Child and Adolescent Psychiatric Disorders [e-mail]

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Child and Adolescent Psychiatric
Disordersdvmays_at_wisc.edu
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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.

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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.

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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

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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.

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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.

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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

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Childhood Internalizing Disorders

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

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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

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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

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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.

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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.

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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

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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.

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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.

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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)

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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

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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

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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

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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.

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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.

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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

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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.

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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.

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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

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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

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Property Destruction

• Engaged in fire setting with the intention of
  causing damage
• Deliberately destroyed others property

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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

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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

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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

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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

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Risks for Conduct Disorder

• Family (cont)
• Inadequate, coercive parenting
• Child abuse
• Insufficient supervision
• School
• Disadvantaged school setting
• Poor school performance beginning in elementary
  school

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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.

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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

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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

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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

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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.

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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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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Time to DecisionIs it a good idea to drink
Drano?
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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.

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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.

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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.

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Laws Restricting Behavior of Youth Under 18
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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.

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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.

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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.

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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.

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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).

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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.

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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.

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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

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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.

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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.

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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.

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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

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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)

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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

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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.

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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.

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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

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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.

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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.

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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

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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.

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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.

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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)