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Mental Illness and Suicidal Behaviour in Children and Youth


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Title: Mental Illness and Suicidal Behaviour in Children and Youth

Mental Illness and Suicidal Behaviour in
Children and Youth
  • Dr Phil Ritchie, Psychologist
  • Childrens Hospital of Eastern Ontario

Mental Illness in Children and Youth
  • Statistics suggest that by the time students
    graduate from high school, 1 in 5 will have met
    criteria for a diagnosable mental illness.
  • Unfortunately, only 1 in 6 of these will have
    received appropriate treatment for this.

  • The period of life when your child kicks you off
    the pedestal theyd put you on only to step up
    onto it themselves.
  • That period that immediately follows your childs
    first sleeping through the night in which they
    decide to stay up all night and sleep through the

Adolescence A Series of Crises (with thanks to
Dr. Tracy Vaillancourt)
  • Identity increasingly self-conscious, who do
    they want to affiliate with, sexuality
  • Autonomy move away from parental influence to
    that of peers
  • Intimacy relationships no longer based on
    common activities, now focuses on meeting
    emotional needs

A Series of Crises contd
  • Sexuality biologically driven
  • Risk-taking stimulation-seeking
  • Egocentrism concerned with how others perceive

The Adolescent Brain
  • Brain develops to mid-20s
  • At puberty, pruning process
  • Motor and sensory areas are quite sophisticated
    while decision-making (important for
    impulse-control and emotional regulation) centres
    remain underdeveloped

The Adolescent Brain contd
  • In short, adolescents are physically capable of
    complex feats, but psychologically ill-prepared
    to make good decisions
  • One giant, tingly nerve looking to get stimulated
    but little judgment about the dangers such
    stimulation might entail

The Adolescent Brain, contd

Anxiety Disorders in Youth A Pattern of False
  • Anxiety is a good thing anticipating future
    danger or misfortune is helpful
  • Keeps us from diving into unknown waters or
    walking in a dangerous neighbourhood late at
  • When anxiety becomes extreme or irrational, it
    goes from adaptive to maladaptive
  • Most common Mental Illness affecting 12 of
    population, half of which will develop as
    children or youth

Anxiety Disorders in Youth contd
  • Panic Disorder
  • Specific Phobia
  • Social Phobia (Social Anxiety Disorder)
  • Obsessive Compulsive Disorder)
  • PTSD (the only 1 that requires a trigger event)
  • Generalized Anxiety Disorder
  • Separation Anxiety Disorder
  • Anxiety Disorder NOS

Anxiety Disorders in Youth contd
  • In general, in order to meet criteria as an
    anxiety disorder, the associated fear may be
    recognized as excessive or unreasonable (though
    sometimes, particularly in children this may not
    be the case), is not just a brief and passing
    phenomenon, and is interfering with regular
    development/normal functioning.

Treating Anxiety Disorders
  • Cognitive Behaviour Therapy (CBT) is
    evidenced-based non-medication treatment of
  • Mood, thoughts, and actions inextricably linked
  • You are their teacher, not therapist, but helpful
    to understand principles (e.g., exposure/response

Classroom Accommodations for the Anxious Student
  • Check in with student on arrival
  • Dont penalize for being late (sx at home often
    interfere with getting out the door)
  • Assist with peer interactions
  • Anticipate difficulty with transitions
  • Give notice re. changes in routine

Classroom Accommodations contd
  • Extra time for tests and assignments
  • Safe place
  • Use of nonverbal cues so as not to centre out the
  • Model appropriate coping behaviours

Interventions for the Anxious Student
  • Worry
  • Answer the what ifs and take away anxiety
    associated with the unknown
  • Track improvements with feedback to the student
  • Have the student rate their fear and then track

Interventions for the Anxious Student contd
  • Emotional Outbursts
  • Identify triggers with the student
  • Encourage them to problem-solve (e.g., CPS)
  • Develop a hierarchy of safe places in which to
    de-escalate from a meltdown

Mood Disorders in Youth
  • Major Depressive Disorder
  • Dysthymic Disorder
  • Bipolar I and II Disorders
  • Cyclothymic Disorder

Mood Disorders contd
  • Important to understand that mood disorders
    affect not just how the student feels, but also
    sleep, appetite, concentration, motivation,
    interests, and energy.
  • This is a recipe for a decline in functioning at
    school (as well as home and social), likely to
    compound an already fragile self-esteem.
  • Treat depression and other factors tend to

Suicidal Behaviour in Children and Youth
  • With thanks to Dr. Allison Kennedy

A Complicated World for Teens
  • Amanda Todds video has almost 6 million views,
    almost 45 thousand likes, and almost 100 thousand
  • There are a number of RIP Amanda Todd Facebook
    sites with 100 of thousands of likes
  • Adolescents have unprecedented access to
    unfiltered information about suicide through
    social media and the Internet

Social Media A Pox on All Our Houses?
  • Preliminary studies suggest that internet use in
    a country was associate with an increase in
  • Cyberbullying has been tied to increased suicide
    risks particularly in adolescents.
  • Social media may help people form suicide pacts
    and unlike more traditional pacts, may involve
    complete strangers and bogus participants/eggers
  • Internet provides a how-to guide for suicide.
  • Internet provides access to pro-suicide sites.

Social Media A Pox on All Our Houses?
  • But social media are also being used to prevent
  • National Suicide Prevention Lifeline (US)
    developed a Facebook chat add-on for users to
    report at-risk individuals.
  • Similar links being developed for Twitter,
    Tumblr, and Google (e.g., I want to kill myself
    results in top sponsored link being to prevention

Canadian trends
  • In Canada, suicide is 3rd leading cause of death
    for 10 to 14-year-olds and the 2nd leading cause
    for 15 to 19 year olds
  • In Canada, suicide is the cause of death for 24
    of 16 to 24-year-olds
  • A large percentage of youth experience suicidal
  • At CHEO, youth are increasingly presenting to the
    ED with suicidal risk

Reasons for suicidal behaviour in adolescence
  • Changes in cognitive development
  • capacity for abstract and complex thinking
  • more capable of contemplating life circumstances,
    envisioning a hopeless future, suicide as a
    possible solution and planning and executing a
    suicide attempt
  • Onset of substance use/abuse
  • Increased rates of mental health problems
  • Increased access to potentially lethal suicidal

Risk Clinical factors
  • Psychiatric history
  • Depression and conduct disorder
  • Drug/alcohol use
  • Previous suicide attempt
  • Hopelessness

Risk Personal and family history
  • History of abuse
  • Family history of suicide/exposure to suicide
  • Exposure reduces the suicidal taboo
  • Issues with family communication and problem
  • Attachment issues, inability to approach parents
    for support

Risk Life stressors
  • Suicidal adolescents present with significantly
    increased levels of life stress
  • Increased interpersonal conflict and social
  • Other stressors may serve as a trigger to
    vulnerable youth who are already at risk (e.g.,
    loss, transition)

Risk Emotional and cognitive factors
  • Problem solving deficits
  • Difficulty generating alternative solutions to
    interpersonal conflict
  • Poor emotional regulation
  • Impulsivity

Sex differences
  • Adolescent girls also are more likely than boys
    to attempt suicide --- although boys are more
    likely to complete it (3 males1 female)
  • Most studies relate the differences in completion
    rates to the method chosen
  • Girls --- overdose or cutting
  • Boys --- hanging or firearms

Other demographic risk factors
  • Age
  • Increased risk with increased age within the teen
  • Race
  • Aboriginal youth at particularly high risk
  • Sexual orientation
  • Gay/transgendered youth at higher risk

Some Statistics
  • 15 to 20 seriously consider suicide
  • 10 to 15 make a suicidal plan
  • 6 to 9 attempt suicide
  • 2 to 3 present for necessary medical treatment
    after a suicide attempt

in a classroom
  • 4 or 5 students will seriously consider suicide
  • 3 students will have a suicidal plan
  • 2 students will attempt suicide
  • Students in an alternative setting are at higher
    risk for suicidal behaviour

How school staff can help
  • Learn
  • the signs of risk in students
  • Identify
  • at risk students
  • Refer
  • to appropriate resources

Warning signs in school
  • Suicidal threats
  • Talking or writing about death, dying, suicide
  • Changes in appearance, mood, attendance, academic
  • Social isolation
  • Bullying

Talking to at-risk students
  • Know your limits
  • Listen
  • Acknowledge feelings, clarify, summarize,
  • Know your resources
  • Act and ask have you thought about killing
    yourself have you already tried to hurt
  • Follow up

School based prevention
  • Be aware of signs and know how to respond
  • Foster a healthy school environment
  • Educate students on coping skills
  • De-stigmatize mental health issues by talking
    about it
  • Educate students regarding mental health
    resources in the community

Non Suicidal Self Injury (NSSI)
  • Intentional self-harm without conscious suicidal
    intent (e.g., cutting, scratching, burning,
  • Relatively common, particularly for girls
  • An attempt to cope that is often learned from
    other youth
  • Primary goal of behaviour is affect regulation
  • Youth who engage in NSSI are at elevated risk for
    suicidal behaviour

Assessment of nonsuicidal self-harm
  • Examine onset, frequency, intensity, and duration
  • Assess risk of injury
  • Identify triggers

The role of parents/caregivers
  • Engage parents whenever possible
  • Parents need to be aware of safety issues
  • Parents need guidance regarding how to respond if
    their teen approaches them
  • Stay calm, listen, dont judge, provide comfort
    and reassurance (e.g., I know that you are in a
    lot of pain right now but I am with you and we
    will get you the help you need to feel better)
  • Parents can call crisis lines directly
  • Even if the teen does not feel comfortable
    directly confiding in them, they can check in,
    monitor, and assist with distraction during an
    episode of acute distress
  • In general, parents and professionals provide
    better support than peers

Follow-up the elephant in the room?
  • Having asked the question and referred to a
    school, community, or hospital-based resource, as
    appropriate, it is important to re-establish your
    relationship with the student.
  • Make time to see the student the next available
    opportunity, let the student know how glad you
    are that s/he spoke with you, that you care about
    how theyre doing, but that you will leave it to
    the mental health professionals to deal with that
    part of things.
  • And that if s/he wants to talk again, youre
    always happy to listen, and that this doesnt
    otherwise change anything about the relationship.

The Adult (i.e., Teacher) Brain (with thanks to
Dr. Matthew Sharps)
  • When communicating with anyone in crisis,
    important to understand how it affects not only
    their thinking, but also ours.
  • Big stress response (HPA Axis) results in blood
    being diverted from neocortex to lower areas
    (limbic and reptilian brains)

The Adult Brain contd
  • Go into survival mode and the reptilian brain
    kicks in
  • Alligators are brilliant survivors, living
    fossils that have existed 200M years
  • Alligators are not so good at conversation,
    investment advice, or problem-solving in the
    midst of crisis

The Adult Brain contd
  • In survival mode, we get alligator stupid
  • Reptilian brain is reliable but rigid and
  • Four Fs feeding, fleeing, freezing, and mating

The Adult Brain contd
  • Survival mode is a vestige of our hunter/gatherer
  • Tunnel vision can be helpful if pursuing a wild
    boar looking to turn it into dinner
  • Not so helpful if staring at the hickey on our
    teenage daughters neck or the crack in the new
    HDTV after our son invited a few friends over
    c/o Facebook while we were out of town

The Adult Brain contd
  • Need our neo-cortex for more advanced
    problem-solving (dont try to fit head in peanut
    butter jar get a spoon)
  • Also need the neo-cortex to manage sub-cortical
    parts of brain, and to separate affect from

Alligator Stupid - There is No Us and Them
  • While negotiating with those in crisis, important
    to get out/stay out of alligator stupid mode,
    and have the higher centres of the brain remain
  • Those with a past of early trauma, chronic
    stress, bad nights sleep, or 12 skinny pumpkin
    spice lattés (they were on sale) compound matters

Alligator Wrestling
  • When appropriate, taking a few slow, big breaths
    can help
  • Your paraverbals calm, not too loud, not too
    fast, but reassuring
  • Become their surrogate neo-cortex get them to
    slow down, help them see that there are other

Web-Based Resources
  • http//
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