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Title: Child and Adolescent Psychiatric Disorders dvmays@wisc.edu


1
Child and Adolescent Psychiatric
Disordersdvmays_at_wisc.edu
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 ones
    emotions from ones 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 MDs 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 ones temper
  • Arguing with adults
  • Actively defying requests
  • Refusing to follow rules
  • Deliberately annoying other people
  • Blaming others for ones 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 someones 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 15-19.
  • 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 16-20 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 dont 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 DecisionIs 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 gt50,
    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.
  • 75-80 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 grade 17
  • 10th grade 33.2
  • 12th grade 47
  • 28 of seniors binge drink
  • Tried an illicit drug
  • 8th grade 21
  • 10th grade 38
  • 12th grade 50

59
Drug Abuse in Children and Adolescents
  • 15 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 - 2004
  • 9 of adolescents experienced a depressive
    episode over the last year.
  • Girls - 13.1 Boys - 5
  • No differences in ethnic group, SES in incidence,
    but those with health insurance were more likely
    to get treatment.
  • lt50 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?
  • Total 25.3
  • Boys 17.6
  • Girls 33.5
  • 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 1981-2001
84
Adolescent Suicidal Behavior 2001 U.S. Data
85
Wisconsin Suicides
  • Suicide is the second leading cause of death in
    adolescents.
  • From 2000-2002, there were 323 suicides (262
    homicides.)
  • The annual rate is 5.7/100,000 - 36 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 dont
  • AODA
  • Severe and enduring hopelessness
  • Isolation
  • Reluctance to discuss suicidal thoughts
  • Psychopathology

87
Gender Issues
  • Girls
  • Attempts to completions 4,0001
  • 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 completions 5001
  • Rate increased 3x since 1955 - Increased AODA?
  • Dropped since 1995 - 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 dont 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, MDs, 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
    childs 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 persons 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. GellerWashington 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
    10-15 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 dont!
  • 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, IQgt70

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 20-29 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
    30-40 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 15-24 year old homicide
    victims are intoxicated.
  • Bullying/Standby Behavior - 7-16 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 60are 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 dont 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
  • Alcoholism 7.4
  • Drug Abuse 10.3
  • Depression 4.6
  • Suicide Attempts 12.2
  • Promiscuity 3.2
  • COPD 3.9
  • Heart Disease 2.2
  • Liver Disease 2.4

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 doesnt 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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