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Mental health disorders

Authors:
  • Independent researcher
Child Trends
Publication # 2013-1 January 2013
Mental Health Disorders
By David Murphey, Ph.D., Megan Barry, B.A., and Brigitte Vaughn, M.S.
Mental disorders are diagnosable conditions characterized by changes in
thinking, mood, or behavior (or some combination of these) that can cause a
person to feel stressed out and impair his or her ability to function. These
disorders are common in adolescence. This Adolescent Health Highlight
presents the warning signs of mental disorders; describes the types of
mental disorders and their prevalence and trends; discusses the
consequences and risk of mental disorders; presents treatment options and
barriers to accessing mental health care; and provides mental health
resources.
The definition and complexities of mental disorders
Medical science increasingly recognizes the vital link between a person’s
physical health and his or her mental/emotional health. Mind and body are
connected as one, each affected by the other, and both are influenced by a
person’s genetic inheritance, environment, and experience. Just as the
absence of disease does not adequately define physical health, mental
health consists of more than the absence of mental disorders. Mental health
is best seen as falling along a continuum, which fluctuates over time, and
across individuals, as well as within a single individual.3
As defined in this Highlight, mental disorders are diagnosable conditions
characterized by changes in thinking, mood, or behavior (or some
combination of these) that are associated with distress or impaired
functioning.4 As with symptoms of physical illness, symptoms of mental
disorders occur on a spectrum from mild to severe. People with mental
disorders, however, often have to bear the special burden of the societal
stigma associated with their condition. This burden sometimes prevents
people from acknowledging their illness and from seeking support and
effective treatment for it. Just as with physical health, failure to address
symptoms early on can have serious negative consequences.
What are the warning signs of mental disorders?
It is important to make a clear distinction between the normal ups and
downs of mood and outlook, and diagnosable mental disorders. Everyone,
especially many adolescents, experiences mood swingsfrom feeling blue,
to expressing giddy excitement, to being anxious or irritable.
Adolescents are biologically prone to have more of these mood swings
because of the hormonal changes associated with this period in life, coupled
with the fact that their brains are still developing.6,8 Many adolescents can
worry that they’re “losing it,” when, in reality, these mood swings may be
normal occurrences.6,10
1. Mental disorders in adolescence are
common: An estimated one in five
adolescents has a diagnosable
disorder.1
2. Adolescence is the time when many
mental disorders first arise. More
than half of all mental disorders and
problems with substance abuse
(such as binge drinking and illegal
drug use) begin by age 14.2
3. The most prevalent mental disorder
experienced among adolescents is
depression,4 with more than one in
four high school students found to
have at least mild symptoms of this
condition.5
4. Adolescents with mental disorders
are at increased risk of getting
caught up in harmful behaviors, such
as substance abuse and unprotected
sexual activity. 1,6,7
5. Many effective treatments exist for
mental disorders, most involving
some combination of psychotherapy
and medication.9
6. The majority of adolescents with
mental disorders do not seek out or
receive treatment, a consequence of
various barriers to care, including
the fear of being stigmatized by
peers and others.4
Fast Facts
ADOLESCENT HEALTH HIGHLIGHT
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However, when psychological symptoms cause major emotional distress, or interfere substantially
with daily life and social interactions over a period of time, professional evaluation is warranted, just
as it is with any serious illness. Not all mental disorders among adolescents have obvious, reliable
symptoms, but parents, teachers, and others should be alert to some warning signs that an
adolescent may be in trouble. These signs include persistent irritability, anger, or social withdrawal,
as well as major changes in appetite or sleep.11,12
What are the types of mental disorders, and which are the most common among adolescents?
Mental health professionals use various classifications to identify the diverse range of mental
disorders. Many adolescent mental disorders fall under the broad categories of mood disorders
(e.g., depression and bipolar disorder); behavioral disorders (e.g., various acting-out behaviors,
including aggression, destruction of property, and some problems of attention and hyperactivity);
and anxiety disorders (including social anxiety disorder, obsessive-compulsive disorder (OCD), post-
traumatic stress disorder, and phobias).4,13 Many adolescents with mental disorders have symptoms
indicative of more than one disorder.3
FIGURE 1:
Percentage of students in grades 9-12 who reported symptoms of depression*, by
gender, 2011
* Symtoms of depression in this survey are an affirmative response to the statement “reported feeling sad or hopeless
almost every day for two weeks or longer during the past year.
Source: Centers for Disease Control and Prevention. (2012). Youth Risk Behavior Surveillance Survey- United States, 2011.
Surveillance summaries: MMWR 2012; 61 (No SS-4) .
Adolescence is a time when many mental disorders first arise; in fact, more than half of all mental
disorders and problems with substance abuse (such as binge drinking and illegal drug use) begin by
age 14, and three-quarters of these difficulties begin by age 24.2 Accurate estimates of the number
of adolescents who have diagnosable mental disorders are difficult to come by, for several reasons:
many adolescents are reluctant to disclose these disorders; definitions of disorders vary; and most
diagnoses rely on clinical judgment rather than on biological markers (such as a blood test).14
However, available data suggest that 20 percent of adolescents have a diagnosable mental
disorder.1 Depression is the single most common type reported by adolescents, though it is often
Adolescents are
biologically prone
to have more mood
swings because of
the hormonal
changes associated
with adolescence,
coupled with the
fact that their
brains are still
developing.
suggest that 20
percent of
adolescents have a
diagnosable mental
disorder, and
depression is by far
the most common.
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accompanied by other mental disorders.4 In 2011, more than one in four (29 percent) high school
students in grades 9-12 who participated in a national school-based survey reported feeling sad or
hopeless almost every day for two weeks or longer during the past yeara red flag for possible
clinical depression (see Figure 1).15
Another survey that collected information from adolescents between the ages of 12 and 17 found
that in 2008, about one in 12 (8 percent) reported experiencing a major depressive episode during
the past year (see Figure 2).16 These estimates have not changed much over the past five to 10
years.5 A slightly lower percentage of adolescents (3 percent) met the criteria for conduct disorders.4
Adolescents with conduct disorders are extremely uncooperative, are persistent in defying societal
rules and authority figures, and are often severely angry, aggressive, and destructive.17
FIGURE 2:
8%
10%
3%
5%
9%
0
2
4
6
8
10
12
14
Major depression
Conduct disorders
Anxiety disorders
Eating disorders
Attention deficit-
hyperactive
disorder (ADHD)
Percentage of adolescents with selected mental disorders*
*These data are from different reporting years: major depression, 2008; anxiety disorders, 1999; conduct disorders, 1995;
and eating disorders and ADHD, 2005. Estimates are based on adolescents’ self-reports of symptoms, not clinical
diagnoses, except for ADHD, where estimates are based parent’s reporting that a professional had given that diagnosis.
Sources: Substance Abuse and Mental Health Services Administration. (2009). Results from the 2008 National Survey on
Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-36, HHS Publication No. SMA 09-4434).
Rockville, MD. Knopf, D. et al. (2008). The mental health of adolescents: A national profile, 2008. National Adolescent
Health Information Center.
An estimated 10 percent of adolescents reported symptoms of an anxiety disorder.4 Among the
more common anxiety disorders are OCD, social anxiety disorder, post-traumatic stress disorder
(PTSD), and phobias. OCD is characterized by recurrent and persistent thoughts, images, or impulses
(obsessions) that are unwanted, and/or repetitive behaviors or rituals (compulsions) that cause
distress.18 PTSD can develop after a person has seen or lived through a dangerous or frightening
event. This disorder is characterized by flashbacks or bad dreams, emotional numbness, and/or
intense guilt or worry, among other symptoms.19 Phobias are intense, irrational fears of things or
An estimated 10
percent of
adolescents have
anxiety disorders,
the most common
of which are OCD,
post-traumatic
stress disorder, and
phobias.
29 percent of high
school students in
grades 9-12
reported feeling
sad or hopeless
almost every day
for two weeks or
longer during the
past yeara red
flag for possible
clinical depression.
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circumstances that pose little or no actual danger. Facing, or even the thought of facing, the feared
object or situation can spur panic attacks or severe anxiety.13 Panic disorders (a type of anxiety
disorder characterized by a racing heartbeat, shortness of breath, and other pronounced physical
symptoms) affect around one percent of adolescents.20
About five percent of adolescents report symptoms of an eating disorder.4 Less common are autism
spectrum disorders (a diverse category of conditions, typically marked by severe impairments in
social and communication skills).21
Adolescents with attention deficit-hyperactivity disorder (ADHD) have difficulty paying attention,
controlling impulses, and staying organized.12 Some estimates put the prevalence of the disorder as
high as nine percent among 12- to 17-year-olds.4 Adolescent males are more likely than are females
to have ever been diagnosed with ADHD.4 However, biases may exist in the identification of young
people with ADHD, including lower rates of diagnosis among Hispanic children22 and higher rates for
those who are young for their grade.23
What are some of the consequences of mental disorders?
Mental disorders take a toll on adolescents, their parents, and friends, and contribute significantly
to health care costs. The consequences can be short- or long-term. Indeed, most mental disorders
diagnosed among adults began during adolescence, although other mental disorders experienced by
adolescents may diminish by early adulthood if they are treated.4,9
Substance abuse disorders frequently go hand in hand with mental disorders.4 In addition, mental
disorders are often associated with other negative emotional and behavioral patterns in
adolescenceincluding impaired relationships, lower academic performance, a higher risk of
unprotected sex and teen pregnancy, and increased involvement with the juvenile justice system.
However, many adolescents who experience these issues do not have a mental disorder, and many
youth with mental disorders do not have these problems.1,6,7 The single most disturbing potential
consequence of adolescent mental disorders is suicidethe third leading cause of death among 10-
to 24-year-olds in the United States. Although suicide can have multiple causes, 90 percent of
adolescents who commit suicide had a diagnosable mental disorder, and up to 60 percent of them
were suffering from depression at the time of their death.24
How do risks of mental disorders vary across adolescents?
Adolescent males generally are more likely than are their female peers to be diagnosed with
behavioral problems, including conduct disorders, ADHD, and autism spectrum disorders.4,25
Adolescent females are more commonly diagnosed with depression and eating disorders than are
males.4,26 Adolescents whose parents have lower levels of education (e.g., no college degree) have
more risk of having a mental disorder than do adolescents whose parents have higher levels of
education. Adolescents whose parents are divorced are also more likely to have mental disorders
than are adolescents whose parents are married or cohabiting.27 Other groups of adolescents
particularly at risk for mental disorders include those involved in bullying (either as victims or
perpetrators), those who have experienced sexual or physical abuse, and those whose parents have
a history of mental disorders.24,28 Among ethnic groups, Hispanic and black adolescent females have
a higher risk of depressive symptoms than do adolescent females from other racial/ethnic groups.15
Some estimates put
the prevalence of
ADHD as high as
nine percent
among 12- to 17-
year-olds.
The single most
disturbing
potential
consequence of
adolescent mental
disorders is
suicide—the third
leading cause of
death among 10-
to 24-year-olds in
the United States.
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How can mental disorders be treated?
As in other arenas of health, early intervention or prevention can be an effective way to address
potential mental disorders before they reach the stage requiring treatment. Although not all mental
disorders are accompanied by early warning signs, people who interact with and care about
adolescents should be alert to marked changes in mood or behavior that may suggest problems. At
the same time, concerned adults can help adolescents maintain positive mental health by providing
caring, supportive relationships, encouraging healthy behaviors, and teaching effective strategies for
coping with stress.29
Most mental disorders are treatable, although what works for particular individuals may vary. Often
a combination of psychosocial therapy (personal or group counseling with a psychotherapist) and
medication is effective. For many types of disorders (e.g., depression and OCD), cognitive-behavioral
therapies and medications have been shown to be effective in many cases.7 Cognitive-behavioral
therapies seek to help people modify negative or irrational thoughts and to replace dysfunctional
behaviors with more rational ones. For other types of disorders (such as ADHD), behavioral parent
training and classroom management techniques may be effective.9 When psychiatric medications
are prescribed, they are typically administered in combination with other treatment approaches,
such as individual psychotherapy, group therapy, or family therapy. In general, experts agree that
medication should not be the only treatment followed, and that any treatment plan should be
supervised by a clinician with specific training in adolescent mental health.9
Other strategies have also been used successfully with particular mental disorders. For depression,
some evidence shows that increased physical exercise may provide some benefits.30 For conduct
disorders, promising results have been found when the young person with the disorder is treated,
together with his or her family and community, using a “systems” approach. The systems approach
attempts to address multiple problem behaviors that the adolescent is exhibiting by providing
multiple types of services, such as education, child protection, juvenile justice, and mental health
services.7 In other words, systems approaches involve coordinating services from different providers
and are tailored to meet the needs of the individual adolescent.
Some families may choose unconventional therapies (sometimes referred to as complementary or
alternative medicine) as a way to treat physical and mental disorders. Examples of these include diet
modifications, such as eliminating sugar, or foods with dyes and additives; herbal or vitamin
supplements; and music or dance therapy. Although these practices have become more widespread
in recent years, particularly for autism spectrum disorders, they have not met the same rigorous
standards of evidence as more traditional treatments, and consumers should be skeptical of
dramatic or poorly substantiated claims for effectiveness.31 Talking to a trained clinician is key in
determining the proper treatment for any mental disorder.
How do adolescents access mental health services, and what are barriers to care?
Parents, other family members, and friends can all play roles in encouraging adolescents who are
experiencing emotional distress to seek help. Mental health services for adolescents are provided by
a mix of specialists (psychiatrists, psychologists, social workers, and others) in the public and private
sectors. In general, this system of diverse providers is crisis-oriented and designed for treating
people with diagnosed mental disorders (particularly as reflected in reimbursement policies.) The
system is less structured to address prevention and health promotion, early identification of
difficulties, and timely, effective treatment.14,32
Parents, other
family members,
and friends can all
play roles in
encouraging
adolescents who
are experiencing
emotional distress
to seek help.
Mental disorders
are treatable,
although what
works for
particular
individuals may
vary. Often a
combination of
psychosocial
therapy and
medication is
effective.
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School health centers are often helpful in identifying the mental health care needs of adolescents,
partly because adolescents spend much of their time in school, and partly because these clinics are
accessible to students in low-income and underserved racial and ethnic minority groups, who are
more likely to be without health insurance.14,33 However, few school mental health professionals are
able to provide intensive care on their own.14 Primary care providers (pediatricians and others) are
often the gatekeepers for identifying mental disorders in adolescents. However, these providers
may lack the time in their practicesas well as the specific expertiseto identify and manage these
disorders. Moreover, efforts to coordinate care between primary care providers and mental health
professionals vary considerably in their effectiveness.
Studies have found that most children and adolescents with mental disorders (between 60 and 90
percent) do not seek out or receive the services that they need.4 The societal stigma associated with
mental disorders may help explain why many adolescents do not seek treatment. Also, parents,
school officials, and medical providers often miss opportunities to address the prevention and early
identification of mental disorders. Additional barriers include services that are poorly coordinated
(e.g., among schools, primary health care providers, and social services agencies); a lack of health
insurance (although most adolescents are insured); restrictions by insurers on coverage for certain
services; and a shortage of providers with specific expertise in adolescent mental health.14
Implications for preventing risky adolescent behaviors
Young people with mental disorders, in general, are more vulnerable to involvement in risky
activities that jeopardize their health and well-being than are young people in the larger adolescent
population.1,6 Suicide attempts and self-injury are the most dire of these threats, but other
troublesome behaviors warrant scrutiny as well. For example, adolescents with depression are also
more likely than are their nondepressed peers to engage in substance abuse and early sexual
activity;5 and adolescents with conduct disorders are more likely to engage in early sexual activity,
early drug and alcohol use, interpersonal violence, and delinquency.12 Thus, preventionin addition
to early diagnosis and treatment of mental disordersis essential for reducing many other serious
problem behaviors.29
Strategies and approaches to reduce mental health disorders among adolescents
The National Prevention Strategy is a comprehensive plan designed the government’s National
Prevention Council to help improve the health of Americans at every stage of life. Its mental health
recommendations include:
Promoting early identification of mental health needs and access to quality services.
Clinicians are key to identifying mental health needs, so integrating mental health care into
traditional health care settings and social service, community, and school settings is
important, especially for adolescents who have experienced trauma.
Reducing the stigma associated with mental health services. Doing so will improve access to
and use of the effective mental health treatment that is available.34
The U.S. Preventive Services Task Force recommends that adolescents (ages 12-18) be screened for
major depressive disorder (MDD) when there are appropriate services available for accurate
diagnosis, psychotherapy, and follow-up.35
Young people with
mental disorders,
in general, are
more vulnerable to
involvement in
risky activities
that jeopardize
their health.
Primary care
providers may lack
the time in their
practices, as well as
the specific
expertise, to
identify and
manage mental
disorders.
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Resources
The Child Trends DataBank includes brief summaries of well-being indicators, including several that
are related to mental disorders and mental health:
Attention Deficit-Hyperactivity Disorder (ADHD): http://childtrendsdatabank.org/?q=76
Adolescents Who Feel Sad or Hopeless: http://childtrendsdatabank.org/?q=node/126
Autism Spectrum Disorders: http://childtrendsdatabank.org/?q=node/372
Bullying: http://childtrendsdatabank.org/?q=node/370
Disordered Eating: Symptoms of Bulimia: http://childtrendsdatabank.org/?q=node/123
Suicidal Teens: http://childtrendsdatabank.org/?q=node/128
Teen Homicide, Suicide, and Firearm Deaths: http://childtrendsdatabank.org/?q=node/124
The Childs Trends LINKS (Lifecourse Interventions to Nurture Kids Successfully) database summarizes
evaluations of out-of-school time programs that work (or not) to enhance children's development. The
LINKS Database is user-friendly and directed especially to policy makers, program providers, and
funders.
Programs related to anxiety disorders/symptoms, conduct/disruptive disorders, and eating
disorders can be found by selecting those boxes under mental health.
Evaluations of programs proven to work (or not) for reducing depression/depressive symptoms,
suicidal thoughts or behaviors, anxiety/anxious symptoms, and post-traumatic stress disorder, in
addition to other mental health behaviors, are summarized in the fact sheet What works to
prevent or reduce internalizing problems or social-emotional difficulties in adolescents: Lessons
from experimental evaluations of social interventions.
Evaluations of programs proven to work (or not) for reducing ADHD are summarized in a fact
sheet What works for acting-out (externalizing) behavior: Lessons from experimental evaluations
of social interventions.
Other selected resources include:
The National Institute of Mental Health (NIMH) provides a number of resources, including fact
sheets on brain development and mental disorders in adolescence
(http://www.nimh.nih.gov/health/topics/child-and-adolescent-mental-health/index.shtml).
The Centers for Disease Control and Prevention (CDC) has information about mental health
changes in early adolescence (http://www.cdc.gov/ncbddd/child/earlyadolescence.htm) and
middle or older adolescence (http://www.cdc.gov/ncbddd/child/middleadolescence15-17.htm),
as well as a number of resources on suicide prevention
(http://www.cdc.gov/ViolencePrevention/suicide/).
The Substance Abuse and Mental Health Services Administration (SAMHSA) provides the Mental
Health Services Locator, an online, map-based program people can use to find facilities in their
vicinity (http://store.samhsa.gov/mhlocator). SAMSHA also maintains an online library of free
publications and resources, with more than 200 documents focused on adolescent behavioral
health issues (http://store.samhsa.gov/home). In addition, SAMHSA supports the Suicide
Prevention Resource Center (http://www.sprc.org), which helps organizations and individuals to
develop suicide prevention programs, interventions, and policies.
The
National
Institute of
Mental Health
provides a
number of
resources,
including fact
sheets on brain
development and
mental disorders
in adolescence.
The Child Trends
DataBank
includes brief
summaries of
well-being
indicators,
including several
that are related
to mental
disorders and
mental health.
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Healthcare.gov provides prevention goals and guidelines for several key indicators of adolescent
mental health, including screenings for depression and decreasing the rate of suicide attempts
(http://www.healthcare.gov/center/councils/nphpphc/strategy/report.pdf).
In addition, health professionals, educators, and others can direct adolescents and their families to a
number of federal resources.
GirlsHealth.gov, from the Office on Women’s Health, offers tip sheets about adolescents
and their feelings, including “How to know if your ‘blues’ are depression”
(http://girlshealth.gov/feelings/).
Adolescents (or anyone) in suicidal crisis or emotional distress can call the National Suicide
Prevention Lifeline at 1-800-273-TALK; calls made to this 24-hour hotline are routed to the
caller’s nearest crisis center.
Acknowledgements
The authors would like to thank Jennifer Manlove, Lina Guzman, and Marci McCoy-Roth at Child Trends for their careful
review of and helpful comments on this brief.
Editor: Harriet J. Scarupa
Adolescents
(or anyone) in
suicidal crisis or
emotional distress
can call the National
Suicide Prevention
Lifeline at 1-800-
273-TALK.
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