July 31, 2003 -- When Monica was told she should consider taking her 2-year-old son to a psychiatrist, her first reaction was that maybe her pediatrician was the one in need of a shrink.
Thirty years ago, most psychiatrists would have agreed with her, but times change.
According to the Office of the Surgeon General, one in 10 children under the age of 18 "suffer from mental illness severe enough to cause some level of impairment."
The National Institute of Mental Health, in its fact sheet for physicians Depression in Children and Adolescents, cited studies that found as many as 2.5 percent of children and 8.3 percent of teenagers suffer from depression.
Some psychiatrists say those numbers may even be conservative, suggesting that as many as one in five children will go through extended periods when they show the symptoms of significant emotional problems by the time they turn 18.
And those periods can begin surprisingly early, some psychiatrists say.
The subject is still controversial, but most child psychiatrists ABCNEWS.com talked to agreed that at least some precursors of serious depression can appear in children as young as 2 years old. Some said that children that young can in fact suffer from full-blown depression or post-traumatic stress disorder.
"Over the past 30 years there's been a general movement towards recognizing that children can suffer from serious psychiatric illnesses," said Dr. Jay Reeve, a clinical psychologist with 17 years experience who is currently the senior psychologist on the Children's Inpatient Unit at Bradley Hospital, a pediatric psychiatric hospital in East Providence, R.I.
He said it shouldn't really come as a surprise that children are vulnerable to emotional problems as serious as adults, because children have so little control over the world they live in, and especially when they are very young and cannot really understand why things happen.
"You've got a person 2 feet tall and vulnerable to anything the big people want to do," he said. "We see kids who are suffering from pretty clear signs of depression every day. I think you're seeing professionals and society becoming more comfortable with saying that kids suffer from these illnesses."
While some psychiatrists said that factors such as the rising number of families in which both parents work, violence in neighborhoods and the mobility of families may all have contributed over recent decades to more instability in young childrens' lives that in some cases might result in serious emotional problems, most said they do not believe that there has been any real growth in the number of children who suffer these problems.
Instead, it is that growing "comfort" with making the diagnosis that accounts for what seems like an increase in the number of disturbed kids in America, they say.
As with some types of cancer, it may not be that there is a rise in the number of children affected, only an increase in the ability to recognize it and call it by its proper name, said Neal Ryan, a professor of child and adolescent psychology at the University of Pittsburgh who specializes in depression and anxiety disorders.
Searching for an Answer
For Monica, "comfortable" may not be the word to describe how she feels about saying her 2-year-old could need a psychiatrist, but when she and her husband considered the alternative, they realized they had to try anything they could.
They decided they could not let their son go on with behavioral problems that include uncontrollable tantrums when he is anywhere with more than just a few people, refusal to interact at all with other children, wearing socks on his hands and a period of eight months when they could not take him out of the house at all because of the tantrums he threw.
Still, she said she has a hard time imagining how a psychiatrist is going to be able to learn anything from her son, much less begin to help him.
"He's talking, but they can't talk to him the way they would talk to me, so I'm wondering how this is going to work," she said. "I personally think that he is very young to go to a psychiatrist, but we have tried every other avenue for help."
Psychiatrists do not expect to be able to speak to a child the way they can speak to an adult, though, and have developed different strategies to try to understand the nature of a youngster's problem.
The difficulty is not as pronounced with teenagers, but with elementary school age children, language is not always the best way into a youngster's thoughts and feelings, psychiatrists say, and with toddlers, simply talking reveals very little.
"Certainly we don't have them lay on the couch and tell us about their dreams," said Dr. Chistopher Peterson, an assistant professor in psychology at Penn State Hershey Medical Center.
From Skeptic to Advocate
One alternative is play therapy, in which a therapist allows the child to play — either with the therapist involved or with the therapist simply as an observer. Either way, the therapist watches the kind of games chosen, the story lines, what happens, and over a period of time is able to draw conclusions from the patterns that emerge from the games.
"I sat in on the first few sessions and was able to see how it worked," said Rachel, a woman whose adopted daughter has been diagnosed with post-traumatic stress disorder. "The therapist had so much insight into things I would have overlooked, how she would play with her dolls. Most of it is free play, but there is tremendous observation by the therapist, identifying emotions."
She said that in the program her daughter is in, the therapists also meet with the childrens' parents weekly to discuss what happens in the home, asking probing questions about the child's behavior and interactions with others.
It has made a difference, at least for her daughter.
"I'm now an advocate," she said.
More Than the ‘Terrible Twos’
Like most parents who fear their child may have an emotional or mental disorder that requires psychiatric care, Rachel did not immediately find doctors who seemed to understand what was going on.
The first step was finding someone who recognized that what the little girl was suffering was more than the "terrible twos." It was when she had a developmental evaluation of the girl done that she first heard about post-traumatic stress disorder, but even then, the answer offered wasn't the one she was looking for.
"They told me, 'We can medicate her if it would make it easier for you,'" she said. "I can't tell you how insulting that is to me, that a doctor could suggest or that a parent could medicate a child just to make it easier for them. That was a frightening idea. And it was never presented that that would help her."
The doctors that ABCNEWS spoke to all said that medications should only be used to help the child, and should only be used in conjunction with a program of therapy.
"What I believe the best meds [medications] are is strong relationships in your life, with your family and your friends and strong confidence in yourself and your ability to do things well," said Dr. John Sargent, professor of psychiatry and pediatrics at the Baylor College of Medicine and director of child and adolescent psychiatry at the Ben Taub Hospital in Houston. "So what I want to do is use my meds to make those meds work."
Changing the Chemistry
Medications are a sore issue with many families, who believe that their children have been unfairly labeled as suffering from attention deficit/hyperactivity disorder and are required by school districts or day care providers to take drugs such as Ritalin.
Studies — Reeve called them "voluminous" — have shown that if a child is properly diagnosed with ADHD, certain medications can help the child not only learn while under the effects of the drug, but also learn to focus so that he can eventually study and succeed without the drug.
The same is true for some medications for depression and other emotional disorders that can affect children, psychiatrists say.
Especially among young children, a large contributing factor to depression can be heredity, meaning that their condition may begin in their brain chemistry, and medications known as selective serotonin reuptake inhibitors work to change brain chemistry.
But medications are not the only way to make these changes.
"Psychotherapy can adjust the biochemistry as well," Reeve said.
A ‘Stage’ or Something More?
Proper diagnosis and treatment are both extremely problematic when it comes to young children, psychiatrists say.
The problem goes back to what Reeve said: That until recently it was not accepted that very young children could suffer such problems, and while more and more psychologists and psychiatrists may now take childhood mental and emotional disorders seriously, they say that too many primary care physicians are not trained to recognize the symptoms.
"Unfortunately, a lot of primary care professionals will be inclined to put parents off with 'they'll grow out of it,'" Peterson said.
Sargent said that he gives most "stages" a child might be said to be going through a month.
"But if a kid is alienating friends, you don't want that going on more than a month," he said. "If his grades are dropping, you don't want that going on for more than a month or two. I would say to a kid, 'Hey, let's get back involved in things,' and if that works, fine. If it doesn't, then I want people to come get some help. Then you eliminate some of the lifetime problems that can result from this."
If a child has a serious problem, whether it is depression, PTSD, bipolar disorder or any other mental or emotional illness, getting the proper treatment can mean getting them back on track for a normal life, he said.
"I would much rather treat a problem in a 3-, 4- or 5-year-old in the first six months of it starting, rather than in a 13- or 14-year-old, when it's been around for 10 years," he said. "A lot of problems that kids face we can prevent if we can start treatment early."
Because these problems manifest themselves in so many different ways, their effect on a youngster can be devastating, psychiatrists say.
The behavioral problems they cause, such as aggressiveness, withdrawal or uncontrollable tantrums, can result in a child being labeled a problem not only by day care or school officials, but by their peers. Once those labels are established, they can be difficult to remove, and they can reinforce the child's emotional problem.
They can also result in eating and sleeping disorders that can stunt physical and mental development, putting them out of step with their peers.
"To be diagnosable, you can't just have symptoms, you have to have trouble functioning in your life," Sargent said. "The symptoms create difficulties that worsen the problem."
Treatments may vary from child to child, depending on his or her individual problem and situation, but psychiatrists agree that there is one constant — the whole family must be involved.