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Child and Adolescent Psychiatric Disorders

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1 Child and Adolescent Psychiatric Disorders

2 Kids and Mental Health Principles: –Diagnosis is very complex!!! –Treatment is difficult and often unsatisfactory. –Families, schools, and social services are all extremely vulnerable to social, political, and financial pressures and emotions run high. –It is difficult to stay focused when there is a continual crisis.

3 Childhood Development We currently believe that each child is born with an inborn temperament which is shaped and molded by the family, caretakers, and environmental experiences. In turn, the behavior of the infant effects the environment. Happy babies who like to be cuddled will elicit warmth and nurturance from the caretakers. Irritable, overly sensitive children may cause caregivers to be impatient and withdraw.

4 Theories of Personality: Trait Theories - Cloninger Temperament and character: 50% of personality is attributed to temperament, 50% to character –Temperament: biologically based, quite stable Novelty seeking Harm avoidance Reward dependence Persistence –Character: psychosocially based, varies throughout adulthood Self-directedness Cooperativeness Self-transcendence

5 Development of Disorders Temperament to Trait to Disorder –Temperament, along with environmental influences, inclines people to develop certain traits. –Personality traits are emotional, cognitive, and behavioral tendencies in which individuals vary from each other. –When traits become maladaptive and dysfunctional, they lead to diagnosable personality disorders. Environmental stressors may amplify certain traits at certain times.

6 What Causes Pathology? Nature and Nurture: Stress-Diathesis model –Most mental illnesses have their beginnings in childhood Does a bad childhood cause mental illness? –The brain is an incredibly plastic organ. Early learning can be reversed by later learning. –Childhood experiences alone do not determine personality traits. –Adverse events in childhood do not regularly cause mental disorders. –Except for vision and language, the evidence for an invariable set of developmental stages that must be mastered at a certain time is slim.

7 Childhood Externalizing Disorders Temperamentally extroverted and impulsive In an unfavorable family environment, at risk for oppositional and conduct disorder They effect peers, adults, and teachers quite negatively. 33% will be diagnosed with antisocial personality disorder Also at risk for substance abuse and mood disorders ADHD with conduct disorder is risk for APD

8 Childhood Internalizing Disorders Children with introverted temperaments who worry a lot and are overly dependent Prone to depression and anxiety symptoms in certain environments

9 Childhood Cognitive Disorders Odd affect, social isolation, poor interpersonal skills, cognitive difficulties Clearly related to premorbid phase of schizophrenia Children are at risk for schizophrenia, schizoaffective disorder

10 Environmental Data: Amplification Effects Externalizing children may be in chronic conflict with peers, teachers, and other adults, and may respond to conflict with greater maladaptive behavior. Shy children who are overly shy may be overly protected

11 Environmental Effects There does not seem to be a one-to-one correspondence between particular stressors and particular disorders. Abusive inconsistent parenting, sexual abuse, early loss, trauma, lack of social cohesion are all implicated.

12 Attention Deficit/ Hyperactivity Disorder Current theories suggest that persons with ADHD actually have difficulty regulating their attention: difficulty inhibiting their attention to nonrelevant stimuli and/or focusing too intensely on specific stimuli to the exclusion of what is relevant. A neurotransmitter imbalance connecting the frontal cortex with the basal ganglia results in distortion of six major aspects of executive functioning.

13 Executive Functions Flexibility: shifting from one strategy or mindset to another Organization: anticipating needs and problems Planning: goal setting Working memory: receiving, storing and retrieving information within short-term memory Separating affect from cognition: detaching one’s emotions from one’s reason Inhibiting and regulating verbal and motoric action: jumping to conclusions, difficulty waiting

14 ADHD 3-7% incidence in many Western countries 50-60% will have another condition, such as learning disorder, restless-legs syndrome, depression, anxiety, conduct disorder, obsessive- compulsive behavior More frequently diagnosed in boys, but it is being recognized more in girls. It is not clear how much is carried over into adulthood. Hyperactive symptoms may decrease with age because of increased self-control. Attention problems may continue.

15 ADHD ADHD is the most common psychiatric disorder in childhood. Incidence of the different subtypes: the inattentive subtype - 4.7%, hyperactive - 3.4%, combined - 4.4%. It is inheritable with concordance in monozygotic twins of 51%, dizygotic 33%. Psychosocial factors do not appear to play an etiologic role, although they may contribute to oppositional and conduct disorders. It has not been proven that environmental abnormalities contribute to ADHD.

16 Diagnosis The diagnosis is made clinically using parent/child/teacher interviews and observations, behavior rating scales, physical and neurological examinations, cognitive testing. There is no laboratory test. Important are past medical history including for other psychiatric disorders (anxiety, bipolar, conduct, depression, eating disorders, learning disability, pervasive developmental disorder, PTSD, psychosis, sleep disorder, AODA…)

17 Diagnosis Social history –School performance –Social skills –Home and family interactions Disorganization of personal space Anger or rage reactions Most awake in the late evening Awakening child in the AM difficult Unable to do chores Homework organization and completion hard Family dysfunction

18 Diagnosis Medical exam –Laboratory work Liver function tests possibly Complete blood count Drug screening if appropriate Thyroid, glucose, other metabolic screen –Imaging - none presently –Physical –Other tests - impulsivity, attention deficit scales, IQ, learning disabilities, executive functions

19 Problems “in vogue” diagnosis Heavy pharmaceutical marketing Those with diagnosis get special considerations Primary care MD’s have difficult time with diagnosis - requires time and testing Diagnosis is unusually dependent on social and educational circumstances Diagnosis has high degree of subjectivity and testing is not specific

20 Treatment Stimulant medication has become the mainstay of treatment. All of the medications seem to be equally effective with about a 70% response rate. They have a positive effect on academic performance, classroom behavior, and academic productivity. Side effects are the same: decreased appetite, initial sleep difficulty, headaches, stomachaches, tics, and irritability. Growth suppression, if at all, appears dose related. There is no evidence of tolerance or later substance abuse.

21 Treatment Medication is useful for a large number of children, but not all. In addition, medication generally does not produce total remission of symptoms. Psychosocial interventions such as parent support groups, parent management training, school based programs, behavior modification, special classes may be helpful.

22 Oppositional Defiant Disorder A recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures –Losing one’s temper –Arguing with adults –Actively defying requests –Refusing to follow rules –Deliberately annoying other people –Blaming others for one’s own mistakes –Being resentful, irritable, spiteful, vindictive

23 ODD Not diagnosed unless it occurs for at least 6 months and is much more frequent than in children of the same age. Prevalence is 6-10%. More common in boys until puberty. Lots of overlap with ADHD and CD. Some see ODD as a precursor for CD. As with CD, temperament (irritability, impulsivity, and emotional intensity) contributes to a pattern of oppositional and defiant behaviors. Negative cycles result.

24 ODD Milder forms may remit. More serious forms evolve into CD. There is high comorbidity with ADHD, learning disorders, CD and internalizing disorders. A comprehensive evaluation is necessary, Treatment involves PMT, medication if appropriate, social skills training, academic support, individual counseling if needed.

25 Conduct Disorder One of the most difficult and intractable mental health problems in children. Present in 2-9%, mostly boys Behaviors: –Aggression toward people and animals –Destruction of property without aggression –Deceitfulness, lying, and theft –Serious violations of rules

26 Aggression Bullies, threatens, or intimidates others Initiates physical fights Has used a weapon that could cause serious physical harm Physically cruel to people or animals Stolen while confronting a victim Forced sexual activity

27 Property Destruction Engaged in fire setting with the intention of causing damage Deliberately destroyed others’ property

28 Deceitfulness or Theft Has broken into someone’s house, building, or car Often lies to obtain goods, favors, or avoid social obligations Has stolen items of non-trivial value without confronting the victim

29 Serious Violations of Rules Often stays out all night despite parental prohibitions, beginning before 13 years old Has runaway from home overnight at least twice (or once for a lengthy period) Is often truant from school, beginning before 13 years old

30 Subtypes of CD Childhood onset –Presence of 1 criteria before age 10 –Typically boys exhibiting high levels of aggression –Often also have ADHD –Problems tend to persist to adulthood (APD) Adolescent onset –No criteria met before age 10 –Less aggressive, more normal relationships –Most behaviors shown in conjunction with peers –Less ADHD. Equal gender distribution –Much better prognosis

31 Risks for Conduct Disorder Individual –Perinatal toxicity –Difficult temperament –Poor social skills –Friends who engage in problem behavior –Innate predisposition for violence Family –Poverty –Overcrowding –Poor housing –Parental drug abuse –Domestic violence

32 Risks for Conduct Disorder Family (cont) –Inadequate, coercive parenting –Child abuse –Insufficient supervision School –Disadvantaged school setting –Poor school performance beginning in elementary school

33 Natural History Signs early as age 2 (irritable temperament, poor compliance, inattentiveness, impulsivity) Early disturbances lead to diagnoses of ADHD or oppositional defiant disorder For some children with severe temperament problems, even a stable home and excellent parenting does not prevent CD. However, more often children have unstable, stressed environments with ineffective or abusive parenting.

34 Natural History Negative cycle: –Difficult temperament in the child –Children resist complying with parental requests –Parents either give in or become more punitive –Child either becomes more defiant or becomes physically aggressive –Parents become increasingly isolated from outside support. They are afraid to take the child out in public. –Child receives less and less parental interaction –Child does not have opportunities to learn more mature behaviors

35 Natural History Elementary school –Children lack social skills, do not recognize social cues, cannot problem solve –Resort to aggression and intense anger rather than verbal problem solving –Blame others for their actions (no self-awareness) Middle and high school –Noncompliance with commands –Emotional overreaction –Failure to take responsibility for their actions

36 Natural History Middle and high school (cont) –Academic failure (poor cognitive development) –Peer group is other high risk children (other peers reject them at a time when friendships are critically important) –Depression often occurs as child is alienated from family, friends, school, other positive social groups –The deviant peer group provides training in criminal and delinquent behavior including substance abuse –If arrested and incarcerated, usually the behavior will worsen

37 Conduct Disorder Co-occurrence with ADHD is at least 50%. It is almost impossible to distinguish these in young children. There is also high comorbidity with internalizing disorders and learning disabilities. Children must be evaluated for academic difficulties as well as for comorbid mental illnesses.

38 Treatment CD is highly resistant to treatment Treatment must begin early and must include mental health, medical, educational and family components Because of the high degree of overlap between CD and ADHD, stimulant medication is usually tried. In ADHD, stimulants control specific symptoms of inattention, impulsivity, and hyperactivity. They do not improve relationships with parents, teachers, or peers No medication is proven helpful for conduct disorder without ADHD

39 Treatment Parent Management Training has the strongest evidence base. PMT offers parents training on how to become more effective in giving positive, specific feedback, how to employ the use of natural and logical consequences, and how to use brief, nonaversive punishments when appropriate.

40 Treatment Individual psychotherapy as an individual treatment has not proven effective Group therapy may have some benefit for younger children. For adolescents, group treatment often worsens behavior. Best is a comprehensive model of treatment: behavioral PMT, social skills training, academic support, pharmacological treatment of ADHD or depression, individual counseling as needed.

41 Natural History Physical aggression peaks around the age of two, then usually decreases as the child develops empathic attachment for others. Adolescent risk taking is a normal transitional step to adulthood. Risky behaviors include: –Alcohol: 40% of adult alcoholics report first having symptoms of alcoholism related behavior between –Gambling: 10-14% of adolescents engage in problem gambling beginning at age 12.

42 Natural History Risky behaviors: –Automobile accidents: drivers of both sexes between are twice as likely to be in accidents than drivers between 20 and 50. It is the leading cause of death for teens. –Sexual activity: adolescents are more likely than adults to engage in impulsive sexual behavior, have multiple partners, and fail to use contraceptives. Younger teens (12-14) are more likely to engage in risky sexual behavior than older teens (16-19). 3 million adolescents a year contract an STD.

43 Risk Taking Conventional wisdom states that teens take risks because they think they are invulnerable, and they don’t think before they act. Intervention programs have typically emphasized the importance of giving teens good information and then expecting them to make good choices. These programs have achieved only limited success.

44 Risk Taking Recent studies demonstrate that teens: –Do not think they are invulnerable any more than adults think they are invulnerable –Tend to overestimate the true risks of potential behavior –After careful consideration, generally decide that the benefits usually outweigh the risks of a choice Intervention programs do not address the allure of potential benefits. They emphasize dangers.

45 Risk Taking Mature adults do not think logically in risky situations - they use intuitively based, bottom line thinking which yields a simple, black and white conclusion. This type of thinking increases with age, experience, and expertise. Mature decision makers will not deliberate about risk versus benefits if there is a reasonable chance of a catastrophic outcome, e.g. playing Russian roulette.

46 Time to Decision: Is it a good idea to drink Drano?

47 Interventions Consider that there are risky deliberators, and risky reactors who are too impulsive to deliberate. For risky deliberators, focus on reducing the perceived benefits of risky behaviors. Encourage teens to develop rapid, unambiguous responses to risky situations (“I do not ride with a drinking driver.”) For risky reactors, monitor and supervise as much as possible. Remove opportunities to engage in risky behavior. Do not rely solely on teaching them how to think.

48 The Teen Brain? The myth: teens are inherently incompetent and irresponsible. Peak age of arrest in the US for most crimes is 18. American parents and teens are in conflict with each other 20x/ month. Research on 186 pre-industrialized societies: –60% had no word for adolescence –Teens spent almost all their time with adults –Teens showed almost no signs of psychopathology –Antisocial behavior in teens was absent in >50%, or very mild when it did occur.

49 The Teen Brain? Trouble begins to appear in other cultures soon after the introduction of Western-style schooling, television, and movies. Until 100 years ago, teens were not trying to break away from adults, they were learning to become adults. We have infantilized our teens, and isolated them from us. Teens in the US are subjected to 10x as many restrictions as adults, twice as many as active duty marines and incarcerated felons.

50 Laws Restricting Behavior of Youth Under 18

51 The Teen Brain When teens are trapped in peer culture, they learn virtually everything they know from one another. When we treat teens like adults, they almost immediately rise to the challenge.

52 Adolescents All segments of the US population have experienced improved health throughout the past 30 years except for adolescents, in large part because they represent a disproportionately large proportion of the drug abusing population. Drug abuse has been implicated in premature deaths of adolescents because of homicide, suicide, and accidents.

53 Camel #9 “light and luscious” Packaged in fuchsia, outlined with a thin red line, designed to appeal to adolescent girls. $2 million for marketing in Wisconsin alone. They must add 100 new smokers each day, because ~20,000 people overcome their addiction each year, and 8,000 die from it, including 1,100 women.

54 Adolescents and Substance Abuse Cigarette smoking –Nicotine dependence begins in adolescence. 25% of seniors smoke. Although teens smoke relatively few cigarettes, usually under the belief that they will not become addicted, the great majority increase their smoking after high school. –Smoking is increasing faster among girls than boys. There is evidence they are more prone to develop nicotine addiction.

55 Adolescents and Substance Abuse Cigarette smoking –Tobacco use in teens is associated with a wide range of risk taking behavior, including violence, high risk sexual activity, and drug use. There is a significant risk of developing a major depression within one year of starting to smoke. Children with psychiatric disorders are also more likely to smoke. –Teenage smoking reached a peak in Wisconsin in 1999 (38.1% of seniors) and has declined to 20.9%. Girls (21.9%) have a slightly higher prevalence rate than boys (19.8%).

56 Prevention of Cigarette Smoking The most effective antidote to smoking is expensive cigarettes. Resistance training skills are helpful to reduce smoking initiation % of initially successful quitters resume smoking within 6 months. If they can stay abstinent for 5 years, risk of relapse is negligible.

57 Drug and Alcohol Abuse Drug use increases in adolescents to young adulthood, then generally declines. In 2005, there has been a decline in alcohol use, LSD and cocaine, but an increase in illicit prescription drugs (oxycodone), marijuana, and club drugs. The use of inhalants is rising among 8th graders. Teenage drinking among girls is rising faster than boys, in large part because they are being targeted in alcohol related ads in the magazines they read.

58 2005 “Monitoring the Future” Survey Drinking in last month –8th grade17% –10th grade33.2% –12th grade47% –28% of seniors binge drink Tried an illicit drug –8th grade21% –10th grade38% –12th grade50%

59 Drug Abuse in Children and Adolescents 1:5 teens has abused Vicodin or OxyContin. 10% have abused a stimulant - Adderall is the most common. 10% have abused cough medicines Most of the time, these prescription drugs are in the family medicine cabinet. There are Internet sites devoted to how to get and abuse drugs. Inhalant abuse can be fatal. Such agents are commonly found in household - glue, shoe polish, spray paints, nitrous oxide, correction fluid, etc.

60 Prevention in Children and Adolescents The younger the child initiates alcohol and other drug use, the higher the risk for serious health consequences and adult substance abuse and dependence. Effective prevention and intervention programs consider cultural context, social resistance skills, and developmental level of the child.

61 Prevention in Children and Adolescents Peers have been successfully used to influence, teach, and counsel young people. Even though education about drugs do not contribute greatly to reducing drug use, the use of peers as facilitators works for the average student. Adolescents believe their peers’ attitudes against drug use. The lower the perceived acceptance rate, the less frequent the drug use. DARE works better than non-interactive programs, but not as well as programs involving peer delivery of information.

62 Prevention in Children and Adolescents Most promising preventive measures are: –Assessment and treatment of psychiatric disorders –Education that targets knowledge and attitudes about substances –Development of proper social and problem solving skills –Treatment of family problems –Increased opportunities for prosocial activities with peers –Limited early access to the use of gateway drugs such as alcohol and nicotine

63 Prevention in Children and Adolescents Risk factors: –Poor self-image –Low religiousity –Poor scholl performance –Parental rejection –Family dysfunction –Abuse –Over or under-controlling by parents –Divorce –Externalizing disorders (ADHD has 3x risk substance use. Those in treatment are at less risk)

64 Protective Factors in Children and Adolescents Nurturing home with good communication Teacher commitment Positive self-esteem Self-control Assertiveness Social competence Academic achievement Regular church attendance Intelligence Avoiding delinquent peers

65 Depression Depression is a constellation of symptoms including social isolation, lack of energy, changes in sleep and appetite, and an inability to experience pleasure that appear in addition to a depressed mood.

66 Substance Abuse and Mental Health Services Administration

67 SAMHSA % of adolescents experienced a depressive episode over the last year. Girls % Boys - 5% No differences in ethnic group, SES in incidence, but those with health insurance were more likely to get treatment. <50% received help for depression. Those with depression were twice as likely to smoke, use alcohol and illicit drugs.

68 Wisconsin High School Survey 2003 During the last 12 months, have you felt sad or hopeless for 2 weeks or more so that you stopped doing social activities? –Total25.3% –Boys17.6% –Girls33.5% –Junior year the worst

69 Depression Depression may manifest itself as irritability and behavior problems in children and adolescents. Research now indicates that substance abuse in boys and girls, and sexual behavior in girls is a cause for subsequent depression in adolescents. Depression can then make teens more vulnerable to substance abuse and other risky behaviors. The use of antidepressants in children and teens is controversial.

70 Antidepressants and Suicide In the summer of 2004, two reviews by Columbia University looked at pharmaceutical industry data from 22 placebo controlled trials involving 4,250 pediatric patients. They found that young people given antidepressants were 1.8x more likely to become suicidal as young people given placebo.

71 Antidepressants and Suicide On October 15, 2004, the FDA issued its strongest possible warning (black box) for all antidepressants stating that these medications may “increase the risk of suicidal thinking and behavior in children and adolescents with major depressive or other psychiatric disorders.”

72 Antidepressants and Suicide The best approach is to monitor everyone who is started on an antidepressant closely for the appearance of suicidal ideation, agitation, and irritability, especially during the initial months of therapy, and be sure that the risk is discussed during the informed consent process.

73 Self-Injurious Behavior SIB - the deliberate alteration or destruction of body tissue without conscious suicidal intent Four types: –Severe - extensive damage (psychotic) –Stereotyped - rhythmic (DD, seizure disorders) –Socially accepted/emblematic - tattooing, piercing, etc… –Superficial/moderate

74 Superficial/Moderate Compulsive: –Habitual, obsessive/comp rather than impulsive. Urge is resisted. (Ego-dystonic) Intrusive thoughts about contamination, inadequacy, bodily shame. Nail biting, trichotillomania, skin picking Episodic: –Occasional impulsive burning and cutting in response to stress or life events. Repetitive: –Repetitive burning and cutting, rumination about self-abuse and identification as a cutter or burner. There is little resistance to the urge. Carefully executed. Has qualities of addiction.

75 Superficial/Moderate Counter-dissociative: –An attempt to re-associate self with here and now reality Parasuicidal: –“suicide gesture” reflecting ambivalence about suicide or as attempt to communicate to others

76 Impulsive, Superficial/ Moderate SIB Skin cutting is the most common, followed by burning and hitting Commonly comorbid with personality disorders Typically includes onset in adolescence, multiple episodes, chronic, associated with depression, despair, anger, aggression, anxiety, cognitive constriction Predisposing factors include lack of social support, male homosexuality, AODA, suicidal ideation in women. Diagnosed as Impulse Control Dis NOS, or BPD

77 Self-Injurious Behavior Worldwide, nonfatal deliberate self-harm is more common in adolescents, especially young females (11.2% girls, 3.2% boys) Boys more frequently need medical attention. Self-harm in adolescents increased with consumption of cigarettes, alcohol and drugs in one large study. Having friends or family members self-harm was also a risk factor. Depression, anxiety, and impulsivity was a risk for girls, who said they were trying to punish themselves or get relief from a terrible state of mind. The Internet may normalize and encourage pre-existing SIB in adolescents.

78 Self-Injurious Behavior There is disagreement about the meaning of the injury: symbolic, impulse disorder, serotonin deficit, endorphin dysregulation. Adolescents are likely to explain their self-harm by saying they wanted relief from unpleasant feelings (depression, anxiety, loneliness, anger) or that the act was impulsive. Childhood abuse is a factor in the descriptive and empirical literature. There are also associations with AODA, PTSD, intermittent explosive disorder, dissociative disorder.

79 Summary of Reasons for SIB Affect regulation –Reconnection with the body –Calming the body during periods of arousal ( exhibit decreases in respiration, skin conductance, heart rate in response to the behavior (like concentration) –Validating inner pain –Avoiding suicide Communication –Express things which cannot be said out loud Control/punishment –Trauma re-enactment –Bargaining and magical thinking –Self-control –Control of others

80 Children and Suicide Suicide attempts are statistically insignificant until the age of 12., but higher in the US in the last 20 years. Suicidal children have a history of impulsive, aggressive behavior, are taller and physically more mature than their classmates, more were more likely to be involved with conflict with parents, and be in a disciplinary crisis. Families must be involved in assessment, prevention and treatment.

81 Warning Signs Past suicide attempts or threats Past violent or aggressive behavior Mental illness or alcohol use Bringing weapons to school Recent experience of humiliation, shame loss Bullying as victim or perpetrator Victim of abuse/neglect Themes of depression, death Vandalism, cruelty to animals, setting fires Poor peer relationships, cults, no supervision

82 Suicide first arises as a public health problem at 12 years old.

83 Suicide Rates:

84 Adolescent Suicidal Behavior: 2001 U.S. Data

85 Wisconsin Suicides Suicide is the second leading cause of death in adolescents. From , there were 323 suicides (262 homicides.) The annual rate is 5.7/100, % higher than the national average. The highest incidence is in northern Wisconsin. Guns are involved in 52%. 27% tested positive for alcohol.

86 Suicidal Ideation In teens, suicidal ideation more strongly indicates antisocial behavior than it does risk of suicide. Features that may separate those who attempt from those who don’t: –AODA –Severe and enduring hopelessness –Isolation –Reluctance to discuss suicidal thoughts –Psychopathology

87 Gender Issues Girls –Attempts to completions4,000:1 –A suicide attempt is not a risk factor for suicide. Having a depressive episode is, often with no precipitating event –Panic attacks are a risk factor for girls Boys –Attempts to completions500:1 –Rate increased 3x since Increased AODA? –Dropped since Increased antidepressants? –Usually within hours of event, before consequences, when anticipatory anxiety is highest. Events include legal problems, relationship problems, humiliation. –Aggression is a risk factor for boys

88 Risk Factors for Adolescents Mental illness –90% have depression, anxiety, AODA a year before suicide. It is estimated that 1 million youths suffer from depression, but 60-80% do not receive help. Fewer than 10% of completed suicides were on antidepressants or in AODA treatment. –50% of teen suicides involve alcohol use. –Parents frequently do not recognize signs of suicidal behavior. Most lay people justify depressive symptoms in themselves and others, blaming it on stress. Stressors can mislead. It may be the mental illness that is causing the stress.

89 Risk Factors for Adolescents Imitation Family history Sexual orientation issues Sexual abuse Other stressors –Interpersonal losses –Bullying (perpetrator or victim) –Lack of affiliation –Males after romantic breakup

90 Suicide Attempts (cont) Girls attempt mostly by ingestion (55%) or cutting (31%). Boys by cutting (25%), ingestion (20%), firearms (15%), hanging(11%). Greatest difference in mental state between an ideater and attempter is the presence of AODA. Suicidal teens who abuse substances are 12.8x more likely to make an attempt.

91 Risk Factors Incarceration –The suicide rate for adolescents in detention centers is 57/100,000. For adolescents housed in adult facilities is 2,041/100,000!!

92 Risk Assessment in Adolescents Although suicidal ideation is very common in this population, suicide should be asked about and evaluated in the context of an accompanying mental illness. Depressed adolescents should always be assessed for suicidality. It is important to include data from many sources, including parents, school, or other significant relationships.

93 Risk Assessment in Adolescents Consider the following: –Predictability of the youngster –Circumstances of suicidal behavior –Intent to die –Psychopathology –Coping mechanisms –Communication –Family support –Environmental stress

94 Risk Assessment in Adolescents Precipitating factors in vulnerable youth may increase immediate risk. –Opportunity Access to lethal means, lack of supervision –Altered states of mind Hopelessness, rage, intoxication, mental illness –Undesirable life events Losses, loss of esteem, humiliation, pregnancy, abuse

95 Prevention Strategies Suicide awareness programs –Popular with normal teens, but they don’t seem to increase self-referrals, help-seeking, or help-giving in adolescents. They may activate suicidal ideation in disturbed adolescents, whose identity is usually not known by the instructor. They may contribute to clustering. They also tend to minimize the role of mental illness.

96 Prevention Strategies Screening –Assessments of depression, AODA, recent or frequent suicidal ideation, past suicide attempts. They identify a number of unknown, untreated cases of depression. –Screening programs that do not include procedures to evaluate and refer should not be used. Gatekeeper training –Teachers, counselors, MD’s, youth workers trained to recognize teens at risk. This may work, but there is no clear research.

97 Prevention Strategies Crisis centers and hotlines –There is little research about the effectiveness of these centers. Few teenagers use them, and those that do are not at highest risk (boys). Restriction of lethal means/alcohol –A modest but statistically significant decrease in teen firearm suicides has been associated with child access prevention laws. –Even adolescents without a mental disorder have 13x greater suicide risk if there is a gun in the home and a 32x greater risk if it is loaded.

98 Restriction of Lethal Means Firearms 17% of households purchase new guns after a child’s suicide attempt. But if they are educated, they are 3x more likely to remove them. –The following reduce suicide risk in an additive manner: Unloading guns Locking guns Storing ammunition separately Locking ammunition Alcohol –States that have increased the minimum drinking age have seen a 7% suicide reduction in teens.

99 Prevention Strategies Skills training –Teaching the problem solving and coping skills in the skills. Some evidence of efficacy. Follow-up appointments –A nighttime phone contact and next day follow-up assures 90% of teens will stay in treatment after an ER visit. Antidepressants –Caregivers need to be alert for decreasing inhibition, irritability, change in sleep, agitation in the first weeks after an antidepressant has been started.

100 Bipolar Disorder Bipolar disorder is a disorder of mood swings, out of proportion with events in a person’s life. These swings include mania and depression. Bipolar disorder in children is enormously controversial! Depending on who you listen to, there is either an epidemic, or it is virtually non- existent. The diagnosis has increased 26% from 2002 to 2004!

101 Dr. Biederman, Mass Gen, Boston Irritability is the determinant, even in the absence of depression, elevated mood, grandiosity, or cycles of behavior. These irritable episodes are not just tantrums, but explosive, long-lasting, and often without triggers. This is the “Broad Phenotype” - Bipolar NOS Supported by parents, insurance companies, and by the observation that many of these children respond to medication.

102 Dr. Geller Washington U, St. Louis Children must have alternating episodes of mania and depression. The cycling can be complex and very short. This is the “Narrow Phenotype.” Children exhibit: –Excessive giddiness –Severe irritability –Grandiosity –Fragmented thought –Aggression

103 Making a Diagnosis Besides symptoms, we generally require three important validators of a diagnosis: –Family history –Course of illness The first presentation of Bipolar Disorder is depression 33-50% of depressed children develop mania in yrs. –Treatment response Bad reaction to antidepressant

104 Bipolar vs. ADHD Most children diagnosed with bipolar disorder appear to also meet ADHD criteria. It is rare that children with ADHD meet bipolar criteria. In adults with bipolar disorder, 33% can be diagnosed retrospectively with ADHD, with about 10% having current ADHD symptoms.

105 Bipolar vs. ADHD? It may be that these represent different developmental presentations of the same condition: –Childhood ADHD –Adolescent anxiety and depression –Young adult bipolar disorder (mania)

106 Problems Children who get amphetamines may have an earlier age of onset of mania than those who don’t! Amphetamines can be harmful neurobiologically, especially after adolescent exposure, with hippocampal atrophy, disturbed dopaminergic activity, enhanced corticosteroid response to stress, and increased long-term depressive and anxiety behaviors.

107 Distinguishing Bipolar Disorder from ADHD Sleep problems are more common in bipolar. Irritability, frustration intolerance and aggression are present in both. Attention problems can be the same. Mood symptoms distinguish the bipolar group, but not until 7 years old. Hallucinations, delusions, suicidal and homicidal behavior is more common in bipolar

108 Bipolar Disorder Treatment is usually with the mood stabilizer Depakote. ADHD symptoms usually do not respond to Depakote. The best evidence is for lithium. Antipsychotics are frequently used, but with very limited data.

109 Severe Mood Dysregulation Suggested diagnosis to try to describe children who seem to be “somewhat” ADHD and “somewhat” Bipolar. Criteria: –Abnormal mood most days (irritability) –Hyperarousal (ADHD) –Increased reactivity to negative stimuli –Not manic mood, not cyclical/episodic, IQ>70

110 Severe Mood Dysregulation Treatment?

111 Overview In spite of the overall decrease in violent and property crimes, the U.S. has the highest rate of imprisonment in the world. 200 million Americans are incarcerated with 4.6 million on probation or parole. The incarceration rate for Black males is 4,810 vs. 649 for white. Black females 349 vs. 68 for white females 13% of the population, 50% of prisons: more Black men between are in prison than in college.

112 Overview Dangerous violence is almost exclusively perpetrated by young men between the ages of 15 and 30. A few men are repetitively violent. 7% of young men commit 79% of repeat violence. These men can be identified in early childhood. They tend to be impulsive, have a low IQ, be hyperactive and attention impaired, oppositional, vindictive, easily angered, resistant to control, deliberately annoying, and likely to blame other people for their problems. These traits are largely inherited, although not entirely.

113 Overview Criminal offending tends to decline with age, even for persistent offenders. Among non-psychopathic individuals, offending peaks in late adolescence and declines soon after. Among psychopaths, the decline does not begin until years of age. This decline is accompanied by age-related changes in neurotransmitters.

114 Neurochemical Variables of Violence Over Time

115 The Etiology of Violent Behavior Prenatal risks for violent behavior include substance abuse in the mother, low birth weight, and prematurity. In the infant, neuropsychological deficits or difficult temperament - fearlessness, lack of prosocial activity, and hyperactivity/impulsivity. Environmental factors including young, single, isolated mother, and poverty.

116 The Etiology of Violent Behavior Lack of empathic care Poor parent-child attachment and bonding Parental loss and inconsistent care-givers. Abusive siblings: 40% of all juvenile perpetrated child sexual abuse is perpetrated by siblings. Not much is known about physical abuse and intimidation in sibling relationships because it has not been studied. Exposure to trauma and maltreatment Brain injury

117 Adolescent-Limited Conduct Disorder Some externalizing disorders develop in adolescence without the strong temperamental predisposition. Late-onset or adolescent-limited conduct disorder is thought to arise due to specific adolescent contexts: having gang members in the community, school failure, low self-esteem and depression, or other stressful life events become predictive. Most delinquent teens (94%) do not go on to develop adult antisocial behavior.

118 Life Course Persistent Offenders Comprise 5% of the population, but a disproportionate amount of crime. They have early conduct disorder. 50% have antisocial conduct as adults. They have difficulty in temperament, social alienation, poor parenting, cognitive deficits, ADHD, impulsivity, and aggressiveness. It is important to identify these teens, since jail sentences for the adolescent-limited offender may increase the risk for becoming a chronic offender.

119 Risk Factors Conduct Disorder –Early conduct disorder is ominous. Conduct disorder first appearing at 6 years old doubles the risk of criminal adult antisocial behavior (71%), compared to those children who first develop conduct disorder at 12 years old.

120 Risk Factors for Violence Firearms are the single greatest risk factor. 28% of families keep guns at home, 39% are unlocked or loaded or both. Alcohol - 40% of all year old homicide victims are intoxicated. Bullying/Standby Behavior % of schoolchildren are bullied in any given semester. Bullying is worst in rural schools. Bullies are 6x more likely to have a criminal conviction by 24, as well as AODA problems. Victims experience social and emotional isolation.

121 Risk Factors for Violence Mental illness: up to 60%are diagnosed. Also includes violent preoccupation, chronic humiliation, grandiosity, lack of empathy Media: controversial, but especially influential in vulnerable children Families who are dismissive and permissive: too much privacy, parents are afraid of the child.

122 Risk Factors for Violence Exposure to abuse: 63% of children exposed to domestic violence don’t do well, Violence is related to emotional development (hypersensitivity to anger, difficulties recognizing emotions or complex social roles, less accurate attention to social cues, less ability to generate competent solutions to interpersonal problems), cognitive problems (lower IQ, poor memory and concentration) and children who end up blaming themselves for the violence.

123 Consequences of Early Exposure to Violence Alcoholism7.4% Drug Abuse10.3% Depression4.6% Suicide Attempts12.2% Promiscuity3.2% COPD3.9% Heart Disease2.2% Liver Disease2.4%

124 Juvenile Gangs Youth gangs are present in more than 2,300 cities. Gang membership ranges from 14-30% in samples of at-risk youth in urban centers. Most gang members are between 12 and 24 years old, and belong to a gang for one or two years. Each gang (or subunit) generally includes from 5 to 25 members. The ethnic distribution is 47% Hispanic, 31% African-American, 13% White, and 7% Asian. Females constitute 4-20%.

125 Juvenile Gangs A history of antisocial behavior, early use of marijuana, poor academic performance, and living in a troubled neighborhood all increase the likelihood of joining a gang. Gang membership is strongly associated with violence. Gang members are more violent, commit more offenses, and are more likely to have and use guns than other delinquents. When a young person quits a gang, they do not usually continue to be violent, although they will continue drug dealing, if that was their gang activity.

126 Adult crime - Adult time –Juveniles moved to adult court are more likely to receive prison time than adults for the same crime. See more recidivism and suicide. What doesn’t work –Arrests for minor offenses –Scared straight/boot camp approaches –D.A.R.E. (Drug Abuse Resistance Education) –Home detention, intensive parole What does work –Prenatal nurse visits to high risk homes –Head start programs –Anti-bullying programs –Life skills classes, programs aimed at risk factors (literacy)


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