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Mental health professionals on children and mental illness

Psychologist Dr. Ian Manion and psychiatrist Dr. Michael Cheng take your questions

Globe and Mail Update

Many adult patients with mental illness, asked to explain where they think it began, go back to their youth. At least 70 per cent of cases of mental illness in adults can be traced back to childhood; many vividly recall the first frightening moment of infinite sadness or the anxiety that makes you want to strip off your own skin.

According to various studies, illnesses such as depression, anxiety and bipolar disorder affect 13 to 22 per cents of Canadian kids. But there is a lot of denial.

"I'm amazed at how many people don't believe mental illness exists in children," says Ian Manion, executive director of the provincial Centre for Excellence in Child and Mental Health at the Children's Hospital of Eastern in Ottawa.

In Canada's health-care system, mental health is an orphan — and children's mental health, it is said, an orphan's orphan. "Mental illness is the single most-pressing health issue for children, yet the public doesn't take it seriously and neither do health professionals," Dr. Manion says.

Do you have questions about children and mental illness? Do you want to know more?

We're pleased Dr. Manion and Dr. Michael Cheng have joined us to answer your questions on the subject from the perspective of a psychologist and psychiatrist. And while they won't be able to diagnose, they will be able to enlighten. Send your questions now and join us until 4 p.m. Their answers will appear at the bottom of this page.

Dr. Ian Manion is a clinical psychologist, researcher and executive director of the Provincial Centre of Excellence for Child and Youth Mental Health at CHEO. He is also the chairman of the National Infant, Child and Youth Mental Health Consortium, a group of dozens of organizations from across the country working together to champion the development and implementation of a national action plan for child and youth mental health.

As a psychologist, Dr. Manion has helped numerous children, youth and families address debilitating social, emotional and behavioural problems. As an advocate, he is supporting provincial, national and international efforts to make child and youth mental health matter.

Dr. Manion is the co-founder of Youth Net/RéseauAdo, a bilingual community-based mental health promotion program — run for youth, by youth — which has grown to include satellite locations across Canada and in Europe. He is a clinical professor in the School of Psychology at the University of Ottawa, a Visiting Professor at the University of Northumbria and a devoted father of five.

Dr. Michael Cheng is a staff psychiatrist at the Children's Hospital of Eastern Ontario, where he works in the Mood and Anxiety Disorders clinic.

His clinical and research interests include mood and anxiety disorders, sensory processing disorders, e-learning and knowledge exchange. Dr. Cheng devotes himself to finding innovative ways to get reliable information into the hands of those who need it most — children, youth, families and other service providers. He is currently a leader on the ever-expanding ementalhealth.ca project, which connects families and professionals to local mental health resources. Dr. Cheng is an assistant professor of psychiatry at the University of Ottawa.

Editor's Note: globeandmail.com editors will read and allow or reject each question/comment. Comments/questions may be edited for length or clarity. HTML is not allowed. We will not publish questions/comments that include personal attacks on participants in these discussions, that make false or unsubstantiated allegations, that purport to quote people or reports where the purported quote or fact cannot be easily verified, or questions/comments that include vulgar language or libellous statements. Preference will be given to readers who submit questions/comments using their full name and home town, rather than a pseudonym.

Christine Diemert, globeandmail.com: Thanks to Dr. Ian Manion and Dr. Michael Cheng for joining us today to talk about children and mental illness. I'll start the discussion by looking back on a very strong statement from Dr. Manion in The Globe's Saturday story.

"Mental illness is the single most-pressing health issue for children, yet the public doesn't take it seriously and neither do health professionals."

Understanding this can't be solved in one answer, my question to both of you is how can we start to make changes? Is it public perception, educating parents, mandating rules for professionals?

Dr. Ian Manion: Thanks, Christine. We appreciate the opportunity and applaud The Globe and Mail for shedding some light on these very important issues.

You are correct, there will be no quick fix for the long-standing problems in child and youth mental health. We can start by recognizing that most of us have a role to play in changing how our society deals with child and youth mental health issues, which have been identified as critical by those working in child and youth health, education, child welfare, youth justice and developmental services — among others. Despite the widespread concern, we don't have a system that works effectively across all these sectors to best meet the mental health needs of our children and youth.

There is no question that all levels of government need to invest more in the mental health of children and youth. The system is chronically under funded. However, it doesn't make sense for us to put more money into a fundamentally broken system, when we can't be confident it will result in better outcomes. We need to change our approach, fix the system and fund it appropriately. True change will require leadership, creativity and innovation.

Achieving the best mental health for every child and youth is about more than just funding services. It also means increasing the knowledge of anyone who works with children and youth and ensuring they understand how mental health can indeed impact every aspect of a child or youth's life. This includes training for doctors, teachers, police officers and coaches, among others. If they know how to promote child and youth mental health and identify those who might be having more difficulty, they can also help them to find a level of support that is consistent with their needs.

Not everyone will need the most intensive interventions. Getting the right support, from the right provider, at the right time and in the right place can make a huge difference in how well a child or youth can cope with whatever mental health issues they may face.

What we need first is a national vision for child and youth mental health. The Mental Health Commission of Canada is in the process of developing this vision with the help of other pan-Canadian groups like the National Infant, Child and Youth Mental Health Consortium and Canadians from coast to coast. As a first step, the Commission has targeted stigma reduction, with a particular focus on children and youth and health care workers from across disciplines. With the guidance of a national framework, provinces and municipalities should implement a full continuum of effective programs designed to prevent, identify and treat mental health problems among children and youth.

S. Juhn from Canada: I would like to know if there are programs available for children, such as the Panic and Anxiety Disorder group programs for adults that are in existence at some hospitals. Is there a database listing treatment centres for children? What action plan would you recommend for a child who lives in a community where this type of cognitive therapy treatment is not available? Can you recommend resources such as CDs for children with anxiety disorders?

Dr. Ian Manion and Dr. Michael Cheng:

Thanks for the question. There are different types of anxiety programs for children and youth across the country, but we recognize it can be hard to know where to find them.

We are not surprised to hear so many questions from people having difficulties accessing child and youth mental health services, especially in rural or remote areas. This is a particular challenge given the geography of our country and the general lack of services in most communities.

The fact that health care is a provincial responsibility also has contributed to the lack of a single source of information about services available for children and youth across the county.

There are online sources of information that are more regional in nature that help inform families and direct them to services in their area. For example, there is a website known as www.eMentalHealth.ca which has detailed listings of local mental health resources from a growing number of communities. Visit the site to see if there are listings for your area. Although this has been recommended for national expansion, this has yet to happen.

In Ontario, there is a service provider directory available through the Provincial Centre of Excellence for Child and Youth Mental Health at CHEO.

Other countries, such as Australia, have reached out to rural and remote areas with web-based tools. Similarly, in Nova Scotia, the Family Help program has found innovative ways to reach out to those in more remote areas with this website.

Investing in a national strategy and centre of excellence for child and youth mental health would allow all Canadians to benefit from these innovative efforts.

Parents should learn everything they can about anxiety because many of the strategies for anxiety can be given by parents. Although parents should keep their role as 'parents' and not try to be 'therapists', there are nonetheless many simple strategies that parents can learn to use to help their child with anxiety.

Parents can learn more from:

- The Offord Centre has good lists of books for children with anxiety, including Keys to Parenting Your Anxious Child by Katharina Manassis and Freeing Your Child from Anxiety, by Tamar Chansky

Consider online anxiety/panic treatments such as , "a free self-help program from the Australian National University which teaches cognitive behaviour therapy skills to people vulnerable to depression and anxiety."

This site, is for adults, but would be nonetheless useful for a teenager)

Also, consider using medications for persistent anxiety when appropriate and always in combination with other approaches, or consider exercise such as yoga or martial arts which may help with anxiety.

jan mcausland from saskatoon: My grandson was diagnosed with ADHD when he was around six years of age. However, I knew before then that there was something starting to happen. It was like enjoying a beautiful day and all of a sudden out of nowhere a dark storm cloud started to blot out all the sunshine, and press down on everything. Is it possible that he was born with ADHD, and that it took several years to make itself apparent?

Dr. Ian Manion and Dr. Michael Cheng: That is an excellent question. Yes, ADHD is felt to be a genetic condition that you are born with.

There are many children who have problems with sustained attention and high activity level that can affect their lives in many ways. Those with the most severe problems in this area are diagnosed with ADHD. What we know about this problem is that it is present from birth but may only become obvious when the need for sustained attention becomes apparent, like when a child begins school.

The child must show the attentional and behavioural symptoms before the age of seven and not as the result of any other cause (e.g., trauma) to be given the diagnosis of ADHD.

We also know that many children with attentional problems also experience learning disabilities.

A lot of research has been done on how to support these children both at home and at school. With the appropriate supports and structure, and by focusing on the strengths that these children possess rather than on their deficits, it is possible to help them function across environments and to better meet their potential.

Andrew Hume from Victoria: Dr. Cheng: Can you please comment on the issue of the potential metabolic side effects of second generation anti-psychotic medications (SGA's) in children and youth as it relates to weight gain, metabolic syndrome, insulin resistance and Type 2 Diabetes? In particular I am interested in hearing your thoughts on effective ways to educate or communicate with parents about SGA's so they can make informed decisions and how best to communicate with physicians regarding the need for monitoring and follow-up once a child has been put on SGA's? Thank you.

Dr. Michael Cheng: Medications, like all treatments have advantages and disadvantages. The particular advantages/disadvantages of a particular treatment must be individually determined for that particular child/youth, at that particular time.

For a child with lifelong anger and impulse control issues that have not responded to non-medication strategies (including counselling/therapy, and all the usual anger management programs), then it is important to keep an open mind and consider medications.

If the medication is helpful, then it can be continued. If there are side effects, then the risks/benefit ratio must be weighed.

In general, we usually use alternatives to medications (or for SGAs for that matter) first.

Good ways to educate/communicate with parents include websites such as The Offord Centre . There are also useful books, including Straight Talk about Psychiatric Medications for Kids by Timothy Wilens.

As you allude to in your question, it is important for physicians to properly monitor and follow-up children and youth who are on medications.

It is also important to appreciate the role of other service providers, parents, and youth themselves.

Tools such as Med Ed (a project from the Provincial Centre of Excellence for Child and Mental Health) can help in the decision-making process around medication as well as monitoring effects (positive and negative) over time. These tools have been built with parents and youth with appreciation of their rights with respect to treatment choices.

maureen beamish from london: If anxiety disorders and bipolar disorders are so common with children and youth, is there information available on accessing mental health providers who can counsel individuals on cognitive behavioural therapy strategies?

The individual has been diagnosed, and is currently stable on medication, and ready for this counselling to solve every day problems and get on with life. Individuals with mental health disorders seem to have to go down many paths before they find help. This would not be tolerated in cardiology, cancer care etc.

Counselling is not covered under Ontario provincial health insurance. Many youth are not covered under a parent's extended health benefits if they are no longer in school. This is a vicious cycle. This topic is very important to the health and happiness of our communities.

Dr. Ian Manion and Dr. Michael Cheng: Thank you for your question about "Is there information available on accessing mental health providers who can counsel individuals on cognitive behavioural therapy strategies?"

Places to find out about such local health providers include:

For children and youth, the Provincial Centre of Excellence for Child and Youth Mental Health has a directory of health providers Children's Mental Health Ontario has information on accreditated children's (mental health) treatment centres)

eMentalHealth (a project in partnership with the Provincial Centre of Excellence for Child and Youth Mental Health) which is an ever expanding directory of local, provincial and national resources for all ages and various mental health issues

The Canadian Register of Health Service Providers in Psychology has information about psychologists throughout Canada

As well, for adults, there is Mental Health Service Information Ontario

Karen Aqua from Canada: I have a teenage son who has been diagnosed with ADHD, depression and anxiety. In addition he often engages in 'acting out' behaviour including some drug use, skipping classes at school and some behavioral problems at school and at home. He is currently receiving treatment.

What suggestions do you have to balance the need for discipline, maintenance of house rules, punishment of violations of these rules etc., and his mental health issues? Each time I discipline him I wonder whether I will trigger another crisis. Any guidelines or suggestions would be helpful.

Dr. Ian Manion: Dear Karen: There is no denying that the mental health needs of children can change as they become adolescents. Such problems can be compounded by unhealthy ways of coping, including risk-taking behaviours (drug use, skipping school, etc.).

The fact that your son is already engaged in treatment is a positive sign as many young people never get there. Your responsibility as a parent includes reinforcing the new ways that your son is learning to cope through therapy.

A mental illness does not mean the removal of all expectations and limits. At times, such limits may need to be renegotiated explicitly given the young person's strengths and limitations. A therapist can help in negotiating such mutual roles and responsibilities between youth and their parents. As a father of five young adults, one of whom suffers from a mental illness, I know that the challenges faced by parents can not be underestimated.

Susan Partridge from Canada: What do parents do if over the years they have gotten many different diagnoses? The teenager is adopted so he does not have a family history and has had the following diagnoses in this order; Anxiety Disorder, Oppositional Defiant Disorder, Bipolar Disorder, Conduct Disorder, Attachment Disorder. The most recent psychiatrist (well known at CAMH with 50 years experience with very difficult children) said that he finds our son very confusing. We are at the end of our patience, energy etc. and do not know what to do. He has had school phobia and will not go to school or even work on his GED.

Dr. Ian Manion and Dr. Michael Cheng: We sympathize with the frustration you must feel. The reality is that, not unlike physical health, there are many questions that still don't have answers in mental health. Young people who present with a variety of problems don't fit neatly into categories or boxes. At times, we must focus on the key symptoms that are interfering the most with a young person being able to live their life to the fullest.

The anxiety and school refusal that you are describing seem to be key components that need to be addressed.

A better understanding of some of your son's strengths might help his service providers in finding ways to engage him more effectively in his own treatment. There are many effective treatments for children and youth experiencing various forms of anxiety, including cognitive behavioural therapy.

As parents, we should not underestimate our own needs for support as we try our best to support our children and youth. This is particularly the case when dealing with complex problems where there is no clear course of action in the short term.

Kay Mahoney from Canada: My son, who is ten, has Anxiety Disorder with OCD and Asperger traits (as diagnosed by two psychologists and two psychiatrists. He is presently unmedicated, except for infrequent use of melatonin. He has above average intelligence, but hates being at school. The school has accommodated him (as a coded student) with an alpha-smart word processor and a part-time teacher's aide, but he seems unable to enjoy himself due to his incessant worrying. He also has very low self esteem and finds it very difficult to cope when plans change.

He has visited with a psychologist several time over the past two years, but, at close to $200 per hour and two hours of travel (we live in a rural area), the costs are getting difficult to absorb. At present, he is not seeing any medical professional. Lately, his physical symptoms are more pronounced. He often complains of headaches (at the top of his head) and crampy stomach pain. He always finds it difficult to go to sleep at night.

Will he ever be able to enjoy life, or will the anxiety block him at every turn? Reassuring him and telling him not to worry is not working. Would you suggest further visits with a psychologist? A psychiatrist? Should we be considering antidepressant or anti-anxiety medication? How ill does he have to be before we should push for more treatment? I welcome any comments you may have. Thank you

Dr. Ian Manion and Dr. Michael Cheng: In response to your question, "Will he ever be able to enjoy life?" although we do not know enough about your son to comment, we can say that there are numerous examples of people coping with anxiety, OCD and Asperger's who manage to cope with their challenges and do well.

For example, there are many famous individuals with Asperger's who have written about their experiences such as:

Look me in the eye by James Robison

The Way I See It by Temple Grandin

Martian in a Playground by Clare Sainsbury

Should he consider medication? You mentioned that he has seen psychologists and psychiatrists in the past; these professionals would be in a good position to let you know whether or not medications might be helpful. We would recommend ensuring that there has been a good attempt to start with non-medication treatments, e.g. coping strategies for anxiety, addressing any sensory issues, using sleep strategies, etc. Should those difficulties persist despite non-medication strategies, then medications may be very helpful.

Although there is no medication for Asperger's per se, there are nonetheless medications that may be helpful for anxiety and obsessive compulsive symptoms, such as specific serotonin reuptake inhibitors (SSRIs).

How ill does he have to be before pushing for more treatment? Treatment doesn't only have to be limited to medications. And things don't have to get worse before different strategies are tried. Just like with physical medicine an ounce of prevention can be worth a pound of cure.

Various therapies can help with self esteem and help cope with stress. Depending on your area special resources may be available to children and adolescents on the autistic spectrum. Often a first step is a diagnosis from a health care provider. Even if your son does not qualify at this time for an official diagnosis of Asperger's many of the strategies can help. Social skills training can help your son feel more comfortable with peers; reading about other children with similar challenges who grew up to lead successful lives can also help your son's resiliency. Many of these people can also relate their own experiences with what has worked for them. Sometimes this does involve medications. More often however treatment or managing also involves non medication methods.

And last but not least, we recommend contacting Autism Canada, which provides information on their website and depending on where you live, may also provide more direct support.

Christine Diemert, globeandmail.com: Thanks Dr. Manion and Dr. Cheng for joining us today. We had a lot of questions I hope we were able to get to most of them. Before we close, I want to ask whether there is anything you'd like to add.

Dr. Ian Manion and Dr. Michael Cheng: The breadth of questions received today speaks to the complexity of the issues at hand and the need for ongoing dialogue. There are many efforts under way to ensure that child and youth mental health continues to be on the national radar. There are clear knowledge gaps as well as major challenges with respect to the co-ordination of care for children and youth across the country. But there is also hope. There is a growing band of champions from across the country who are committed to making things better.

The Globe and Mail should be commended for its efforts to bring awareness to the serious mental health issues faced by Canadian children and youth. While we might tend to focus on the most serious and dramatic situations impacting young people and their families, let us not forget those experiencing day-to-day symptoms that may be less obvious but also have serious impacts on the quality of a young person's life. In some respects, those young people may benefit most from our efforts at prevention and early intervention. It is also clear that many parents are struggling as they do their best to support their children and youth. A comprehensive system also needs to attend to the needs of parents and caregivers and recognize their critical role in such a system.

Mental health issues can affect each and every one of us, both directly and indirectly. The people who have spoken out today are contributing to a more open conversation that all Canadians need to participate in. Only through such dialogue will we be able to make a system that actually works for our children and youth.

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