Common mental health problems and disorders
In spite of the fact that the majority cultures have recognized the existence of mental problems in some form, there are substantial discrepancies between cultures concerning what is measured to be unacceptable behavior. The Yoruba of Nigeria, for instance, are much less likely than the average Britishers to believe that someone showing the symptoms of paranoid schizophrenia is mentally ill. What is unacceptable can as well change within a society over time, as can be seen in the case of homosexuality (which used to be ranked as a mental illness).
In an effort to regulate the way that societies react to such individuals, and to remove any probable subjective prejudice that a particular clinician might have, efforts have been made to prepare criteria which will offer an agreed definition of abnormality. The legal as well as social consequences for an individual categorized as abnormal are substantial, ranging from compulsory treatment and loss of freedom to social rejection. Consequently it is necessary to develop criteria that can be universally and unmistakably applied.
Abnormal behaviour has been described using five different sets of criteria:
• Statistical criteria describe it as deviation from the average
• Deviation-from-the-norm criteria define it as deviation from expected ways of behaving
• Mental health criteria define it as the absence of socially desirable characteristics and behaviors (Jahoda, M. 1958)
• Social/psychological criteria define it by the presence of undesirable behaviours (Rosenhan, D. L. and Seligman.1984)
• Mental illness criteria describe it by the presence of clusters of symptoms
This last approach is the most generally used. The clusters of behavioral symptoms identified are thought to point out the presence of an underlying mental illness which may respond to treatment. For instance, the most commonly used categorization system at the moment is DSM IV, which describes mental disorder as:
“A clinically significant behavior or psychological syndrome or pattern that occurs in a person and that is associated with present distress (a painful symptom), disability (impairment of one or more important areas of functioning), a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely an expectable response to a particular event such as, for example, the death of a loved one”. (Gross, R. and McIlveen. 1996)
When it comes to the classification of mental disorders, it might quite sensibly be expected that different therapies will be appropriate to different disorders. Therefore it is necessary to establish a reliable and valid classification system at the beginning, in order that we can recognize a disorder and then recommend a suitable treatment.
Common mental health problems and disorders are:
· schizophrenia and other psychotic disorders
· mood disorders
· anxiety disorders
· somatoform disorders
· dissociative disorders
· factitious disorders
· sex/gender disorders
· eating disorders
· impulse control disorders
· adjustment disorders
· disorders of childhood and adolescence
· cognitive disorders (e.g. dementia, amnesia)
· substance-related disorders
· sleep disorders
One of the main purposes of having a classification system is to found categories of disorder which have common genesis and will benefit from the same treatment. In practice, though, this has not proved to be so easy, and both the reliability as well as validity of the present systems has been questioned. Concerning reliability, a number of studies have found agreement between clinicians to be as low as fifty-four to eighty-four per cent. More current research proposes that this figure may have improved; however given that subjective judgment is still needed during the diagnostic process it is improbable that agreement will become a great deal higher. When validity is considered, numerous categories contain individuals who emerge to differ extensively from one another in their behavior, and do not react to the same kinds of treatment. Other categories for example the anxiety disorders do not emerge to have any common origins, and react to a variety of treatments.
Child protection, abuse and domestic violence
The incidence and frequency of maltreatment varies not merely with the type of maltreatment under consideration, however as well with the specific definitions and methodology used in any particular study.
Physical Maltreatment: Physical abuse is the infliction of physical injury by beating, burning, biting, kicking, or further means. Physical neglect is the failure to supply the normal physical necessities of life, for example food, clothing, sleep, bathing, or health care. It comprises abandonment and exposure of children to preventable hazard and danger.
Psychological Maltreatment. Psychological or emotional abuse is behavior that results in emotional or cognitive disabilities or retardation. Psychological or emotional neglect is the withdrawal of contact as well as support that brings on similar developmental difficulties. The result of psychological abuse may often be more devastating that physical abuse. Psychological maltreatment is difficult for outsiders to recognize, and numerous cases may go unreported.
Sexual Abuse. Sexual abuse simply viewed is criminal sexual activity of any sort with a child. It may range from inappropriate fondling to rape and sodomy, however it as well includes indirect acts such as sexually exploiting children through prostitution and involvement in pornography. The shocking impact of a sexual act depends on how it is understood by the child, even though inappropriate acts leave a child with distorted understandings and beliefs. Abuse is generally related to a power differential, a knowledge differential or a gratification differential for the abuser. The occurrence of sexual abuse is quite common.
Educational Neglect. Although merely recently cataloged, it is possible as well to describe educational neglect. This form of neglect includes permitted chronic truancy, failure to register a child in school, and inattention to a special educational need, for example for special education. It may be subsumed under the further forms of neglect, however.
Even though there may be both physical and psychological damage from abuse, in the majority cases it is the psychological damage that is generally measured to be the most overwhelming aspect of the experience. That is, in most, even though definitely not all cases, bruises and broken bones heal, and whipping may have little physical impact. However it is the psychological impact from these types of maltreatment that makes them mainly harmful to the child.
Maltreatment does not produce results that are associated to any one diagnostic category; the outcomes are diverse. Research, though, proposes that maltreatment causes psychological maladjustment, and may foresee serious emotional and behavioral disorders. Reactions are emotional, physical, and social in nature and have an impact on school learning. (Simon Kemp. 1990)
Without a considerable change in our socioeconomic-political system, there will always be maltreatment. Consequently, any primary prevention activity intended at individuals or families will fail to prevent maltreatment completely unless and until considerable sociocultural changes are made. Particularly, we have to put and end to poverty, change to an egalitarian and cooperative society, make work a meaningful experience, and change our culture to one where children are highly valued and violence and coercion are seen as illegal. School personnel have to continue to work for changes in societal conditions that create a world that is safe for children.
Other cultures may have other child disciplinary practices as well as attitudes toward sexuality than do members of the dominant culture in the United States and United Kingdom. Care has to be taken in evaluating what appears to be maltreatment and consider how the child perceives the act in his or her cultural context. Yet, we must expect those living in the West to abide by the law and turn out to be acculturated in their treatment of children. Cultural informants could help in the identification of abuse; however school-based professionals are bound by reporting laws.
Strengths and resilience in children and young people
Research on resiliency proposes that a child needs to have one positive, stable, close relationship with an adult in or outside of the family. With open lines of communication, it makes it more probable that the child will be willing to tackle the feelings, beliefs, and behavior resulting from maltreatment, rather than accepting any intimidation or engaging in long-term repression, denial, guilt, and all that. This relationship as well would offer an all significant positive model of a relationship in contrast to the one in which the maltreatment occurred. There is no cause to think that this positive, stable, intimate relationship could not be with an adult in the school or other agency. As part of providing for the psychological well-being of all children, a school or agency professional might have as an aim to insure that each vulnerable child has as a minimum one such relationship. Briefly, if a child has a positive self-concept, one positive relationship with a important adult, and adequate information regarding appropriate and inappropriate treatment, should maltreatment occur, the child will be more likely to look for help, to look for the help more quickly, and to use the help more efficiently.
Social inclusion & culturally competent practice
Culture is recognized as an important factor in the assessment of psychological functioning and treatment of mental disorders. Regarding children and adolescents mental health, the Diagnostic Classification of Mental Health and Developmental Disorders of children and adolescents states that, any intervention or treatment program must include an assessment of family functioning and cultural and community patterns besides developmental history, symptoms, and assessment of the child’s current functioning.
According to the members of the work group charged with developing the Outline for Cultural Formulation in the Diagnostic and Statistical Manual of Mental Disorders, there that the need to recognize culture has been growing recognition that psychiatric diseases require to be understood not merely as biological processes, but rather, in the background of an illness experience, which is in part determined by cultural interpretations of the disease. Kleinman (1988) was one of the first authors tolatio talk about the concepts of disease and illness in this way. By considering disease in the context of an “illness experience,” there is an acknowledgment that the experience of disease specifically, its symptoms, its remedy, and all that are unique to a particular individual who is situated in a particular sociocultural context. (Castillo, R. J. 1997)
At the same time as the inclusion of the Outline for Cultural Formulation in DSM-IV has made an important contribution to the assessment of adult psychological functioning in the context of culture, the field of children and adolescents mental health assessment has lagged behind. This is not astonishing, considering the novelty of the field and the fact that appreciation of cultural factors in development generally has lagged behind other approaches. It is as well not surprising that the need to recognize culture has come increasingly into our awareness, given the changing demographics of the U. K. population.
In spite of current acknowledgment of the significance of culture in our work as psychologists, psychiatrists, and other mental health providers, the notion of culture has remained abstract and so difficult to apply in real-world situations. Certain advances, for instance the inclusion of a cultural case formulation in Appendix I of DSMIV, are conducive to making culture a more routine element in the assessment, diagnostic, and treatment process. Though, as Garcia Coll and Magnuson (2000) emphasize, academicians and clinicians alike have had what they call and to include in the ass relationship with culture as it influences the lives and well-being of young children.
Multi-cultural, ethnic, service user, spiritual ; alternative frameworks and explanations of mental health
Thus far, the multifactorial considerations concerning prevention of emotional and psychological sequelae, professionals’ restricted understanding of risk factors and their long-term effects, the complex nature of human development, and the ethnic and cultural diversity of our society, carry on to defy professionals’ capability to make focused, efficient and appropriate clinical intervention efforts. The ethnic and cultural diversity of society is a dimension often inadequately integrated when planning interventions.
Striving to make the most of development needs a better understanding of factors contributing to a child’s cognitive, emotional, and social development. Yet, our knowledge concerning the meaning of childhood competence, health, and well-being is not well-defined, nor is our understanding of how ethnic diversity contributes to variations in development. The range of adaptive skills within differing cultural contexts are hardly ever fully acknowledged or considered. However, assessment is essential to be capable to understand variations in developmental differentiation within a cultural context and to offer programs addressing the adaptive needs of children in different cultural contexts. (La A. M. Greca, & Varni J. W. 1993)
A rising interest in ecology and development acknowledges that human development is a function of cultural and biological factors. The supposition that indications of social and psychological competence, health, and response to stress or illness are uniform across individuals or cultures is inaccurate. Therefore, interventions require us to put together multiple factors relevant to individual development for diverse population groups. The diversity of the pediatric population’s psychological, behavioral functioning, as well as cultural perspectives are modifier that minimize the probability that a particular strategy will be uniformly effectual. Though, the fact that preplanning and outcome strategies and assessment tools, primarily developed by European-Americans, continue to be applied to children from different cultures remains a difficulty.
Preventative practice and early intervention
In recent years, mental health professionals have turn out to be highly sensitive to the pervasiveness of mental health disorders and the rising cost of treatment. Even though the goals of preventive interventions in mental health are to optimize development and minimize developmental problems, and given that prevention signifies considerable benefits to society as a whole, preventive programmatic efforts are few. The preventive approach is not given high priority in present mental health delivery paradigms. Though, the economic climate and social philosophy regarding the health care delivery system has changed. It needs that professionals assess the organized health care delivery system so as to incorporate and maximize preventive interventions, rather than exclusively provide remedial intervention programs.
La Greca and Varni (1993) conceptualized that intervention pertinent to prevention must include promoting health and health-related behaviors, and preventing illness and injury among children and youth. Prevention professionals characteristically classify preventive interventions into primary and secondary efforts occurring before the onset of a disorder. Primary prevention targets all children with the goals of maximizing development, striving for health, and minimizing problems. Early identification is necessary and some areas of intervention may comprise early immunization, nutrition, and prevention of physical abuse. Governmental legislation is often helpful in implementing these interventions.
Secondary prevention targets children considered at risk because of physical or environmental factors. Environmental influences may place the child at risk for other problems because of his or her affiliation with a group that demonstrates problems (e.g., low socioeconomic status; child whose parents are mentally retarded or substance abusers). The Institute of Medicine suggests various types of preventive mental illness interventions that give emphasis to aspects of physical well-being, for instance maternal prenatal care, immunizations, and treatment of developmental disorders. Secondary interventions as well focus on those children with a higher likelihood of developing mental illness based on biological, psychological, or social risk factors. Children with observable behavioral or biological signs that forecast the emergence of a mental disorder would fall in this category.
Even though these guidelines serve to focus intervention efforts, most are characteristically ambiguous. Definite intervention programs need delineating the focus of prevention, the target of intervention, a process intended to attain the desired goal, and a location of intervention (e.g., home, school). The strength of intervention efforts may range from mild intensity, for example distributing reading material, to complete programmatic efforts or combinations thereof. Guiding a program’s intervention methods are fundamental predictive assumptions and hypotheses concerning outcome of success. As such, prevention programs need ongoing assessments to document the association of statistically determined risk factors and behavior, and to find out the relationship of intervention methods to successful interventions. Preventive interventions need to inspect the validity of the assumptions, the paradigm of intervention, also the outcome of the interventions.
Theoretically, the objective of psychological prevention programs is to intercept processes, interactions, or acts to thus promote emotional, intellectual, and physical well-being. Consequently, a main goal of preventive programs includes addressing factors that place a child at risk for victimization or stopping the process of victimization by changing the environment or the adaptive capacity of the child within the environment. A child’s state of dependency and immaturity contributes to a reliance on the environments provided by parents as well as immediate family. Preventive interventions as a result need to assess and address risk factors stemming from caregivers and family context. A better understanding of how to intervene with the caretaker, who has the principal accountability for promoting the safety, and emotional and physical health of the child, is a requirement.
The legal framework
Consent to treatment: A parent has the right to give consent to treatment for a child under 18, provided it is in the child’s interests. In cases where a parent refuses to consent to treatment that doctors consider to be in the child’s best interests, the child may be made a ward of court. The court can then overrule the parent’s refusal. Many pediatricians feel children should have treatments explained to them and their consent sought whenever possible. There is evidence that even young children can often understand quite complicated medical issues. A study of children undergoing orthopedic surgery found that relevant experience of illness, treatment or disability was far more important than age for acquiring competence. www.mind.org.uk
The Mental Health Act (1983): There is no lower age limit to the Mental Health Act (1983) and there are no specific provisions in the Act relating to children. In theory, children and young people may be treated or compulsorily detained under it, but in practice very young children are not detained under the Act, with the majority being admitted as ‘informal’ patients by their parents.
The National Service Framework for Children: The National Service Framework for Children, Young People and Maternity Services (NSF), which was published in September 2004 by the Department for Education and Skills, sets out national standards for children’s health and social services. It proposes the following standards for the care of children and adolescents. www.mind.org.uk
· The promotion of health and wellbeing, identifying needs and early intervention, led by the NHS in partnership with local authorities.
· Supporting parenting, by providing information and support for parents to help them care for their children and equip them for life.
· The provision of child-, young person- and family-centered services, tailored to individual needs and taking account of their views.
· The development of age-appropriate services responsive to need.
· Safeguarding and promoting the welfare of children and young people, preventing harm, promoting welfare and addressing needs.
· Implementing timely access to appropriate and effective services to meet the health, social, educational and emotional needs of children and young people who are ill, throughout their period of illness.
· The provision of high quality, evidence-based hospital care for children and young people in hospital, developed through clinical governance in appropriate settings.
· The development of coordinated, high quality family-centered services for disabled children and young people and for those with complex health needs, promoting social inclusion, enabling them to live ordinary lives.
· Promoting the mental health and psychological wellbeing of children and young people, by providing access to timely, integrated, high quality multidisciplinary mental health services to ensure effective assessment, treatment and support.
· Making sure children, young people, their parents or careers, and health care professionals in all settings can make decisions about medicines based on sound information about risk and benefit. www.mind.org.uk
The Children Act 2004: The Children Act 2004 provides the legislative foundation for the changes outlined in the National Service Framework. The Act provides for the establishment of a new Children’s Commissioner for England, working with close counterparts in the rest of the UK, whose role will be to raise awareness of the best interests of children and young people. The first Commissioner, Professor Al Aynsley-Green, was appointed in March 2005. The Commissioner is required to involve children and young people closely in his work, but will look at individual cases only in so far as they have implications for public policy. www.mind.org.uk
The Act also places a duty on local authorities and other agencies caring for children to cooperate and take part in joint arrangements. Children’s trusts will be set up with the primary role of securing integrated commissioning, leading to more integrated service delivery. They will be based in local government, but be formed through pooling the resources of local education authorities, children’s social services, certain health services, Connexions, and, where agreed locally, youth offending teams.
Therapeutic interventions in working with children and adolescents
A therapy is a purposeful intervention which seeks to treat mental disorder and make it more controllable. A therapy may be an effort to ‘cure’ or it may be an effort to educate the individual how to handle the problem. What follows is an overview of the range of therapies available for children and adolescents. Therapies can be divided generally into somatic therapies (footed on the medical model) and psychotherapies (footed on the other models).
Somatic therapy started in the early days of asylums, when ‘therapy’ was often purely custodial, inmates being kept in chains for the protection of themselves and others. This was altered by Pinel in 1792, whose first move on taking over a Paris asylum called the Bicêtre was to remove all chains and restraints. Even in the early 19th century, though, treatments were frequently barbaric. One instance is the ‘whirling chair’, a device into which inmates were strapped and rotated at speed, supposedly until blood ran from their ears. At present, somatic therapy has a three-pronged approach, using drugs (recognized as chemotherapy), electro-convulsive shock therapy (ECT) and/or destruction or functional isolation of brain tissue (psychosurgery).
Psychodynamic therapies Initiate from Freud’s system of psychoanalysis. In its original form, the plan was to bring into consciousness those unconscious conflicts which were at the root of the mental disorder, where they could be dealt with by the therapist. To do this required the use of the techniques of free association as well as dream interpretation, plus an analysis of the ways in which the client related to the therapist. The latter was thought to make known, through a process of transference, the problems that had occurred in other noteworthy relationships. More recent procedures derived from this comprise psychoanalytically oriented psychotherapy, and group psychodynamic therapies. There are as well psychodynamic therapies based on theorists other than Freud; Klein, for instance, has developed her own therapy for adolescents and play therapy for use with children.
Humanistic therapies, such as Rogers’ person-centered therapy (1980), aim to encourage personal growth and development by providing, in the therapeutic relationship, an environment in which this is possible. Unlike many of the approaches mentioned earlier, the individual is encouraged to take control of their situation and to make decisions without the intervention of the therapist. Other approaches developed from this include encounter groups and family therapy, where the way that individuals communicate with and relate to one another is used as a basis for treating their behavior disorders. (Thomas H. Ollendick, John S. March. 2004)
Cognitive-behavioral therapy (CBT) is one of the most extensively researched approaches for childhood and adolescence psychological problems. CBT has been productively applied to a wide variety of problems in childhood and adolescence from phobias and generalized anxiety disorder, to depression, to impulsivity, and to antisocial behavior. Particularly, the success of child-focused CBT has been greatest for children and adolescents with internalizing disorders. Empirical support for CBT has as well been accumulated for treatment of antisocial youth, however the data have not been as strong and other treatment approaches appear as, if not more, effectual (e.g., parent management training). Still, lots of clinical researchers continue to see a role for child-focused CBT in a broader treatment plan for antisocial youth.
CBT is an integrative treatment approach combining two distinct schools of psychotherapy: behavior therapy as well as cognitive therapy. The integration of the two therapeutic approaches was thought to offer a comprehensive treatment model capable to address the cognitive and behavioral deficits of clients. In its original form, CBT drew heavily from the work of information-processing and social-learning theorists. Though, the approach is by design open to integration of new empirical findings. Therefore there has been increasing attention to other theoretical points of view, including a recent emphasis on the role of emotion in the development and treatment of child adolescent psychopathology. (Thomas H. Ollendick, John S. March. 2004)
The cognitive-behavioral model views psychological problems as related to emotional, behavioral, and cognitive antecedents. A therapist using CBT pays close attention to emotional factors for example a child’s emotion regulation (e.g., the purposeful and dynamic ordering and adjusting of emotion), together with an assessment of the extent to which this set of developmental processes has been detoured. Concerning children, there is proof that youth with oppositional defiant disorder show difficulties regulating negative emotion such as anger. Additionally, a child’s emotion understanding (e.g., a child’s knowledge of the causes of emotions and ways of coping with feelings) is viewed as a key factor in conceptualizing and planning treatment.
Behavioral factors related to child psychological problems are as well examined. These factors include a child’s familial and extrafamilial (e.g., peer relationships) experiences, which are inspected for evidence of limited learning opportunities or potentially pathogenic experiences (e.g., child abuse, marital conflict). Also, a child’s learning history is closely examined, frequently via a functional assessment of the presenting problems to recognize reinforcements related to maintaining problem behaviors. Along these lines, research has pointed out that the negative (e.g., aggressive) behavior of antisocial youth has received reinforcement, while their prosocial behavior has been largely ignored.
In terms of cognitive factors, cognitive-behavioral theory distinguishes between cognitive distortion and cognitive deficiency. Some children process information in a distorted fashion (e.g., misinterpretation of the intentionality of others), while others evidence deficiencies in their cognitive processing leading to action that does not benefit from forethought. These different cognitive processing difficulties have been linked with a variety of childhood and adolescence disorders. For instance, aggressive and antisocial youth show both cognitive distortions and cognitive deficiencies. CBT as well focuses on social information-processing and problem-solving biases that often lead to maladjustment. For instance, some children and adolescents exhibit problem-solving biases toward agonistic or avoidant solutions (or both), and these patterns appear to augment risk for psychopathology. (Jonathan E. Alpert, Maurizio Fava. 2004)
Castillo, R. J. 1997. Culture and mental illness. Pacific Grove, CA: Brooks/Cole.
Garcia Coll, C., ; Magnuson, K. 2000. Cultural differences as sources of developmental vulnerabilities and resources. New York: Cambridge University Press.
Gross, R. and McIlveen. 1996. Abnormal Psychology, London: Hodder ; Stoughton .
Jahoda, M. 1958. Current Concepts of Positive Mental Health, New York: Basic Books.
Jonathan E. Alpert, Maurizio Fava. 2004. Handbook of Chronic Depression: Diagnosis and Therapeutic Management; Marcel Dekker
Karen A. Cerulo 2001. Culture in Mind: Toward a Sociology of Culture and Cognition; Routledge
La A. M. Greca, ; Varni J. W. 1993. “Interventions in pediatric psychology: A look toward the future”. Journal of Pediatric Psychology, 18, 667-679.
Rosenhan, D. L. and Seligman.1984. Abnormal Psychology, New York: W. W. Norton.
Simon Kemp. 1990. Medieval Psychology; Greenwood Press, 1990
Thomas H. Ollendick, John S. March. 2004. Phobic and Anxiety Disorders in Children and Adolescents: A Clinician’s Guide to Effective Psychosocial and Pharmacological Interventions; Oxford University Press