Infants, young children, and adolescents all have different stresses and issues -- just like their parents. As a general pediatrician I am frequently asked if a child's behavior is normal. It doesn’t matter how old the child is -- parents question if their child needs mental health help.

Dr. Barbara Keith Walter, a licensed psychologist, helps us understand who should be referred for evaluation and who the appropriate providers are to evaluate their children.

-- Dennis Clements, MD, PhD, MPH

Barbara Keith Walter, PhD, MPHMental health disorders are more common in children and adolescents than many people realize. Studies show that at least one in five children and adolescents have a mental health disorder. At least one in 10, or about six million, has a serious emotional disturbance.

When is a child displaying enough concerns with emotions, behavior, development, or school performance to warrant a referral to a mental health specialist?

Like adults, children and adolescents can have developmental, learning, or mental health disorders that interfere with the way they think, feel, behave, and learn.

When untreated, mental health disorders can persist into adulthood and can be very costly to individuals, families, communities, and the health care system. Untreated disorders can lead to school failure, family conflicts, substance abuse, violence, crime, and suicide.

Unfortunately, there are many barriers that make it difficult for people with mental health disorders to receive appropriate care, including:

• Lack of health insurance, insurance restrictions, and other financial barriers
• Complex and fragmented mental health service delivery systems
• Perceived stigma that discourages families from seeking care
• Lack of culturally appropriate care
• Lack of available mental health professionals with expertise in treating children and adolescents

Signs of a Problem

The American Academy of Child and Adolescent Psychiatry (AACAP Facts for Families, No. 24, updated March 2011, http://www.aacap.org/publications/factsfam/whenhelp.htm) has described the following signs which may indicate a problem that requires further evaluation from a qualified mental health professional:

Younger Children (Ages 5 to 10)

• Marked fall in school performance
• Poor grades in school despite trying very hard
• Severe worry or anxiety, as shown by regular refusal to go to school, go to sleep, or take part in activities that are normal for the child’s age
• Hyperactivity, fidgeting, or constant movement beyond regular playing
• Persistent nightmares
• Persistent disobedience or aggression (longer than six months) and provocative opposition to authority figures
• Frequent, unexplained temper tantrums
• Threatens to harm or kill oneself

Pre-Adolescents and Adolescents (Ages 11 to 18)

• Marked decline in school performance
• Inability to cope with problems and daily activities
• Marked changes in sleeping or eating habits
• Extreme difficulties in concentrating that get in the way at school or at home
• Frequent physical complaints
• Sexual acting out
• Depression shown by sustained prolonged negative mood and attitude, often accompanied by poor appetite, difficulty sleeping, or thoughts of death
• Severe mood swings
• Strong worries or anxieties that get in the way of daily life, such as at school or socializing
• Repeated use of alcohol or drugs
• Intense fear of becoming obese with no relationship to actual body weight; excessive dieting, throwing up, or using laxatives to lose weight
• Persistent nightmares
• Threats of self-harm or harm to others
• Self-injury or self-destructive behavior
• Frequent outbursts of anger, aggression
• Repeated threats to run away
• Aggressive or non-aggressive consistent violation of rights of others; opposition to authority, truancy, thefts, or vandalism
• Strange thoughts, beliefs, feelings, or unusual behaviors

When considering whether your child or adolescent would benefit from seeing a mental health professional, it is important to not just focus on individual signs and symptoms, but to look at the intensity, frequency, and persistence of the presenting symptoms and the degree to which they interfere with the child’s functioning.

However, it is also very important to be aware that you should seek an urgent evaluation if you believe that your child is at immediate risk of harm to self or others or there has been an acute deterioration of thinking, emotions, or behavior that could place the child at risk for harm to self or others.

Where to Go for Help

Once you have decided to seek help for your child or family, it is often confusing to know where to start.

Parents often find it helpful to discuss their concerns with a family member, friend, teacher, school counselor, church leader, or primary health care provider.

The variety of mental health practitioners can also be confusing, and your insurance may have a specific network of providers from which you must choose or services you might need a referral or prior authorization to use with your insurance benefits.

In addition, in many communities, there is a shortage of specialists trained in the identification, diagnosis, and treatment of childhood mental disorders.

Parents should try to find a mental health professional with advanced training and experience with the evaluation and treatment of children, adolescents, and families. However, it is also very important to find a good match between your child, your family, and the mental health professional.

There are a variety of mental health professionals who can evaluate and treat children and adolescents with mental disorders, including child and adolescent psychiatrists, developmental and behavioral pediatricians, pediatric neurologists, clinical or pediatric psychologists, clinical social workers, psychiatric nurses, pastoral counselors, and a variety of other types of licensed counselors and therapists.

All of these professionals have training in the evaluation and treatment of children and adolescents, but the nature and extent of their training varies.

Parents should always ask about the professional’s training and experience. While some physicians, nurses, and social workers are trained in administering some tests as part of their assessment, psychologists typically receive specialized training in administering and interpreting developmental, psychological, and educational tests.

And in most states only physicians, such as child and adolescent psychiatrists, developmental and behavioral pediatricians, and pediatric neurologists, can prescribe and monitor medication.

-- Barbara Keith Walter, PhD, MPH, is a pediatric psychologist who is an assistant clinical professor of medical psychology in the Department of Psychiatry & Behavioral Sciences at Duke University Medical Center and the clinical coordinator of the Behavior, Development, and Mental Health Team at Duke Children's Primary Care.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.