Spanning roughly 20 years, childhood and adolescence are marked by dramatic changes in physical, cognitive, and social-emotional skills and capacities. Mental health in childhood and adolescence is defined by the achievement of expected developmental cognitive, social, and emotional milestones and by secure attachments, satisfying social relationships, and effective coping skills. Mentally healthy children and adolescents enjoy a positive quality of life; function well at home, in school, and in their communities; and are free of disabling symptoms of psychopathology (Hoagwood et al., 1996).

The basic principles for understanding health and illness discussed in the previous chapter apply to children and adolescents, but it is important to underscore the often heard admonition that“children are not little adults.” Even more than is true for adults, children must be seen in the context of their social environments, that is, family, peer group, and their larger physical and cultural surroundings. Childhood mental health is expressed in this context, as children proceed through development.

Development, characterized by periods of transition and reorganization, is the focus of much research on children and adolescents. Studies focus on normal and abnormal development, trying to understand and predict the forces that will keep children and adolescents mentally healthy and maintain them on course to become mentally healthy adults. These studies ask what places some at risk for mental illness and what protects some but not others, despite exposure to the same risk factors.

In addition to studies of normal development and of risk factors, much additional research focuses on mental illness in childhood and adolescence and what can be done to prevent or treat it. The science is challenging because of the ongoing process of development. The normally developing child hardly stays the same long enough to make stable measurements. Adult criteria for illness can be difficult to apply to children and adolescents, when the signs and symptoms of mental disorders are often also the characteristics of normal development. For example, a temper tantrum could be an expected behavior in a young child but not in an adult. At some point, however, it becomes clearer that certain symptoms and behaviors cause great distress and may lead to dysfunction of children, their family, and others in their social environment. At these points, it is helpful to consider serious deviations from expected cognitive, social, and emotional development as“mental disorders.” Specific treatments and services are available for children and adolescents with such mental disorders, but one cannot forget that these disorders emerge in the context of an ongoing developmental process and shifting relationships within the family and community. These developmental factors must be carefully addressed, if one is to maximize the healthy development of children with mental disorders, promote remediation of associated impairments, and enhance their adult outcomes.

The developmental perspective helps us understand how estimated prevalence rates for mental disorders in children and adolescents vary as a function of the degree of impairment that the child experiences in association with specific symptom patterns. For example, the MECA Study (Methodology for Epidemiology of Mental Disorders in Children and Adolescents) estimated that almost 21 percent of U.S. children ages 9 to 17 had a diagnosable mental or addictive disorder associated with at least minimum impairment (see Table 3-1). When diagnostic criteria

Table 3-1. Children and adolescents age 9–17 with mental or addictive disorders, combined MECA sample, 6-month (current) prevalence*

* Disorders include diagnosis-specific impairment and CGAS < or = 70 (mild global impairment)
Source: Shaffer et al., 1996a

required the presence of significant functional impairment, estimates dropped to 11 percent. This estimate translates into a total of 4 million youth who suffer from a major mental illness that results in significant impairments at home, at school, and with peers. Finally, when extreme functional impairment is the criterion, the estimates dropped to 5 percent.

Given the process of development, it is not surprising that these disorders in some youth are known to wax and wane, such that some afflicted children improve as development unfolds, perhaps as a result of healthy influences impinging on them. Similarly, other youth, formerly only “at risk,” may develop full-blown forms of disorder, as severe and devastating in their impact on the youth and his or her family as are the analogous conditions that affect adults. Characterizing such disorders as relatively unchangeable underestimates the potential beneficial influences that can redirect a child whose development has gone awry. Likewise, characterizing children with mental disorders as “only” the victims of negative environmental influences that might be fixed if societal factors were just changed runs the risk of underestimating the severity of these conditions and the need for focused, intensive clinical interventions for suffering children and adolescents. Thus, the science of mental health in childhood and adolescence is a complex mix of the study of development and the study of discrete conditions or disorders. Both perspectives are useful. Each alone has its limitations, but together they constitute a more fully informed approach that spans mental health and illness and allows one to design developmentally informed strategies for prevention and treatment.

Normal Development

Development is the lifelong process of growth, maturation, and change that unfolds at the fastest pace during childhood and adolescence. An appreciation of normal development is crucial to understanding mental health in children and adolescents and the risks they face in maintaining mental health. Distortions in the process of development may lead to mental disorders. This section deals with the normal development of understanding (cognitive development) in young children and the development of social relationships and temperament.

Theories of Development

Historically, the changes that take place in a child’s psyche between birth and adulthood were largely ignored. Child development first became a subject of serious inquiry at the beginning of this century but was mostly viewed from the perspective of mental disorders and from the cultural mainstream of Europe and white America. Some of the“grand theories” of child development, such as that propounded by Sigmund Freud, grew out of this focus, and they unquestionably drew attention to the importance of child development in laying the foundation for adult mental health. Even those theories that resulted from the observation of healthy children, such as Piaget’s theory of cognitive development, paid little attention to the relationship between the development of the“inner self” and the environment into which the individual was placed. In contrast, the interaction of an individual with the environment was central to the school of thought known as behaviorism.

Theories of normal development, introduced in Chapter 2, are presented briefly below, because they form the basis of many current approaches to understanding and treating mental illness and mental health problems in children and adults. These theories have not achieved the broader objective of explaining how children grow into healthy adults. More study and perhaps new theories will be needed to improve our ability to guide healthy child-rearing with scientific evidence.

Development Viewed as a Series of Stages
Freud and the psychoanalyst Erik Erikson proposed a series of stages of development reflecting the attainment of biological objectives. The stages are expressed in terms of functioning as an individual and with others—within the family and the broader social environment (particularly in Erikson’s theories) (see Chapter 2). Although criticized as unscientific and relevant primarily to the era and culture in which they were conceived, these theories introduced the importance of thinking developmentally, that is, of considering the ever-changing physical and psychological capacities and tasks faced by people as they age. They emphasized the concept of“maturation” and moving through the stages of life, adapting to changing physical capacities and new psychological and social challenges. And they described mental health problems associated with failure to achieve milestones and objectives in their developmental schemes.

These theories have guided generations of psychodynamic therapists and child development experts. They are important to understand as the underpinnings of many therapeutic approaches, such as interpersonal therapy, some of which have been evaluated and found to be efficacious for some conditions. By and large, however, these theories have rarely been tested empirically.

Intellectual Development
The Swiss psychologist Jean Piaget also developed a stage-constructed theory of children’s intellectual development. Piaget’s theory, based on several decades’ observations of children (Inhelder & Piaget, 1958), was about how children gradually acquire the ability to understand the world around them through active engagement with it. He was the first to recognize that infants take an active role in getting to know their world and that children have a different understanding of the world than do adults. The principal limitations of Piaget’s theories are that they are descriptive rather than explanatory. Furthermore, he neglected variability in development and temperament and did not consider the crucial interplay between a child’s intellectual development and his or her social experiences (Bidell & Fischer, 1992).

Behavioral Development
Other approaches to understanding development are less focused on the stages of development. Behavioral psychology focused on observation and measurement, explaining development in terms of responses to stimuli, such as rewards. Not only did the theories of the early pioneers (e.g., Pavlov, Watson, and Skinner) generate a number of valuable treatments, but their focus on precise description set the stage for current programs of research based on direct observation. Social learning theory (Bandura, 1977) emphasized role models and their impact on children and adolescents as they develop. Several important clinical tools came out of behaviorism (e.g., reinforcement and behavior modification) and social learning theory (cognitive-behavioral therapy). Both treatment approaches are used effectively with children and adolescents.

Social and Language Development

Parent-Child Relationships
It is common knowledge that infants and, for the most part, their principal caretakers typically develop a close bond during the first year of life, and that in the second year of life children become distressed when they are forcibly separated from their mothers. However, the clinical importance of these bonds was not fully appreciated until John Bowlby introduced the concept of attachment in a report on the effects of maternal deprivation (Bowlby, 1951). Bowlby (1969) postulated that the pattern of an infant’s early attachment to parents would form the basis for all later social relationships. On the basis of his experience with disturbed children, he hypothesized that, when the mother was unavailable or only partially available during the first months of the child’s life, the attachment process would be interrupted, leaving enduring emotional scars and predisposing a child to behavioral problems.
A mother’s bond with her child often starts when she feels fetal movements during pregnancy. Immediately after birth, most, but by no means all, mothers experience a surge of affection that is followed by a feeling that the baby belongs to them. This experience may not occur at all or be delayed under conditions of addiction or postnatal depression (Robson & Kumar, 1980; Kumar, 1997). Yet, like all enduring relationships, it seems that the relationship between mother and child develops gradually and strengthens over time. Some infants who experience severe neglect in early life may develop mentally and emotionally without lasting consequences, for example, if they are adopted and their adoptive parents provide sensitive, stable, and enriching care, or if depressed or substance-abusing mothers recover fully (Koluchova, 1972; Dennis, 1973; Downey & Coyne, 1990). Unfortunately, however, early neglect is all too often the precursor of later neglect. When the child remains subject to deprivation, inadequate or insensitive care, lack of affection, low levels of stimulation, and poor education over long periods of time, later adjustment is likely to be severely compromised (Dennis, 1973; Curtiss, 1977).

In general, it appears that the particular caregiver with whom infants interact (i.e., biological mother or another) is less important for the development of good social relationships than the fact that infants interact over a period of time with someone who is familiar and sensitive (Lamb, 1975; Bowlby, 1988). One of the problems in the later development of children who experience early institutionalization or significant neglect is that there may have been no opportunities for the caretakers and the infants to establish strong and mutual attachments in a reciprocating relationship.

Origins of Language
Recent research has established that successful use of language and communication is a cornerstone of childhood mental health. Not only are strong language capabilities critical to the development of such skills as listening and speaking, but they also are fundamental to the acquisition of proficient reading and writing abilities. In turn, children with a variety of speech and language impediments are at increasing risk as their language abilities fall behind those of their peers. Caretaker and baby start to communicate with each other vocally as well as visually during the first months of life. Many, but not all, developmental psychologists believe that this early pattern of mother-infant reciprocity and interchange is the basis on which subsequent language and communication develop. Various theorists have attempted to explain the relations between language and cognitive development (Vygotsky, 1962; Chomsky, 1965, 1975, 1986; Bruner, 1971; Luria, 1971), but no single theory has achieved preeminence. While a number of theories address language development from different perspectives, all theories suggest that language development depends on both biological and socio-environmental factors. It is clear that language competence is a critical aspect of children’s mental health.

Relationships With Other Children
To be healthy, children must form relationships not only with their parents, but also with siblings and with peers. Peer relationships change over time. In the toddler period, children’s social skills are very limited; they spend most of their time playing side by side rather than with each other in a give-and-take fashion.

As children grow, their abilities to form close relationships become highly dependent on their social skills. These include an ability to interpret and understand other children’s nonverbal cues, such as body language and pitch of voice. Children whose social skills develop optimally respond to what other children say, use eye contact, often mention the other child’s name, and may use touch to get attention. If they want to do something that other children oppose, they can articulate the reasons why their plan is a good one. They can suppress their own wishes and desires to reach a compromise with other children and may be willing to change—at least in the presence of another child—a stated belief or wish. When they are with a group of children they do not know, they are quiet but observant until they have a feeling for the structure and dynamics of the group (Coie & Kuperschmidt, 1983; Dodge, 1983; Putallaz, 1983; Dodge & Feldman, 1990; Kagan et al., 1998).

In contrast, children who lack such skills tend to be rejected by other children. Commonly, they are withdrawn, do not listen well, and offer few if any reasons for their wishes; they rarely praise others and find it difficult to join in cooperative activities (Dodge, 1983). They often exhibit features of oppositional defiant or conduct disorder, such as regular fighting, dominating and pushing others around, or being spiteful (Dodge et al., 1990). Social skills improve with opportunities to mix with others (Bridgeman, 1981). In recent years, knowledge of the importance of children’s acquisition of social skills has led to the development and integration of social skills training components into a number of successful therapeutic interventions.

Temperament

During the past two decades, as psychologists began to view the child less as a passive recipient of environmental input but rather as an active player in the process, the importance of temperament has become better appreciated (Plomin, 1986). Temperament is defined as the repertoire of traits with which each child is born; this repertoire determines how people react to the world around them. Such variations in characteristics were first described systematically by Anna Freud from her observations of children orphaned by the ravages of World War II. She noticed that some children were affectionate, some wanted to be close but were too shy to approach adults, and some were difficult because they were easily angered and frustrated (A. Freud, 1965).

The first major longitudinal observations on temperament were begun in the 1950s by Thomas and Chess (1977). They distinguished 10 aspects of temperament, but there appear to be many different ways to describe temperamental differences (Goldsmith et al., 1987). Although there is some continuity in temperamental qualities throughout the life span (Chess & Thomas, 1984; Mitchell, 1993), temperament is often modified during development, particularly by the interaction with the caregiver. For example, a timid child can become bolder with the help of parental encouragement (Kagan, 1984, 1989). Some traits of temperament, such as attention span, goal orientation, lack of distractibility, and curiosity, can affect cognitive functioning because the more pronounced these traits are, the better a child will learn (Campos et al., 1983). Of note, it is not always clear whether extremes of temperament should be considered within the spectrum of mental disorder (for example, shyness or anxiety) or whether certain forms of temperament might predispose a child to the development of certain mental disorders.

Developmental Psychopathology

Current Developmental Theory Applied to Child Mental Health and Illness
A number of central concepts and guiding assumptions underpin our current understanding of children’s mental health and illness. These have been variously defined by different investigators (Sroufe & Rutter, 1984; Cicchetti & Cohen, 1995; Jensen, 1998), but by and large these tenets are based on the premise that psychopathology in childhood arises from the complex, multilayered interactions of specific characteristics of the child (including biological, psychological, and genetic factors), his or her environment (including parent, sibling, and family relations, peer and neighborhood factors, school and community factors, and the larger social-cultural context), and the specific manner in which these factors interact with and shape each other over the course of development. Thus, an understanding of a child’s particular history and past experiences (including biologic events affecting brain development) is essential to unravel the why’s and wherefore’s of a child’s particular behaviors, both normal and abnormal.

While this principle assumes developmental continuities, to the extent that early experiences are“brought forward” into the current behavior, it is also important to consider developmental discontinuities, where qualitative shifts in the child’s biological, psychological, and social capacities may occur. These may not be easily discerned or predicted ahead of time and may reflect the emergence of new capacities (or incapacities) as the child’s psychological self, brain, and social environment undergo significant reorganization.

A second precept underlying an adequate understanding of children’s mental health and illness concerns the innate tendencies of the child to adapt to his or her environment. This principle of adaptation incorporates and acknowledges children’s “self-righting” and“self-organizing” tendencies; namely, that a child within a given context naturally adapts (as much as possible) to a particular ecological niche, or when necessary, modifies that niche to get needs met. When environments themselves are highly disordered or pathological, children’s adaptations to such settings may also be pathologic, especially when compared with children’s behaviors within more healthy settings. This principle underscores the likelihood that some (but not all)“pathologic” behavioral syndromes might be best characterized as adaptive responses when the child or adolescent encounters difficult or adverse circumstances. Notably, this ability to adapt behaviorally is reflected at multiple levels, including the level of brain and nervous system structures (sometimes called neuroplasticity).

A third consideration that guides both research-based and clinical approaches to understanding child mental health and illness concerns the importance of age and timing factors. For example, a behavior that may be quite normal at one age (e.g., young children’s distress when separated from their primary caretaking figure) can be an important symptom or indicator of mental illness at another age. Similarly, stressors or risk factors may have no, little, or profound impact, depending on the age at which they occur and whether they occur alone or with other accumulated risk factors.

A fourth premise underpinning an adequate understanding of children’s mental health and illness concerns the importance of the child’s context. Perhaps the most important context for developing children is their caretaking environment. Research with both humans and animals has demonstrated that gross disruptions in this critical parameter have immediate and long-term effects, not just on the young organism’s later social-emotional development but also on physical health, long-term morbidity and mortality, later parenting practices, and even behavioral outcomes of its offspring. Moreover, context may play a role in the definition of what actually constitutes psychopathology or health. The same behavior in one setting or culture might be acceptable and even“normative,” whereas it may be seen as pathological in another.

Yet another principle central to understanding child mental health and illness is that normal and abnormal developmental processes are often separated only by differences of degree. Thus, supposed differences between normal and abnormal behavior may be better understood by taking into account the differences in the amount or degree of the particular behavior, or the degree of exposure to a particular risk factor. Frequently, no sharp distinctions can be made.

The virtue of these developmental considerations when applied to children is that (a) they enable a broader, more informed search for factors related to the onset of, maintenance of, and recovery from abnormal forms of child behavior; (b) they help move beyond static diagnostic terms that tend to reduce the behaviors of a complex, developing, adapting, and feeling child to an oversimplified diagnostic term; (c) they offer a new perspective on potential targets for intervention, whether child-focused or directed toward environmental or contextual factors; and (d) they highlight the possibility of important timing considerations: windows of opportunity during a child’s development when preventive or treatment interventions may be especially effective.

In the sections that follow, these considerations will help the reader understand the important differences from chapters focusing principally on adults, as well as the unique opportunities for intervention that occur because of these differences.