Children

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Childrens Mental Health Pathology Why We Need
to KnowWelcomeUmesh Jain MD, DABPN, FRCP(C),
PhD, MEdAssociate Professor of
PsychiatryUniversity of Toronto
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Disclosure

• Pharmaceutical Industry Sponsorships for
  Research, Ad Boards and Talks
• Eli Lilly Inc.
• GSK
• Janseen-Ortho Inc.
• Purdue Pharma
• Shire Biochem

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Objectives

• Review the prevalence literature associated with
  childhood mental health
• Disturbing trends
• Three models of mental impairment simple but
  relevant

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How big is the problem?

• Lifetime prevalence Adolescents (median age of
  onset)
• 31 anxiety disorder ( 6)
• 19.1 disruptive behavior disorders (11)
• 14.3 mood disorders (13)
• 11.1 substance use disorders (15)
• 40 of affected individuals had more than one
  condition (OCHS suggests 68)

Merikangas, et al. (2010). Lifetime prevalence of
mental disorders in U.S. adolescents results
from the National Co-morbidity Survey
Replication. Journal of the American Academy of
Child and Adolescent Psychiatry, 49(10), 980-989.
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How big is the problem?

• Prevalence rates for Mental Disorders
• in 6-16 year olds, BC
• Anxiety Disorder 6-8
• ADHD 2-10
• Conduct Disorder 2-6
• Substance Use Disorder 0.1-6
• Any Depressive Disorder 1-4
• OCD 0.2
• Autism 0.2
• Schizophrenia 0.1
• Eating Disorders 0.1

Waddell et al., (2002). Child and Youth Mental
Health Population Health and Service
Considerations. University of British Columbia
Press, Vancouver, BC
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Implication

• Why are children so anxious at such an early age?
• What role does the school play in identifying
  Disruptive Behavior Disorders?
• Are Mood Disorders related to onset of puberty?
• Is Substance Abuse inherently an extension of
  adolescence?
• If there are developmental links to these
  disorders, why arent there pre-emptive strikes
  before they happen?

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Trends that are alarming

• Increased use of cannabis (the new gateway drug)
  in the 13 population
• Nicotine is still a problem but there has been
  some inroad (smoking in public area bans, better
  warnings, peer pressures, access)
• Energy drinks have proliferated- high adrenaline
  states
• B.C. data

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Trends that are alarming

• Proliferation of gaming both in hrs/day and
  exposure to content
• On line gambling
• On line gaming
• Increase in aggressive and sexual content
• Social media as an alternative social connection

Winters, Stinchfield, Wilerson. (2010). Patterns
and characteristics of adolescent gambling. J
Gambling Studies. 9(4), 371-386.
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Trends that are alarming

• Weight and related disorders
• Obesity in children
• Directly tied to physical health
• Evidence of poor nutrition and poverty
• Sedentary society
• Self esteem
• Eating disorders
• Body image issues
• 2nd highest rate of mortality in psychiatry

Uuay Albala, Obesity trends from underweight
to overweight American Society of Nutritional
Science. 131893S-899S.
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Trends that are alarming

• Physical health of children
• 32 increase in allergies in 10 years
• Increased respiratory illnesses (e.g. asthma) by
  75 in just 10 years
• Tubes are the new tonsils
• Unrecognized risks of sleep disorders
• Greater risks with neonatal survival
• Native population

Martinez FD, Wright AL, Taussig LM, et al. Asthma
and wheezing in the first six years of life, N
Engl J Med 1995 332133-138. Akinbami, L.
Asthma prevalence, health care use and mortality
United States 2003-05, CDC National Center for
Health Statistics, 2006. Summary Health
Statistics for U.S. Children National Health
Interview Survey, 2008.
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Trends that are alarming

• Dissolution of the family unit
• Increased rates of divorce
• Decrease in the role of religion
• Increase in single parent families
• Decrease role of community- loss of ethnic
  heritage
• Less contact with parents in intact families
• Both parents working

CDC, National Health Survey 2008
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Trends that are alarming

• Pseudo-maturity of children due to competitive
  pressures
• What do children watch?
• Children save the parents
• The shrinking world and exposure to worry
• Expectations to succeed
• The value of post-secondary education?

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Kids are at risk but

• Stigma of mental health is reducing
• Depression, ADHD, Bipolar
• Doctors are better trained
• Royal College requirements
• There are more vocal and better educated
  advocates
• ASD lobby

Corrigan, P. (2004). How stigma affects mental
health. American Psychology, 59(7), 614-625.
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Entry Point

• Is still very much starts with a medical
  diagnosis
• Psychoeducational assessments may be initial
  triggers
• Sometimes activated by justice, social service,
  or educational systems

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The Medical Model

• Diagnostic and Statistical Manual
• DSM-IV-TR
• DSM-V
• ICD-10
• Medical Model of Classification
• Disconnect between child and adult pathology
• Failure to lead to etiology
• Re-evaluation of the diagnostic system

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What Are We Really Treating?

• Symptom
• Discrete complaint self esteem, fever, cough
• Syndrome
• Collection of symptoms occurring together- DSM
• Gonorrhea, Measles, Bipolar
• Behavioral dimension
• Behavior with physiological basis
• Impulsivity, Anxiety

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Levels of Intervention
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Symptom Management

• Addresses the core symptom that requires
  management
• Has more relevance for the application of
  treatment and promotes prevention
• Easier to use as an educational vehicle
• Patients have a better understanding and allows
  them to take a proactive approach
• Does not label the child
• However, without a syndrome diagnosis, may not be
  able to get resources

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Example aggression

• Easy to quantify in frequency and intensity
• Prevents us from using a label that gets fixated
• Multi-disciplinary approach can be taken
• Even though it comes from multiple sources, the
  treatments are the same

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Aggressive Spectrum
ADHD Spectrum
Bipolar Spectrum
Tourettes/OCD
Sexual Compulsions
Impulse Control Disorders
PTSD
SubstanceUse Disorder
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Dimensional Systems

• Impulsive-compulsive spectrum

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Impulsivity vs Compulsivity

• Compulsivity Impulsivity

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Impulsivity vs compulsivity

• Impulsive
• Reactive
• Feeling
• Emotional
• Short fuse
• Externalizing
• Heart

• Compulsive
• Ruminative
• Thinking
• Constrained
• Cant let it go
• Internalizing
• Head

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Last time asked you to do some introspection

• Go back to your childhood
• How many of you feel you are on the impulsive
  spectrum- heart people
• How many are on the compulsive spectrum head
  people

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Categorical versus Dimensional

• Compulsivity Impulsivity
• Depression ADHD
• Anxiety disorders Bipolar disorder
• Cluster C personalities Cluster B
  personalities
• NORMAL
• Impulsivity vs Compulsivity, Oldham et al, 1996

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Developmental Model

• Epigenetic- building on foundations
• We are genetically driven down the same
  developmental path regardless of events
• Highly predictable
• Cyclical, much like cell differentiation
• Growth- stable - growth

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Normal Childhood Development

• Children cry to communicate

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Child Development

• 0-18 months
• Trust versus mistrust
• A childs sense of security
• Bonding
• 18 months to 2 ½ years
• Autonomy versus doubt
• Individuation- Object Permanence
• True independence or a feeling of apprehension
• anal retentiveness- holding on
• What if you cut my ears off
• or What if? the core basis of impulse control

Erikson, Erik H. Identity, Youth and Crisis. New
York Norton, 1968.
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Normal Development 2 ½ - 6

• Initiative versus guilt
• Do children feel frightened by the interpretation
  of their world
• Do I need to be in control?
• Gender identification
• Autonomy
• Peer development
• Physical Change
• Self directedness

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Child Development 7-12

• Industry versus inferiority
• Role models
• Love to get positive attention
• Creative learning
• Quiet time of development
• Great to be a parent

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Child Development 12-18

• Adolescence 2 ½ -6
• Gender awakening and sexuality
• Autonomy and independence
• Physical change puberty
• Peer development friends become important
• Self - cooperation
• Identity versus role confusion
• Unresolved issues from childhood come back

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Adult Development 18 - 45

• Stable period just like latency 6-12
• Intimacy versus isolation
• Building families, assets, careers
• Highly predictable likelihood of success
• Work ethic
• Families starting later
• New dynamic but doesnt change developmental path

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Adult Development 45-60

• Just like 2 ½-6, just like adolescence
• Generativity versus stagnation
• Midlife Crisis
• Gender issues- sexuality changes
• Autonomy free from childhood burden
• Physical change
• Peer stability
• Self-transdecence working for societies good

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Prevention and Resiliency model

• If the way children are brought up defines us as
  adults and defines us as a society- why are we
  not making primary prevention the priority?
• The medical model glorifies pathology
• The school system poorly handles uniqueness
• The social system is in reactive mode
• Parental models and community lost

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Children are our future

• They must be a priority in the mental health
  system