What Troubled Children Look Like

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What Troubled Children Look Like

• P. Alex Mabe, Ph.D.
• Professor
• Department of Psychiatry and Health Behavior
• Medical College of Georgia

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The Problem with At Risk Children
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Indicators of mental health in our children

• A recent study at the University of Pittsburgh
  found that between 1979 and 1996, the rate of
  psychosocial problems identified in the primary
  care setting increased dramatically, from about
  7 to more than 18 of all visits to the
  pediatrician by 4- to 15-year-olds
• (Pediatrics. 20001051313-1321).

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Children and Their Education

• Harold Hodgkinson , director of the Center for
  Demographic Policy, estimates across the nation
  40 of students are in "very bad educational
  shape" and "at risk of failing to fulfill their
  physical and mental promise.
• 12 fail to complete high school

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The State of Mental Health Services for Children
and Adolescents
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The State of Mental Health Services for Children
and Adolescents
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The Stigma of Mental Illness

• Children and their parents believe that the
  services are not relevant, too demanding, and
  have stigma attached.
• The majority of children who enter outpatient
  mental health services, dropout after only one or
  two sessions.

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Ineffective Service Response
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The test of the morality of a society is what it
does for its children.
Dietrich Bonhoeffer

• Houses by an unnamed child from Vienna

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What is Mental Illness?

• Clinically significant patterns of behavioral or
  emotional functioning that are associated with
  some level of distress, suffering (pain, death),
  or impairment in one or more areas of functioning
  (e.g., school, work, social and family
  interactions). At the basis of this impairment is
  a behavioral, biological, or psychological
  dysfunction, or a combination of these.

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What is Mental Illness - continued

• The BIOPSYCHOSOCIAL MODEL

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Domains of Functioning

• Physical Development and Health
• Sleep
• Eating weight
• Cognitive Functioning
• Interpersonal Relationships
• Mood-Internal States
• Behavioral Regulation

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Domains of Functioning

• Physical Development and Health
• Growth Problems
• Gross and Fine Motor Development
• Multiple somatic complaints
• Chronic Illness
• Frequent unintentional injuries

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Domains of Functioning

• Sleep
• Persistent sleep disturbances have been found in
  around 12 of children
• Sleep problems appear to be associated with an
  increased risk for psychiatric problems (odds
  ratio of 2.45)

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Domains of Functioning

• Eating/Weight
• Obesity
• Concerns with weight and shape

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Domains of Functioning

• Cognitive Functioning
• Lower IQ has consistently predicted poorer
  outcomes for children.
• Neurocognitive deficits have been observed among
  conduct-disordered and aggressive youths
• Difficulties in attending and poor organization
  associated with mental disorder
• Delays in talking associated with mental disorders

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Domains of Functioning

• Interpersonal Relationships
• Peer Relationships - neglected, rejected,
  bullying, sexual relations.
• Family Relationships - Parent Psychopathology,
  parental alcohol/drug abuse, parenting styles,
  family conflict, child compliance with rules.

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Domains of Functioning

• Mood-Internal States
• Inexpressive, callous
• Irritable
• Highly expressive
• Depressive mood
• Anxious mood
• Mania

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Domains of Functioning

• Behavioral Regulation
• Children with disruptive behavior problems
  exhibit Poor self-regulation, high approach
  tendency, deficits in executive function,
  perseverative interest in reward with reduced
  attention to environmental cues of challenging
  contingencies and increasing punishment, deficits
  in planning of and persisting in task-relevant
  activities while inhibiting task-irrelevant
  thoughts and actions, errors in emotional
  labeling and less difficulty in talking about
  emotions, increased positive beliefs about the
  positive consequences of antisocial behavior and
  less attentiveness to the negative impact of
  antisocial behavior, deficiency in empathy and
  perspective taking, and deficiency in moral
  reasoning.

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Domains of Functioning

• Behavioral Regulation - continued
• Children with disruptive behavior problems also
  exhibit
• Deficits in attention to and immediate memory for
  social cues.
• Hostility bias in interpretation of social cues.
• Goals of revenge and domination.
• Relatively few response options in dealing with
  conflict

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Protective Factors in Child Development

• Child Characteristics
• Good Physical Health
• Easy Temperament
• Secure Attachment
• Even Development
• Normal Language Development
• High Intelligence
• High Academic Achievement
• Physical Attractiveness

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Protective Factors in Child Development

• Child Characteristics - continued
• Moderate Activity Level
• Adequate Attention
• Internal Locus of Control
• Negative events are viewed as challenges to be
  overcome
• Flexible Coping Strategies
• Good Social Skills

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Protective Factors in Child Development

• Child Characteristics - continued
• High Self-Esteem-Perceived Competence
• Intolerant attitude toward deviance
• Commitment to traditional values and norms
• Use of humor
• Religious Affiliation

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Protective Factors in Child Development

• Family/Environment Characteristics
• Two Parent Home (Good relationship with at least
  one caring adult)
• Fewer Children in the Home
• Family Cohesiveness
• Consistent Discipline rearing
• Higher Socioeconomic Status
• Good Individual and Agency Support

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Protective Factors in Child Development

• Family/Environment Characteristics-continued
• High Parent Education
• Adequate Child Care Resources
• Adequate Financial Resources
• Peers who behave in conventional manner
• Cohesive and supportive school environment

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Protective Factors in Child Development

• Family/Environment Characteristics-continued
• Teachers convey positive attitude toward students
  
• Opportunities for extracurricular activities that
  support conventional behavior
• Low Stress
• Rural Environment

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Protective Factors in Child Development

• Parent Characteristics
• Good Psychological Adjustment
• High Intelligence
• More Years of Education
• Mature Mother
• Sensitive/Responsive
• High levels of involvement with their children

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Protective Factors in Child Development

• Parent Characteristics - continued
• Availability
• High Self-Esteem
• Good Parenting Models
• Flexible Coping Style
• High Nurturance/Warmth
• Knowledge of Development Expectations
• (Benevolent) Authoritative Discipline

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Protective Factors in Child Development

• Parent Characteristics - continued
• Close Supervision
• Good Physical Health

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Common Mental Disorders in Children
Tree in Storm Chrissy 5 y.o. U.S.A.
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DSM-IV and Multivariate Statistical Studies
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Attention Deficit Hyperactivity Disorder

• Core Symptoms
• Inattention
• Hyperactivity
• Impulsivity
• Prevalence 1.8 to 3.3 of children

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Conduct Disorder

• Core Symptoms
• Aggression to people and animals
• Destruction of property
• Deceitfulness, lying, stealing
• Serious violation of rules
• Prevalence 1-4 of 9-17 year olds

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Anxiety Disorders

• Separation Anxiety Disorder
• Core Symptoms
• An excessive and unrealistic fear of separation
  from an attachment figure, usually a parent. In
  particular, children worry about harm to either
  the attachment figure or to themselves that would
  result in separation.
• Prevalence 2 to 4 of children

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Anxiety Disorders- continued

• Generalized Anxiety Disorder
• Core Symptoms
• Involves worry of a general nature. These
  children show excessive and unrealistic worry
  about the future, the past, and their own
  competence.
• Prevalence 3 of children

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Anxiety Disorders- continued

• Childhood-Onset Social Phobia
• Core Symptoms
• Involves a persistent fear of one or more social
  situations in which the person is exposed to
  possible scrutiny by others and fears that he may
  do something or act in a way that will be
  humiliating or embarrassing. Can also involve
  social avoidance in which the child shrinks from
  contact with unfamiliar people.
• Prevalence 1 of children

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Anxiety Disorders- continued

• Simple Phobias
• Core Symptoms
• Characterized by a persistent fear of a
  circumscribed object or event, leading to
  avoidance of that object of event. The fear is
  excessive and out of proportion to the demands of
  the situation, cannot be reasoned away, are
  beyond voluntary control, persistent over time,
  and are maladaptive.
• Prevalence 2-3 of children

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Anxiety Disorders- continued

• Post-Traumatic Stress Disorder
• Core Symptoms
• This diagnosis requires exposure to an event
  outside the realm of usual human experience that
  would distress anyone, intrusive reexperiencing
  of the event, avoidance of stimuli associated
  with the trauma or numbing of general
  responsiveness, and persistent symptoms of
  increased arousal.
• Prevalence Unknown

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Anxiety Disorders- continued

• Obsessive-Compulsive Disorder
• Core Symptoms
• Characterized by recurrent obsessions or
  compulsions that are distressful or interfere in
  ones life. Obsessions are defined as persistent
  thoughts, images, or impulses that are
  ego-dystonic, intrusive, and, for the most part,
  senseless. Compulsions are repetitive,
  purposeful, and intentional behaviors that are
  performed in response to an obsession, according
  to certain rules, or in a stereotyped fashion.
• Prevalence 0.3 to 0.4 for children and 1 for
  adolescents

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Depression

• Core Symptoms
• Affective Symptoms - dysphoric mood, diminished
  pleasure.
• Cognitive Symptoms - negative self-evaluations,
  hopelessness
• Motivation - suicidality
• Physical Symptoms - sleep disturbance, somatic
  complaints
• Prevalence0.4 to 2.5 for children and 0.4 to
  8.3 for adolescents

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Bipolar Disorder

• Core Symptoms
• Episodes of depressed mood
• Episodes of hypomanic or irritable mood involving
  inflated self-esteem or grandiosity, decreased
  need for sleep, pressured speech, flight of ideas
  or racing thoughts, distractibility, increased
  goal-directed activity, or excessive involvement
  in activities with the potential for painful
  consequences
• Prevalence Unknown

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Other Common Disorders

• Drug/Alcohol Abuse
• Eating Disorders
• Learning Disorders
• Pervasive Developmental Disorders

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Problems/Disorders presenting by Age
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What Causes Mental Disorders
Environment
Person
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Identifying Troubled Children
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Identifying Troubled ChildrenDomains of
Functioning

• Physical Development and Health
• Sleep
• Eating weight
• Cognitive Functioning
• Interpersonal Relationships
• Mood-Internal States
• Behavioral Regulation

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Identify children that are members of high-risk
groups

• Subnormal intelligence or specific learning
  disabilities.
• Chronic Health Problems
• Living in conditions of poverty/overcrowding
• Obese
• Incarcerated or having legal charges before age
  12
• Bisexual or homosexual
• Admitted into psychiatric inpatient service

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Identify children experiencing high-risk
situations

• Death of a close family member or friend
  (particularly if a suicide death)
• Family instability involving frequent moves
• Family violence/abuse or break-up
• Serious school failure or discipline incident
• Legal problems or incarceration
• An episode of public humiliation
• Sexual trauma

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Identify children exhibiting high-risk behaviors

• Inattention and/or hyperactivity
• Impulsive and/or aggressive behaviors resulting
  in discipline problems at home or in school.
• Persistent disobedience or aggression (longer
  than 6 months) and provocative opposition to
  authority figures.
• Uncharacteristic delinquent behavior such as
  theft, vandalism, other forms of rule violations

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Identify children exhibiting high-risk behaviors
- continued

• Affiliation with delinquent peers.
• Social withdrawal or isolation
• Threats of self-harm or harm to others
• Evidence of self-harm (e.g., marks on body
  suggesting self-mutilation)
• Evidence of excessive interest in sexual activity
  as noted by frequent comments regarding sexual
  interest or acting out
• Strong interests in counter-cultural clothing and
  music

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Identify children exhibiting high-risk behaviors
- continued

• Troubled by school failure, frequent absences,
  and school dropout
• Substance Abuse (including cigarette and alcohol
  use)
• Strange thoughts and feelings (e.g., beliefs that
  others are plotting against them) and unusual
  behaviors (e.g., talking to themselves, appearing
  to be seeing or hearing things)

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Identify children exhibiting mood disturbance

• Frequent sadness, tearfulness, crying
• Decreased interest in activities or inability to
  enjoy previously favorite activities
• Unusual neglect of personal appearance
• Persistent boredom low energy
• Social isolation, poor communication
• Extreme sensitivity to rejection or failure
• Increased irritability, anger, or hostility
• Difficulty with relationships

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Identify children exhibiting mood
disturbance-continued

• Frequent complaints of physical illnesses such as
  headaches and stomachaches
• Frequent absences from school or poor performance
  in school
• A major change in eating and/or sleeping patterns
• Refusal to go to school
• Talk of or efforts to run away from home
• Panic or agitation

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Identifying children exhibiting suicidal
interests or self-harm behavior

• Talk of not being present in the near future.
  (E.g., I wont be a problem for you much
  longer.)
• Giving away or throwing away favored possessions.
• Having suicidal themes in literature or art
  class.
• Questions about suicide.
• Open talk of suicide.
• Self-mutilation

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Identifying children exhibiting the potential for
violence- Signs over a period of time

• A history of violent or aggressive behavior
• Serious drug or alcohol use
• Gang membership or strong desire to be in a gang
• Access to or fascination with weapons, especially
  guns
• Threatening others regularly
• Trouble controlling feelings like anger
• Withdrawal from friends and usual activities
• Feeling rejected or alone
• Having been a victim of bullying
• Poor school performance

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Identifying children exhibiting the potential for
violence- Signs over a period of time continued

• History of discipline problems or frequent
  run-ins with authority
• Feeling constantly disrespected
• Failing to acknowledge the feelings or rights of
  others

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Identifying children exhibiting the potential for
violence- Immediate Warning Signs

• Loss of temper on a daily basis
• Frequent physical fighting
• Significant vandalism or property damage
• Increase in use of drugs or alcohol
• Increase in risk-taking behavior
• Detailed plans to commit acts of violence
• Announcing threats or plans for hurting others
• Enjoying hurting animals
• Carrying a weapon

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Schools Support Mental Health in Children in
Three Ways

• Environmental
• Programmatic
• Individual

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Building Protective Factors in the School

• Good instruction
• Emphasis on intelligence as malleable
• Develop a sense of belonging
• Effective structure and discipline
• Give a sense of vision

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Teddy Stoddards Story