The Neurobiology of Mental Illness

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The Neurobiology of Mental Illness

• Richard M. Marshall, Ph.D.
• PARENTS AND TEACHERS
• AS ALLIES
• February 7, 2009
• Lakeland, FL

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Isnt It Curious

• Children with
• mental illness 20
• served in ESE 14
• reading disabilities 20

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Isnt It Curious?

• Children with severe
• mental illness 5-9
• reading disabilities 3-5

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Isnt It Curious

• Children with
• severe cognitive impairment 1.5
• nonreaders 1.0

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WHAT ARE WE GOING TO DO WITH THESE CHILDREN?

• Lets see what we are doing

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Childrens Mental Health

• 5,000,000--children and adolescents in the U.S.
  suffer from a serious mental disorder that causes
  significant functional impairments at home, at
  school, and with peers.
• 80 -- fail to be identified and to receive
  treatment
• 6 8 years from onset to treatment for mood
  disorders
• 9 -23 years from onset to treatment for anxiety
  disorders
• Consequences of an untreated mental
  disorder--includes suicide, addictions, school
  failure, criminal involvement, and huge problems
  for society as they enter adulthood.
• Information obtained from National Alliance on
  Mental Illness web site Aug. 2007

Society benefits when Mental Health is addressed
early
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What Disorders?

• ADHD, CD, ODD
• Anxiety Disorders
• Mood Disorders (depression bipolar)
• Psychosis (schizophrenia)
• Learning and Communication
• Autism Spectrum
• Tourettes
• Eating Elimination

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ARENT THEY JUST BRATS??(ADHJNAGBW)
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EMOTIONAL REGULATION

• They cant inhibit
• They cant regulate their emotions, especially
  arousal
• Increased arousal is related to antisocial
  behavior and aggression (especially in males).

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Okay, so where do we begin?
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• THE NEUROBIOLOGY OF
• EMOTIONAL REGULATION

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Three Interacting Systems

• Cortex
• Limbic Structures
• Autonomic Nervous System

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Cortex
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CORTICAL STRUCTURES EMOTIONAL REGULATION

• Green orbital prefrontal cortex
• Brown ventromedial prefrontal cortex
• Blue dorsolateral prefrontal cortex
• Beige amygdala
• Yellow anterior cingulate

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FRONTAL LOBE

• suppresses negative emotion from the amygdala.
• reduced PFC functioning results in reduced
  suppression of the amygdala (and slower
  extinction of arousal and negative affect).
• that is, some children experience arousal and
  negative affect more often and they hold on to it
  longer.

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LIMBIC SYSTEM
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THE AMYGDALA AND DEFENSIVE AGGRESSION
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Hypothalamic-Pituitary Axis
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AUTONOMIC NERVOUS SYSTEM
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CORTISOLthe stress hormone

• you release it when you experience stress and
  anxiety
• low resting cortisol (ODD, CD) is related to
  reduced self-control
• children with ODD CD produce more when stressed

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ADHD

• Decreased inhibition
• Decreased impulse control
• Diminished attentional capacity
• Increased activity level

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NEUROBIOLOGICAL CORRELATES (ADHD)

• Electrophysiological (QEEG ERP)
• reduced electrical activity in the right
  prefrontal regions (sustained attention)
• Structural (MRI)
• lack of frontal asymmetry (smaller right frontal)
• smaller corpus callosum
• smaller basal ganglia
• not brain damage, just smaller than normal
  (genetic?)
• Blood Flow (rCBF fMRI)
• reduced blood flow to the frontal lobes
• increased with MPH (Vaidya, 1998)

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OPPOSITIONAL DEFIANT DISORDER

• temper tantrums
• arguing with adults
• noncompliance
• blaming others
• anger/resentment
• swearing
• revenge seeking
• The real problem is that ODD can become CD

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ODD

• Hormonal Differences
• higher adrenal androgens
• lower median cortisol levels
• ANS
• lower baseline heart rates underaroused
  ANS

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CONDUCT DISORDER

• AGGRESSION
• PROPERTY DESTRUCTION
• DECEITFUL BEHAVIORS
• RULE VIOLATIONS

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NEUROCHEMICAL FACTORS Conduct Disorder

• LOWER CORTISOL (underarousal stimulation-seeking)
  
• in aggressive males
• in habitual violent offenders
• in girls with CD
• persists in boys with DBD
• LOWER CATECHOLAMINES
• in aggressive children (beginning at age 3)
• in adult criminals violent offenders
• lower serotonin family increases risk of
  violence by 3x
• INCREASED TESTOSTERONE ADRENAL ANDROGEN
• LOWER GABA

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AUTONOMIC NERVOUS SYSTEM CD

• Arousal is lower in children with antisocial
  behavior.
• Fearlessness Theory low levels of arousal low
  levels of fear (risk taking less fear of
  punishment) and low levels of inhibition.
• Self-stimulation Theory ASB turns me on.
• Structural
• violent offenders who suffered severe child abuse
  had reduced right temporal cortex functioning.
• Neurochemical
• Lower Cortisal (released during flight/fright)
• in aggressive adults
• in habitual violent offenders
• in girls with CD
• In 7-12 year old aggressive boys
• Lower GABA
• Higher Testerone (in girls with CD)

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COMMON PATHWAYS

• Cortex reduced frontal lobe activation
  INHIBITION
• Limbic amygdala-frontal lobe disruption
  AGGRESSIVE
• ANS under-aroused
• STIM. SEEKING

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Executive Dysfunction

• the inability to delay reward
• the inability to modify behavior to match
  context
• an underestimated sense of harm
• a lack of regard for consequences.

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PLEASE REMEMBER

• Once students with these disorders are
  stimulated by the possibility of a reward, they
  become less sensible to the possibility of
  punishment.

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Q WHAT IS IT WITH TEEN-AGERS?

• A increased hormonal activity in the presence
  of inadequate inhibition, because of frontal lobe
  maturation.

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• INTERVENTIONS

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THERAPIES TO AVOID

• Reactionary
• Confrontational
• Inoculation Approaches (boot camp)
• This is a marathon not a sprint there is no
  quick fix.

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General Rule for Interventions

• Behavioral approaches tend to focus on
  Consequences
• There are two problems with this

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TWO PROBLEMS

• By definition, children and adolescents with
• impulse control and self-regulation deficiencies
  do not consider consequences before they act.
• Behavioral consequences (especially if they are
  aversive) introduce provocation,
  confrontationand escalation.

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YOUR PREDICAMENT

• One Flew Over the Cuckoos Nest

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Three-Tier Model of Behavioral
Intervention/Support
Tier 3 Intensive, Individual Behavioral
Interventions
1 - 5
1-5
Tier 2 Targeted Group Interventions
10-15
80 - 90
Tier 1 School-wide Discipline Positive
Behavior Supports Whole-class Interventions
10 - 15
80 - 90
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Individual counseling/therapy
Individual Behavior Plan Rapid Response
In-school alternative education Frequent, daily
mentoring But Whats Really Going to Happen
There???
TIER III Intensive Behavior Programs
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INTERVENTION REFERENCES

• AACAP. (2007). Practice parameter for the
  assessment and treatment of children and
  adolescents with ODD. J. Am. Acad. Child.
  Adolesc. Psychiatry, 461, 126-141.
• Barkely, R.A., Benton, C.M (1998). Your Defiant
  Child Eight Steps to Better Behavior. NY
  Guilford.
• Faedda G.L. Austin, N.B. (2006). Parenting a
  Bipolar Child. Oakland, CA. New Harbinger.
• Flippin, R. (2005). Making peace with your
  defiant child. ADDitude, June/July. 41-45.
• Fulkerson, R.C. Webb, A.R. (2005). What are
  effective treatments for oppositional and
  defiant behaviors in preadolescents? Journal of
  Family Practice. 542, 162- 165.
• Kelsberg, G. St. Anna, L. (2006). What are
  effective treatments for ODD in adolescents?
  Clinical Inquiries. 5510, 911-913.
• Maag, J.W. (2000). Managing resistance.
  Intervention in School and Clinic. 353,
  131-140.

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THANK YOUQuestions?

• Richard M. Marshall, Ph.D.
• Associate Professor
• University of South Florida Lakeland
• 3433 Winter Lake Road
• Lakeland, FL 33803
• [phone]
• rimarsha_at_poly.usf.edu