One of the biggest challenges facing parents, teachers and primary health-care providers is how to tell the difference between a clinically significant mental health problem and the normal ups and down of daily life that beset all children and teens.
The irony is most people think that mental health problems in children and youth are very rare, when in fact they are quite common. As a result, such problems are often dismissed as part of normal development. Since these usually occur in the context of unfortunate life events, parents, teachers and family doctors frequently “explain away” the problem by reference to certain circumstances such as being the victim of bullying, difficulty getting along with a strict teacher, the breakup of the parents’ marriage or other stressful events.
A recent editorial in the prestigious scientific journal The Lancet reported that roughly 40 per cent of adults do not know what the signs and symptoms of a significant mental health problem are in a child or youth. In addition, many were reluctant to even raise the issue in case they were mistaken. Roughly 40 per cent of adult males believe that many children and youth diagnosed with mental health illness are just showing “bad” behaviour. Sadly, research has also shown that primary care providers and teachers often carry the same misconceptions.
It is natural for everyone (including children and teens) to occasionally show the warning signs of a mental health challenge, which include symptoms of anxiety, worry, sadness, difficulty concentrating, being non-compliant, being overactive and impulsive. Those symptoms can be a natural reaction to certain situations.
Some kids have more of these warning signs than others, while others have fewer. The key is to know where to draw the threshold so that only those that are above a certain cut-off are screened by a primary health-care provider or mental health professional to decide who needs a comprehensive assessment and who doesn’t.
Below are three useful tips that mental health-care professionals use to distinguish the ups and downs of normal development from problems that require assessment and intervention.
Symptoms and impairment of function
To identify a mental health problem, symptoms and impairment in function need to both be present.
For a clinically significant mental health problem to be present, signs of anxiety, sadness or depression must also be accompanied by some impairment which represents a change or deterioration in functioning in school performance, in getting along with family members or peers.
In addition, those impairments must be tied to the actual symptoms such as sadness or are a direct result of difficult behaviour. There are children and youth who have symptoms of mental health challenges, but no impairment. We would not say they necessarily have a clinically significant mental health problem.
There are also children who have an impairment but do not have mental health symptoms; this, too does not constitute a clinical problem. Both symptoms and impairment must be present and must be linked to each other.
Duration of symptoms
Another important element has to do with how long symptoms have been present. The rule is that if symptom and impairment last for a “long” time, then, there is cause for concern. There is no golden rule as to how long, “long” is; it really depends on the symptom.
If symptoms of depression last most of the day and for longer than two weeks, a clinical assessment would be the next step. For most symptoms, however, three months is a useful signpost to use. Any anxiety problem or oppositional behaviour that lasts more than three months is certainly worth inquiring about.
There is one exception: any expression of self-harm or suicidal thinking requires an immediate assessment.
Number and intensity of symptoms
The number and intensity of symptoms are also important criteria. One or two mental health problems is nothing really to worry about, but if over time more and more symptoms accumulate, or become more intense, then there is genuine cause for concern.
Symptoms can accumulate in multiple settings, such as both at home and at school, and that too is cause for concern. If a parent is worried about the mental health of their child or youth, asking the teacher whether any symptoms are also seen at school is an extremely important and useful course of action.
Let me give a personal example. I remember as a kid walking by a door and insisting that it be closed. I had this somewhat unreasonable thought that if a door was open there was a greater likelihood that something awful might happen to my mother or father.
This unreasonable thought then led me to engage in a ritual of going around and closing all the doors in the house and in the house of my best friend. I knew that this ritual would not have the intended impact that I was hoping for but it was hard for me to stop doing this.
Though this behaviour lasted more than six months, it did not cause significant impairment with my school work, with my friends, nor did my relationship with my parents deteriorate. I also didn’t t have other unreasonable thoughts or worries. Therefore, looking back, this symptom really constituted a typical reaction to stress (my father’s long workday) and was not really a mental health disorder.
The bottom line is that any mental health symptom is worth paying attention to. Watchful waiting, continued surveillance and frequent checking are good ways to deal with any emerging mental health concern.
If things begin to deteriorate and symptoms accumulate, and if impairment develops, then the parent, teacher or family doctor can intervene and access services as soon as possible. It is always better to be very sensitive to possible mental health challenges than to prematurely reassure and postpone intervention until it is too late.
Dr. Peter Szatmari is chief of the Child and Youth Mental Health Collaborative at SickKids, CAMH and the University of Toronto.