EMMA routinely tells her doctor that she feels like committing suicide. She
is being treated for depression, receives counselling and spends several days a
month in hospital. She is seven years old.
Emma鈥檚 case is far from unique. 鈥淭he incidence of depressive illness is
really, really significant,鈥� says Audrey Wise, Labour MP for Preston and a
member of the House of Commons Health Select Committee, which this month will
publish results of a year-long investigation into the health of British
children. The committee is so concerned about mental illness in children that it
has decided to publish a special supplement on the issue. 鈥淎ll the professionals
we talked to expressed fears about the mental health of children,鈥� says
Wise.
The problem appears to be increasing. The Royal College of Nursing reports in
a survey of a few British psychiatric centres that the number of adolescents
attending rose by 50 per cent between 1990 and 1995. Suicide and attempted
suicide rates in young people have also been rising, according to the Department
of Health (DoH). Late last year Richard Williams of the NHS Health Advisory
Service, a health watchdog with a special interest in mental health, told the
committee that 40 per cent of children could expect to suffer some sort of
mental difficulty at some point during childhood. He added that 鈥渨ithin that
category, there are young people who suffer a [diagnosable] mental disorder鈥�,
and that in urban areas they could number as many as 10 per cent of children and
20 per cent of adolescents.
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It is these two groups which most worry experts. 鈥淚鈥檝e got seven-year-olds
trying to kill themselves,鈥� says Mark Berelowitz, a consultant child and
adolescent psychiatrist at the Royal Free Hospital, London. His priority, he
says, 鈥渋s trying to get them to live until next week鈥�. The British Psychological
Society (BPS) also estimates that 10 per cent of children suffer mental
illnesses serious enough to warrant treatment. It warns that in some deprived
inner city areas the figure could be as high as 25 per cent in older children
and adolescents.
The BPS told the Select Committee that many children who have emotional and
behavioural problems will carry them into adulthood, 鈥渨ith resulting impact on
adult mental health and services鈥�. As Stephen Scott, senior lecturer in child
and adolescent psychiatry at the Institute of Psychiatry in London says,
severely disruptive behaviour in childhood has a very high continuity rate. 鈥淎
disruptive little boy is likely to be a disruptive adult.鈥� Berelowitz agrees.
鈥淒epressed kids are likely to be depressed adults,鈥� he says.
As well as looking at the links between childhood mental health and later
adult mental problems, Berelowitz also points to the social implications. For
example, he says: 鈥淚f we don鈥檛 treat attention disorder children, they will have
poor educational experiences.鈥� Delinquency, unemployment and depression could
follow, he stresses.
Child psychologists fear that most childhood mental illnesses go untreated.
Scott estimates that only 20 to 30 per cent of depressed children who need
treatment actually receive it. The BPS backs this figure. Roger Hirschfeld, head
of psychiatry and behavioural sciences at the University of Texas and chairman
of a panel of American experts that is looking into the undertreatment of
depression, says: 鈥淲e have every reason to believe that depression is as common
in children as it is in adults and that the number of children being treated is
hopelessly insufficient. Part of the problem is the reluctance on the part of
drug companies to test new treatments on children for legal reasons.鈥�
Another problem is that mental illnesses in children often go unnoticed, or
are even ignored. 鈥淒isruptive kids are picked up quite quickly and the depressed
and anxious ones are not,鈥� says Berelowitz. He claims that at his own hospital,
which lies within a few kilometres of another five big teaching hospitals and
some of the best family doctors in the country, 鈥渁 girl can get down to 60 per
cent of what she should be weighing鈥� before anyone acknowledges that she has
anorexia.
Age stigma
One of the difficulties is that mental problems which are traditionally
termed 鈥渟evere鈥�, such as manic depression or schizophrenia, are virtually
unheard of in children and only rarely seen in adolescents. Schizophrenia, for
instance, is believed to arise out of a mixture of genetic, biological and
environmental factors and usually takes 18 to 20 years to appear 鈥攈ence
its rarity in younger people. And some experts claim there is a stigma attached
to childhood mental illnesses because children are simply too young for experts
to be able to cite long-term environmental causes for their illness, and tend to
be considered as genetically abnormal or potential victims of abuse. As a
consequence, childhood mental illness is often wrongly dismissed as temporary or
not serious.
There is now a suspicion among child psychiatrists that this attitude may
have resulted in suicides which could have been prevented if the depression had
been tackled early enough. 鈥淚 routinely ask mildly depressed seven-year-olds
about suicidal feelings,鈥� says Berelowitz. 鈥淲e didn鈥檛 ask that eight years ago
and now we regret it.鈥� In other words, lives could have been saved if problems
had been recognised.
There are three main categories of mental illness in children, according to
Dora Black, a psychiatrist who founded the Traumatic Stress Clinic in London:
emotional disorders, including anxiety, depression and phobias; conduct
disorders, such as aggression, which could lead to delinquency; and attention
deficit disorders.
Serious adult mental illnesses that have their roots in childhood tend to
fall into one of two categories: neurotic illnesses and personality disorders.
Neurotic illnesses include depression, hysteria and obsessive or compulsive
disorders such as anorexia. Personality disorders, such as Borderline
Personality Disorder which affected Marilyn Monroe, are often linked to sexual
abuse as a child. Sufferers have great difficulty in forming relationships and
are often tempted to harm themselves.
Children who experience intense traumas are particularly vulnerable to mental
problems. This year Black publishes some of the results of a study of 360
children who have had one parent killed by another. These parents, over 90 per
cent of whom are male, all went to jail, but the majority served less than three
years and some are now back with their children.
Children in these situations tend to be quiet and obedient at first, she
says, leading people to think that they are coping emotionally. 鈥淎nd I think the
reason is that they鈥檙e very frightened and what they鈥檙e frightened of is if they
do anything wrong they might be attacked and killed like their mother.鈥� However,
during adolescence they are likely to rebel and deliberately provoke their
father to test his propensity for violence, she says.
Cases for treatment
But such children can be helped if any problems they develop are noticed
early on. Indeed, there are effective treatments available for most serious
childhood mental illnesses, which makes it all the more tragic if they go
unnoticed. Later this year, Berelowitz will publish research commissioned by the
DoH which shows that psychotherapy can reduce some of the mental problems that
sexually abused children might face later in life. 鈥淭his is an example where
intervention works,鈥� he says.
But he adds that studies into the effects of swift treatment for mentally ill
children pose moral dilemmas for researchers. 鈥淭rials need to be done, but
they鈥檙e fantastically hard to do. Ethically they鈥檙e a problem, particularly in
child abuse cases, because are we right to get them to recall their experiences
if they鈥檙e now healthy? Sometimes putting it behind them is part of the
谤别肠辞惫别谤测.鈥�
But experts agree that this should not hinder the search for better
treatments and better ways of identifying those young patients who could benefit
from them. 鈥淲e do our children a grave disservice if they are told they鈥檒l grow
out of it,鈥� says Berelowitz. He claims that compared with adults, children鈥檚
mental problems are not taken seriously enough.
For instance, a literature search on the British Medical Journal鈥檚
database for articles about the ill effects of steroids on mental health
identifies around 1500 studies on the effects these drugs have on adults. But
there are no articles about their effects on children, despite the fact that
these drugs are increasingly being used in common childhood diseases such as
asthma.
In his evidence to the Health Select Committee, Kenneth Calman, the
government鈥檚 Chief Medical Officer, stated that all of the government鈥檚 27
Health of the Nation public health targets were 鈥済oing the right
way鈥攅xcept three鈥�. These three, he said, concerned obesity, cigarette
smoking and suicides and were all relevant to children. Failure to take
childhood mental illness seriously could turn thousands of disturbed children
into disturbed adults.
