have depression, which can also look like ADHD. “Older children may sulk, get into trouble at school, be negative and irritable, and feel misunderstood” (psychcentral.com, 2010, para.3). As stated by R. Woliver (2009, p. 143), “When the level of neurotransmitters, brain chemicals that carry signals through the nervous system, diminishes, it affects the ability of a person to feel good. This in effect, causes depression.” Children with depression will have angry outbursts, headaches, inability to express pleasure or excitement, memory loss, refusing to go to school, mood change, and difficulty thinking clearly. Some of the symptoms sound like attention deficit disorder, while others sound like something else completely. These signs can be confused as ADHD or typical normal mood swings, thus it is difficult to diagnosis accurately.

According to the National Institute of Mental Health (2010), there are different forms of depression: major depressive disorder, dysthymic disorder, psychotic depression, postpartum depression, and seasonal affective disorder (SAD). My daughter was diagnosed with dysthymic disorder. “Dysthymic disorder, also called dysthymia, is characterized by long-term (two years or longer) but less severe symptoms that may not disable a person but can prevent one from functioning normally or feeling well” (nimh.nih.gov, 2010, para.3). I continued to bring my daughter to therapy thinking this will get better now that we know what is ‘really’ going on. I started to research attention-deficit hyperactivity disorder and depression. “Children who have depression must be treated” (Alphabet Kids, 2009, p.141, para.4). My daughter couldn’t have depression, she was too happy. Although I noticed her happy times were fewer and fewer. I spoke to a psychiatrist about depression and medication.

Psychiatric Pharmaceutical Medications

The psychiatrist suggested trying antidepressants. “Antidepressants work to normalize naturally occurring brain chemicals called neurotransmitters, notably serotonin and norepinephrine (nimh.nih.gov, 2010, para.5). According to the National Institute for Mental Health (2010), “Research has yielded increasing evidence that treating the depression can also help improve the outcome of treating the co-occurring illnesses.” My daughter was given serotonin reuptake inhibitors (SSRI’s) such as Celexa and Zoloft. When those didn’t seem to help, the psychiatrist prescribed serotonin and norepinephrine reuptake inhibitors (SNRI’s) such as Effexor, and Cymbalta. According to the National Institute of Mental Health (2010), “SSRI’s and SNRI’s are more popular that the older class of antidepressants, such as tricyclics and monoamine oxidase inhibitors (MAOI’s) because they tend to have fewer side effects.” With every new medication came side effects that she could not tolerate.

Figure 2: Medication is an important treatment component for children and adults with mental health illnesses. Although it is scary to think of our children taking psychotropic medications that alter the mind, it is imperative for the proper care of co-morbid mental disorders.

According to the NIMH website (2010), “Despite the relative safety and popularity of SSRI’s and other antidepressants, some studies have suggested that they may have unintentional effects on some people, especially adolescents and young adults.” I was unsure of treating my daughter with these types of medications. “The most common side effects associated with SSRI’s and SNRI’s include: headache, nausea, insomnia, nervousness, and agitation” (nimh.nih.gov, 2010, para.12). When the side effects were too much for her to cope with, especially when she became angry, rageful, frustrated, and refusing to comply with the rules at home and at school, we decided to take her off the antidepressant medication. Life was beginning to seem like a big mystery to me while I was learning about depression in children. My daughter was entering her pre-teen years when she was diagnosed with oppositional defiant disorder, or more commonly referred to as ODD.

Oppositional Defiant Disorder

“Depression often co-exists with other illnesses. Such illnesses may precede the depression, cause it, and/or be a consequence of it” (nimh.nih.gov, para.1). According to R. Woliver (2009, p.318), “While the specific cause of oppositional defiant disorder is not know, it is believed that there are several possible causes for it that include psychological, genetic, biological, and environmental factors.” My daughter was already diagnosed with attention deficit hyperactivity disorder and depression; now she also has oppositional defiant disorder. I thought all adolescents go through a ‘rebellion stage’ when they act out, push boundaries, break the rules, argue with parents, and talk back.

According to the American Academy of Child & Adolescent Psychiatry website (2009), “One in sixteen percent of all school-age children and adolescents have oppositional defiant disorder (ODD).” Symptoms may include arguing, talking back, disobeying the rules and defying parents, teachers, and other adults. This may look like normal developmental behavior in younger children; however it is more serious when it affects the social, family, and academic life of the child.

“Children’s severe anger outburst, sometimes called ‘rages’, have been associated with many disorders, including mania, severe mood dysregulation, and oppositional defiant disorder” (Carlson, Potegal, Margulies, Gutkovich, & Basile, 2009, p.1). Oppositional defiant disorder is a behavior disorder in children thus, “research indicates that there is still no medication that is prescribed exclusively for the treatment of ODD and all of its symptoms” (Oppositionaldefiantdisorder.org, n.d.). I was told the best treatment for ODD was psychotherapy. It was recommended to me that we try cognitive behavioral therapy, dialectical behavior therapy, and family-focused therapy.

Cognitive Behavioral Therapy

According to the National Institute of Mental Health (2010), “Cognitive behavioral therapy (CBT) is a blend of two therapies: cognitive therapy (CT) and behavioral therapy. CBT helps a person focus on his or her current problems and how to solve them; with depression, they restructure negative thought patterns.” After searching for about a year, we found a therapist who my daughter felt comfortable with. When they started building a relationship, my daughter found out that the therapist was transferring to a new location; the location was too far for us to drive. We had to start the process all over again until we found one close to home that also offered dialectical behavior therapy in a group setting. The therapist had formed a deep connection to my daughter and a solid foundation for a relationship. The therapist mentioned to me that my daughter may have borderline personality disorder.

Personality Disorders

Figure 3

Borderline and Histrionic Personality Disorders

“Borderline personality disorder is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior” (nimh.nih.gov, 2010). A person with BPD will show symptoms such as rapid changes in mood, impulsivity, intense unstable interpersonal relationships, lack of own identity, and instability in self-image. A person with HPD will have similar symptoms including exaggerated and often inappropriate displays of emotional reactions, theatrically behavior nearly every day, and sudden or rapid emotion expressions.

Runaway

According to the National Runaway Switchboard (n.d.), an organization that takes calls and helps kids who have run away, “one in seven kids between the ages of 10 and 18 will run away from home at some point.” Children run away from home for a variety of reasons: problems at school, the use of alcohol or drugs, family financial worries, or they believe they have done something they are ashamed of and afraid to tell the parents. Around this time, my daughter had run away from home a few times. The last time she ran away from home, I was told to contact the police and have her placed into a shelter for runaway girls.

“The shelter staff works toward helping the client gain some perspective of their situation. This thrust is an effort to enable the youth to feel a sense of self-control with a resulting sense of security and hope” (HarborShelter.net, n.d.). My daughter was in Harbor Shelter for about two weeks until she was ready to come home. “When a child is having issues in two or more areas, a Case Manager will work with the family to coordinate services for the child” (Guidance-Center.org, 2006). During her stay, I contacted social services and inquired about family-focused therapy and a child mental health case worker to help us.

Dialectical Behavior Therapy

As stated on the National Institute of Mental Health website (2010),

DBT emphasizes the value of a strong and equal relationship between patient and therapist. The therapist consistently reminds the patient when his or her behavior is unhealthy or disruptive – when boundaries are overstepped – and then teaches the skills needed to better deal with future similar situations. Individual sessions are used to teach new skills, while group sessions provide the opportunity to practice these skills.

As soon as my daughter came back home, I had many services in place; group DBT with her previous individual therapist, in home family-focused therapy with also included a DBT structure while also working as her individual at-home therapist. The group therapist also used an individual component teaching my daughter new skills and effective communication.

Family-focused Therapy

“Family-focused therapy (FFT) was developed for treating bipolar disorder.” The therapist work to identify difficulties and conflicts among family members while helping to find more effective ways to resolve those conflicts and difficulties. According to the National Institute of Mental Health (2010) states, “The therapist educates family members about a loved one’s disorder, its symptoms and course, and how to help manage it more effectively while creating an action plan that involves all members.” During this time, the in-home family therapist suggested my daughter may have a personality disorder or bipolar. She educated the family on both disorders, focusing on bipolar as possibly being inherited from my daughter’s father.

Bipolar Disorder

According to R. Woliver (2009, p.133-134),

There is no one cause known for bipolar, but there are factors that can bring on the disorder. Brain chemistry and genetics are the two most cited reasons. It has been reported that people with bipolar have more of a certain type of neutransmitter called monoamines. Theses monoamines release the brain chemicals dopamine, serotonin, and norepinephrine, all of which are involved in mood regulation, stress responses, pleasure, reward, and cognitive functions like concentration, attention, and executive functions.

Bipolar Disorder (BD) is not easy to spot when it starts. Many of the symptoms look like a combination of other disorders, thus making it difficult to diagnose and treat. “People with bipolar disorder experience unusually intense emotional states that occur in distinct periods called ‘mood episodes’” (nimh.nih.gov, 2010). A person with BD may have defiant behavior, agitation, delusions, and change in energy, grandiosity, hyperactivity, feelings of guilt or worthlessness, poor communication, poor judgment, rapid speech, social isolation, poor academic progress, inability to concentrate, and impulsivity. These behaviors will go from one extreme to the other, feeling high and happy to feeling depressed and sad.

Hospitalization

I had to hospitalize my daughter, now in her teen years, for ‘rages’ so terrible that I thought I was going insane. According to the psychiatric news article, Adolescent Hospitalizations Often Result of Mental Disorder, data collected from 1996 to 1998 states “mental disorders were a noteworthy cause of hospitalization for the 15- to 17-year-olds, consisting of 13 percent of all diagnoses, third only to pregnancy and childbirth-related diagnoses (38.2 percent) and to injury and poisoning (14.5 percent).” She would have bouts of crying spells, followed by yelling, screaming, coming at me to get physical, to hiding in her room, sullen, falling asleep for minutes only to wake and start all over again. The hospital prescribed medications to help stabilize and regulate her emotions while reliving stress and starting new therapy sessions. She would not be discharged to come home – she was to be discharged to a temporary foster care home until the entire family was ready for her to come home and give her support.

Foster Care

According to the Minnesota Department of Human Services (2010), “Of approximately 12,000 children in out-of-home placements in 2009, foster families provided temporary care to 8,400 of them. Approximately 75 percent of children in out-of-home care were reunited with their birth parents or found permanency with relatives.” While in temporary foster care, my daughter started a therapeutic day school program, which set short-term goals and long-terms goals to help achieve success of treatment.

As stated by Lifespan website, short-term goals include: “stabilize behavior and emotional crisis, respect, develop therapeutic relationship the staff, adjust to program structure, recognize reasons for placement and to begin to identify and express feelings appropriately.” The long-term goals include: “explore and effectively deal with individual and family concerns, develop support system, improve functioning of family and relationships, increase positive coping skills.” While each step is taken, rewards are given. As children and adolescents grow and achieve success within the school, they are eventually ready to begin transitioning to mainstream school.

Returning home

During a psychotherapy session at school, my daughter finally spoke of the trauma that was committed on her when she was younger. “Children often protect themselves by blocking/repressing or dissociating these kinds of memories” for many years (allaboutcounseling.com). Many times children repress memories until something triggers the memory and they can recall it and discuss it with a trusted adult. When I found out of the trauma, I wanted to bring my daughter home where she belongs so we can now work on what caused the mental illness together.

My daughter still continues to attend her therapeutic school while I take the necessary legal steps. We are continuing to fight the battle of mental illness with the help of many others. The battle is not easy, neither is the decision to medicate a young child. However, when the mental illness worsens, it is necessary to medicate to help the child learn how to cope effectively with life and all of its challenges.

References

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American Academy of Child & Adolescent Psychiatry (2009). Children with Oppositional Defiant Disorder. Retrieved from http://www.aacap.org

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Guidance Center (2006). Children & Adolescent Mental Health Services. Retrieved from http://www.guidance-center.org

Harbor Shelter & Counseling Center (n.d.). A Safe Place to heal and grow. Retrieved from http://www.harborshelter.net

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Minnesota Department of Human Services (2010). Children/Foster Care and Other Out-of-home Placement. Retrieved from http://www.dhs.state.mn.us

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National Runaway Switchboard (2010). Why They Run. Retrieved from http://www.nrscrisisline.org

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Calrson, G., Potegal, M., Margulies, D., Gutkovich, Z., & Basile, J. (2009). Rages – What Are They and Who Has Them?. Journal of Child and Adolescent Psychopharmacology, 19(3), 281-288. Doi:10.1089/cap.2008.0108

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