Understanding Mental Health Disorders

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Understanding Mental Health Disorders

• David Mays, MD, PhD
• dvmays_at_wisc.edu

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Office of Childrens Mental Health

• Created by Scott Walker in 2014 to improve
  provision of mental-health services to
  Wisconsins children 535,400.
• Still in the data gathering stage.
• Elizabeth Hudson, trauma-informed care
  specialist, is the coordinator. The following
  slides are from her 2014 annual report to the
  Wisconsin Legislature.
• Contact 608-266-2771

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Wisconsins Office of Childrens Mental
HealthCoordinating and Integrating Services to
improve the lives of children and families
Office of Childrens Mental Health
Stakeholders
WCHSA-2015
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The Good News

• WI is better than the national average when it
  comes to
• Insuring kids
• Identifying kids with emotional distress (EBD) in
  schools
• Fewer suicide attempts (but worse than the
  national average on actual suicide rates)
• Lower poverty rates
• Having safe, strong neighborhoods with good
  schools (61 of youth)
• Positive home environments for children (33 of
  youth)

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Home Environment Measures

• Smokers at home?
• Childs screen time
• Frequency of family meals
• Ever breastfed?
• Frequency of reading to child
• Frequency of stories and songs
• Has parent met childs friends?
• Child earned money from chores or jobs?

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Prevalence Rates Are Higher For

• LGBT Youth
• 57 experienced depressive symptoms in last month
• African Americans
• Nationally, black youth have about 25 higher
  incidence of mental health challenges than white
  youth
• Those in Poverty
• Twice the rate of severe emotional disturbance
  as non-poor kids

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Low Income Kids

• In Jan 2015, the Southern Education Foundation
  reported that for the first time, 51 of children
  in public schools qualified for free or
  subsidized lunches (2013.) In 1989, only 33
  qualified. In 2000, only 38. (Mississippi had
  75 of children qualify, Wisconsin 41, Minnesota
  38.)
• Studies show that half of low income children
  start kindergarten with dramatically lower
  vocabularies and are less ready to learn than
  peers.

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Almost Half of WIs Children have Experienced any
Adversity
46 have at least one Adverse Childhood
Experience
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Adverse Childhood Event (ACE)

• Some of the most intensive and frequently
  occurring sources of stress that children may
  suffer early in life. These experiences include
  physical, sexual and emotional abuse neglect
  violence between parents of caregivers alcohol
  and substance abuse mental health issues for
  caregivers incarceration of a household member
  divorce and peer and community violence.

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WI has 1,033 residents per provider (vs. 7501
nationally) Mental Health America WI is 42nd
Nationally in Mental Health Workforce capacity
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• Rate of hospitalizing in state facility is 4.5
  times the national average and the highest in the
  Midwest
• 22 (1 in 5) WMHI hospital patients are under 18
  years of age, in contrast with the national
  average of 6 (1 in 16)
• 30-day hospital readmission rates for children
  are approx. twice the national average
• (16 vs. 8 for 0 to 12yo and 14 vs. 7 for
  13-17yo)

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• In Wisconsin
• One in seven students reported seriously
  considering suicide
• Youth suicide rate is 40 higher than the
  national average yet WI has one of the lowest
  suicide attempt rates
• Suicide is the second leading cause of death for
  youth (first is accidents)

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• WI would need the following student support
  professionals in order to be adequately staffed
  in the schools
• Five times as many social workers
• Twice as many school counselors
• 50 more psychologists

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• Students with any form of disability are at an
  increased risk of suspensions
• Suspensions have been decreasing for all students
  BUT
• Gap is growing wider students with disabilities
  were 2.38 times more likely to be suspended but
  in 2012-13 they were 3.35 times more likely to be
  suspended.

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Kids with Emotional/Behavioral Challenges Have
Low Graduation Rates

• .

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Shift Our Perspectivefrom a primarily Clinical
Approach to a Public Health Approach
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Onset of Mental Illness (Gladstone 2011)
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What Causes Pathology?

• Most mental illnesses have their beginnings in
  childhood. But adverse events in childhood do not
  regularly cause mental disorders. Most children
  are resilient.
• In some people, childhood adverse events have
  been linked to high risk behavior, substance
  abuse, adult trauma, psychiatric illness, and
  homelessness. We believe that there is an
  interaction with genetic vulnerability and
  environmental stress in these cases.

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Childhood Maltreatment

• Maltreated children are more likely to develop
  depression, bipolar disorder, anxiety, PTSD,
  substance abuse, personality disorders, and
  psychosis. Disorders emerge earlier, with greater
  severity, more comorbidity, and a less favorable
  response to treatment. They may have discernible
  brain abnormalities, experience a wide array of
  medical problems, shortened life expectancy, and
  reduced telomere length.

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Early Adversity

• Effects of early deprivation
• Cognitive delays
• Motor delays
• Language delays
• Absence of crying
• Failure to seek nurturance
• Repetitive, stereotyped behaviors
• Problems in school
• Impulsivity, difficulty with peers
• Genetic changes (shortened telomeres)

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Abuse

• Neglect, physical abuse, and sexual abuse have
  immediate and long-term effects on child
  development. We see higher rates of psychiatric
  disorder, increased rates of substance abuse, and
  relationship difficulties.
• Children who are sexually abused are at
  significant risk for developing anxiety disorders
  (2x), major depression (3.4x), alcohol abuse
  (2.5x), drug abuse (3.8x) and antisocial behavior
  (4.3x).

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The Epigenome

• Our genome is the instruction book for making a
  human body. But the genes themselves need
  instructions for what to do, and when and where
  to do it. These chemical markers and switches are
  located along the double helix and are known as
  the epigenome. They are the software code that
  induces the DNA hardware to manufacture a variety
  of proteins and cell types.
• Epigenetics provides the link between nature and
  nurture.

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The Epigenome

• The epigenome is as critical as the actual DNA
  for the development of healthy organisms. During
  development, it determines which cells become
  heart, which bone, which the brain.
• In recent years, it has been discovered that the
  epigenome is very sensitive to its chemical
  environment, and vitamins, toxins, even
  affectionate mothering can effect the epigenome,
  and thereby change DNA production, sometimes
  reversibly, sometimes for life.

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Attachment

• The effects of secure attachment include trust,
  intimacy, self-esteem, impulse management,
  autonomy and resilience. Individuals with secure
  attachment feel comfortable with intimacy and
  desire to be close to others during times of
  threat. They perceive their adult partners as a
  source of support and love. They report a sense
  of contentment and meaning in life.
• The attachment circuitry remains plastic and we
  are able to form very strong attachments even
  late in life. Ask any grandparent how they feel
  about their grandchildren! We are never too old
  to fall in love.

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Recovery

• There is some evidence that children who are
  taken out of orphanages and placed in homes
  before their second birthday recover some of
  their abilities.
• (This is the period that the US invests the least
  amount of money on health and prevention. For
  example, GED programs actually provide
  comparatively little benefit to the community or
  individual, vs. early nurse home visits.)

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The Unattached

• Unattached individuals feel a deep sense of
  uncertainty, that others dont give enough and
  are not reliable. They have difficulty with bonds
  and show greater dissatisfaction, cynicism, and
  distrust. They are more likely to suffer from
  eating disorders, maladaptive drinking, and
  substance abuse.

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Comorbidities With Attachment Problems

• Oppositional Defiant Disorder
• Conduct Disorder
• Attention Deficit Hyperactivity Disorder
• Bipolar Disorder
• Major Depressive Disorder
• Substance Abuse

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Differential Diagnosis
ADHD Bipolar Unattached
Course may improve worsens Conduct disorder, antisocial
Attention impaired varies hypervigilant
Mood friendly irritable charming, phony
Conscience remorse limited devious
Peers makes friends but loses them Mood dependent none
Anxiety uncommon wired appears invulnerable
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ADHD Incidence and Prevalence

• ADHD is the most common psychiatric disorder in
  childhood. The CDC recently reports that 11 of
  all school-aged children and 20 of high school
  boys are diagnosed with ADHD!!! 66 are on meds.
• 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.

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ADHD Incidence and Prevalence

• More frequently diagnosed in boys, but it is
  being recognized more in girls, who may have more
  of the inattention subtype.
• 50-60 will have another condition, such as
  learning disorder, restless-legs syndrome,
  depression, anxiety, conduct disorder,
  obsessive-compulsive behavior.
• It is not clear how much is carried over into
  adulthood. NCR estimates persistence into
  adolescence in 40-60, into adulthood in 36.
  Hyperactive symptoms may decrease with age
  because of increased self-control. Attention
  problems may continue. A recent review of 1,500
  showed gt50 lost their diagnosis 2 years later.

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A Growing Problem

• Express Scripts, the biggest prescription manager
  in the US reports that the number of young
  American adults taking medication for ADHD
  doubled from 2008-2012.
• 110 adolescent boys take medication for this
  disorder.
• Many experts agree that the disorder is being
  diagnosed and treated with medication in children
  far beyond reasonable rates.

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Overdiagnosed?(Diller, 2014)

• For the vast majority of children, the issue
  isnt so much hyperactivity and impulsivity. The
  issue is that some children have a personality
  that makes it difficult to do things they are not
  interested in. This is being called ADHD in this
  country. In North Carolina, for example, 30 of
  parents have been told by someone that their son
  has ADHD.

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Etiology

• There are multiple causes of ADHD. 65-75 of the
  variance is believed to be from genes with
  another 15 caused by maternal cigarette smoking,
  alcohol use, premature birth, maternal
  respiratory infections, maternal anxiety, and
  high maternal phenylalanine levels.
• Post-natal risk include head trauma, hypoxia,
  infection, lead poisoning, etc.

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The FDA

• In 2011 the FDA convened to hear testimony on the
  evidence of the relationship between artificial
  food colors and ADHD. AFCs require a warning
  label in the EU. The FDA ultimately decided (8-6
  vote) not to recommend banning AFCs or requiring
  a warning label. (If AFCs werent already in
  foods in the US, they probably would not be
  allowed.)
• Various studies have shown that the introduction
  of AFCs have negative effects on the behavior of
  children with and without ADHD.

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Chemicals and ADHD

• A British study and meta-analysis by Columbia and
  Harvard suggests that removing artificial
  coloring agents from children with ADHD would
  likely be 1/3 to ½ as effective as stimulants,
  for some children.
• A follow-up study in 2010 suggests that children
  with a variation of a histamine gene represent
  the sensitive group. Histamine effects activity
  levels in animals and there is strong evidence
  that artificial colors can trigger histamine
  release. The gene in question weakens the childs
  ability to clear histamine from the blood.

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The Bottom Line

• Parents can try removing the major sources of
  artificial colors and additives junk food,
  candy, brightly colored cereals, fruit drinks,
  soda for a few weeks to see if their behavior
  improves. The difficulty is parents are not good
  evaluators. (When mothers think their children
  are getting high levels of sugar, they routinely
  rate them as hyper.)
• Studies concerning omega-3s and micronutrients
  (zinc, iron, magnesium, etc) are inconclusive.

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Neurology

• Identified are disruptions of circuits in the
  frontal lobe, pre-central motor cortex, and locus
  ceruleus.
• Brain structures mediating executive functions
  undergo continuous development into adulthood.
  There appears to be a 3 year lag time in brain
  development at age 16 in ADHD children.

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Executive Functions and ADHD

• 1) Self-awareness the ability to see yourself
  and monitor your actions. ADHD patients do not
  monitor their actions and are less aware of their
  failures. They also tend to have a positive
  illusory bias.
• 2) Non-verbal working memory the ability to
  remember the past and predict the future. People
  with ADHD are terrible at time management and
  making predictions.
• 3) Verbal working memory using internal language
  to reason with and guide yourself

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Executive Functions and ADHD

• 4) Inhibition inhibit initial reactions and
  responses to situations and things.
• 5) Emotional regulation tools to regulate
  feelings when they occur. These children come
  across as very emotional, quick to anger,
  silliness, overly affectionate. People forgive
  the silliness, but not the hostility. 50-70 of
  ADHD children have no friends by the 3rd grade.
• 6) Self-motivation People with ADHD are very
  dependent on immediate feedback, If there are no
  consequences, they fall apart. They can pay
  attention to video games, but cant sit still to
  do homework.

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Comorbidities with ADHD
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ADHD and Substance Abuse

• The long-term Multimodal Treatment Study of ADHD
  (MTA) at 8 year follow-up shows that children
  with ADHD are at significant risk for substance
  abuse by adolescence. Marijuana and nicotine were
  especially problematic.
• Rates of abuse were neither increased or
  decreased related to treatment with medication.

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Diagnosis

• The diagnosis is made using parent/child/teacher
  interviews and observations, behavior rating
  scales, physical and neurological examinations,
  cognitive testing. There is no laboratory test.
• Symptoms may be absent when the child is
  receiving frequent rewards for an activity, is
  under close supervision, is in a novel setting,
  is interested, is in a one-on-one situation.

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Problems Diagnosing ADHD

• Complicated diagnosis inattention and
  impulsivity are seen with bipolar disorder,
  depression, anxiety, oppositional defiant
  disorder, conduct disorder, learning disabilities
• 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

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Teachers Screen

• The best instrument isnt very good, but it is
  The Swanson, Nolan, and Pelham IV Scale (SNAP-IV.)

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Treatment

• Stimulant medication is the mainstay treatment.
  These medications seem to be equally effective.
  Studies of efficacy beyond 2 years are rare. Core
  symptoms seem to benefit, but associated domains
  (social skills, achievement, family function) do
  not.
• Also required are psychoeducation, behavioral
  interventions, parent training, and school
  support (daily report cards, homework assistance,
  contingency management, etc.)

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Why Do Stimulants Work?

• In healthy volunteers, methylphenidate reduces
  brain fatigue associated with effortful attention
  and suppresses the emergence of the default brain
  network (mind wandering, task-irrelevant
  thinking.)
• The effect is more than just keeping you awake.
• You do not have to have ADHD to benefit from a
  stimulant.

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Stimulants

• Stimulants do not benefit pre-schoolers.
• 80 of school-aged children show a positive
  response, including reduced hyperactivity,
  impulsivity, improved attention and concentration
  and improved fine motor skills, reduced
  oppositional behaviors.
• These results are seen in both ADHD children and
  controls!

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Side Effects of Stimulants

• Side effects of all the stimulants are the same
  decreased appetite (25), initial sleep
  difficulty, headaches, stomachaches, tics, and
  irritability.
• Cardiovascular effects include a slight increase
  in blood pressure and heart rate. Children should
  be screened for cardiac problems.
• Growth suppression, if at all, appears dose
  related during the first year of treatment ( 2
  cm).
• Preschoolers also show the side effects of
  listlessness and social withdrawal. Children lt5
  do not show benefit.
• The question of stimulants leading to substance
  use disorders remains unsettled. Controlling for
  conduct disorder is difficult.

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Multimodal Treatment Study of Children With ADHD
(MTA)

• MTA is a large (579 children) study that has been
  ongoing for 8 years. Initially, each child
  received 14 months of treatment medication
  alone, psychosocial therapy alone, both together,
  or treatment as usual in the community.
• At 14 and 24 months, the best results occurred in
  children on medication alone or with psychosocial
  treatment.
• At 36 months, after the children had resumed care
  in the community, the advantage of being on
  medication had completely disappeared.

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Multimodal Treatment Study of Children With ADHD
(MTA)

• At 8 years, long-term outcomes show, that while
  treatment reduces ADHD symptoms, it does not
  enable children to function as well as their
  healthy classmates. They lag behind on 91 of the
  outcome variables.
• The best outcomes were for children with the
  mildest symptoms at outset and the most stable,
  well-off families. Type of treatment didnt
  matter.
• The conclusion is that a flexible, individualized
  approach is best with periodic discontinuation of
  the medication to see if it is helping.
• Improvement in ADHD is difficult to sustain.

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Non-FDA Approved Medicines for ADHD

• bupropion (Wellbutrin) antidepressant
• imipramine, nortriptyline tricyclic
  antidepressants
• clonidine similar to guanfacine, an alpha2
  -adrenergic agonist (now approved)
• modafinil (Provigil) works, but at higher doses
  than used for fatigue

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Treatment Efficacy (Effect Size)

• Methylphenidate 0.78
• Clonidine 0.58
• Atomoxetine 0.64
• Omega-3 fatty acids 0.31

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Nutritional Supplements

• Omega-3 fatty acids limited evidence, little
  downside in a trial. Fish oil is inexpensive,
  1000-2000 mg/day for 3-6 months for a trial.
• L-Carnitine no evidence of efficacy
• Zinc no evidence of efficacy
• Iron only if there is iron deficiency
• Megavitamins no efficacy and possibility of
  harm. A multivitamin might be useful if the child
  is not eating a balanced diet.

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Behavioral Treatments

• Parent training
• Educational interventions or classroom or
  contingency management
• Social skills training
• Intensive summer programs

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Resources for Parents

• Parent to Parent help and education for parents
  with children with ADHD. 301-306-7070 ext. 133 or
  parent2parent_at_chadd.org
• Your Child in the Balance
• Kevin Kalikow, New York CDS Books, 2006.

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Disruptive, Impulse Control, and Conduct Disorders

• Oppositional Defiant Disorder
• Symptoms now in 3 types angry/irritable,
  argumentative/defiant, vindictiveness
• May co-occur with conduct disorder
• Severity scale
• Intermittent Explosive Disorder
• Now must be older than 6, no longer requires
  physical aggression, may also have ADHD, conduct
  disorder, ODD, ASD
• Conduct Disorder
• childhood or adolescent onset specifier
• Limited Prosocial specifier (Callous and
  Unemotional)
• Kleptomania
• Pyromania

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Lack of Research

• Despite the frequency of these disorders, they
  have been relatively understudied. Controlled
  trials are usually non-existent, and there are no
  FDA approved medications for any of these
  conditions.

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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 Conduct Disorder.
  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 Parent Management Training,
  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
• 50 will also be diagnosed with ADHD. Co-occurs
  with mood disorders, PTSD, and learning problems.
• Behaviors
• Aggression toward people and animals
• Destruction of property without aggression
• Deceitfulness, lying, and theft
• Serious violations of rules

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Risks for Developing 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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Fearlessness

• Fearlessness has been linked to lower scores on
  conscience development in young children.
  (Internalization of parental and societal norms
  is dependent on fear of potential punishment.)
• Fearlessness may also interfere with empathy
  development.

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Fearlessness

• It is not known whether this personality trait is
  inherited or the result of traumatic
  environmental experiences.
• It is also not clear to what degree this can be
  modified. In one study, both fearful and fearless
  children showed higher levels of guilt with
  better parenting behaviors, but the fearless
  group required much higher levels of consistency.

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Presentation

• 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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Presentation

• 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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Natural History The Negative Cycle

• 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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Subtypes of CD

• Childhood onset
• Presence of 1 criteria before age 10
• Typically boys exhibiting high levels of
  aggression, may also be diagnosed as 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
  (e.g. gang members)
• Less ADHD. Equal gender distribution.
• Much better prognosis
• Limited Prosocial Specifier

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Limited Prosocial Specifier

• Lack of remorse or guilt
• Callous, lack of empathy
• Unconcerned about performance
• Shallow or deficient affect

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Limited Prosocial

• These youth are less likely to show empathy to
  others in distress, although they are capable of
  cognitively recognizing distress in others
  (unlike some autism).
• They are less sensitive to punishment and tend to
  be thrill-seeking and uninhibited.
• These youth are more likely to show both
  instrumental and reactive aggression.

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Reactive Aggression

• Reactive aggression is characterized by impulsive
  defensive responses to perceived provocation.
  Over-reaction to minor threats is also seen.
• Such children may selectively attend to negative
  social cues, fail to consider alternative
  explanations for behavior, fail to consider
  alternative responses, and fail to consider the
  consequences.
• Most reactive aggression is associated with
  anxiety and depression.

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Treatment of Reactive Aggression

• These youth generally are poorly socialized and
  have difficulty with emotional modulation
• Deal with hostile-attributional biases and
  hypervigilance to hostility
• Promote self-control mechanisms
• Work with managing intense anger
• Treat depression and anxiety

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Instrumental Aggression

• In instrumental, or predatory, aggression,
  violence is used as a means to an end. These
  youth often show emotional detachment rather than
  emotional dysregulation.
• They do not focus on the negative effects of
  their behavior on others and resistant to
  punishment.
• Instrumental aggression in pre-adolescence
  predicts delinquency, violence, disruptive
  behavior during mid-adolescence, and criminal
  behavior with psychopathy in adults.
• Instrumental aggression is very difficult to
  treat.

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Pharmacological Approaches

• Conduct disorder and oppositional defiant
  disorder do not respond to medications alone.
• The most difficult to treat patients have
  long-standing anxiety or learning disabilities.
• In children with autism, developmental
  disabilities, or traumatic brain injury often
  respond to rapid dose changes by becoming
  aggressive.
• Start with adrenergic agents (guanfacine,
  clonidine) which are safe and work quickly. They
  may give the child a few extra seconds to get
  control by slowing agitation.

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Treating Conduct Disorder

• Sometimes stimulants can help. If depression and
  anxiety are present, treat those.
• Individual psychotherapy as a treatment has not
  proven effective because young people with
  Conduct Disorder resist it.
• Group therapy may have some benefit for younger
  children. For adolescents, group treatment often
  worsens behavior.
• Of the 16 treatments likely to be effective for
  disruptive behavior in children and adolescents,
  the most effective interventions involve parents
  or caregivers.

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Treatment of Limited Prosocial CD

• Conduct disordered youth with these traits
  respond less well to treatment. They are more
  likely to respond to reward-oriented
  interventions than punishment.
• It is not clear whether CU traits are the result
  of inherited temperament, or whether the CU
  results from lack of good quality attachment and
  bonding, but CU traits may decrease somewhat when
  the quality of parental care improves.
• In addition, sometimes a change in peers (a
  friend made at school vs. friends in the
  neighborhood) can make a difference.

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Family-Based Treatment

• Helping the Noncompliant Child is most
  appropriate for children 3-8. Therapists coach
  parents in how to reward positive behaviors and
  give clear instructions. The goal is to improve
  interactions between parent and child.

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Family-Based 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.
  It is most effective for 3-12 year olds.

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Other Treatments

• Boot camp type treatments are usually ineffective
  and may worsen problems. Weaker youths may learn
  more criminal behaviors from older kids.
  Long-term data show high arrest records for youth
  who have been in boot camps.

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Bipolar Disorder in Young People

• Bipolar disorder in children is enormously
  controversial! Depending on who you listen to,
  there is either an epidemic, or it is vastly
  over-diagnosed.
• The problem is that there is little agreement on
  
• the validity of symptoms such as elated mood and
  grandiosity in children
• the role of irritability
• whether symptoms must be episodic

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Classic Bipolar Symptoms in Children

• Mania
• Hyperactivity
• Irritability
• Psychosis/grandiosity
• Elated/expansive mood
• Rapid speech/racing thoughts
• Sleep - doesnt need it or want it

• Depression
• Personality change
• Drop in grades
• Morbid/suicidal
• Pessimistic
• Somatic

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Bipolar Disorder or ADHD?

• Most children diagnosed with bipolar disorder
  also appear to meet ADHD criteria. Overlapping
  symptoms include distractibility, pressured
  speech, psychomotor agitation, racing thoughts,
  and increased goal-directed activity.
• However, it is unusual that a child with ADHD
  will meet strict bipolar criteria for mania.

87
Distinguishing Bipolar Disorder from ADHD

• Symptoms specific to mania and not ADHD in
  children
• Decreased need for sleep (not insomnia)
• Hypersexuality
• Flight of ideas, pressured speech, racing
  thoughts
• Grandiosity and euphoria (is not amusing,
  inappropriate)
• Hallucinations, delusions
• Suicidal and homicidal behavior

88
The Narrow Definition

• A young person meeting the classic criteria would
  be said to fit the narrow phenotype. They would
  be likely to be genetically related to another
  person with bipolar disorder. They will most
  likely continue to have bipolar disorder symptoms
  as an adult.
• There is little controversy about this group
  among clinicians.

89
The Broad Definition

• These are children who are described by parents
  as having mood swings, who have explosive
  outbursts of extreme intensity and duration.
  Parents have to walk on eggshells.
• They are not particularly at risk for developing
  becoming bipolar adults. They are more likely to
  have problems with depression and anxiety as
  adults.
• Their parents are less likely to have
  psychopathology than parents with bipolar
  children.

90
Disruptive Mood Dysregulation Disorder

• Severe recurrent temper outbursts 3 times/week
• General mood is irritable and angry
• Present for 12 or more months
• Between 6 and 18, onset before 10
• Not better explained by another disorder (autism,
  PTSD)
• Cannot be comorbid with ODD, intermittent
  explosive disorder, or bipolar disorder

91
ADHD
BIPOLAR
DMDD
More aggressive
More continuous
More labile
Disruptive Behavior Disorders
92
Long-Term Prognosis(Am J Psych April 2014)

• A prospective study of 1,400 youth followed
  children and adolescence into adulthood. Youth
  who met the criteria for DMDD had elevated rates
  of anxiety and depression and were more likely to
  meet criteria for more than one disorder relative
  to children without DMDD, even if they had a
  different psychiatric disorder. They were also
  more likely to have adverse health outcomes, be
  impoverished, have reported police contact, and
  have low educational attainment.

93
A bit more

• The patterns of increased psychopathology and
  poor adaptive functioning seen in this study of
  DMDD reflect risks often seen in ADHD. Some
  preliminary research is pointing to EEG findings
  that distinguish ADHD children who have chronic
  irritability versus those who have ADHD alone. It
  is possible that it is the chronic irritability
  that leads to the worst ADHD outcomes, not the
  ADHD.

94
Bipolar mania ADHD Dis. Mood Dysreg Disord Disruptive Behavior Disorders
Episodic X
Euphoria, grandiosity, hypersexuality, delusions hallucinations X
Mood lability X X
Insomnia X /- /-
Pressured Speech X X X
Intrusiveness X X X /-
Irritability X X X Headstrong
Rage attacks X X X
95
Diagnosing DMDD

• In field trials this disorder had poor
  inter-rater reliability. The primary problem was
  apparently difficulty differentiating
  oppositional defiant disorder from DMDD. There
  were also problems with duration often these
  periods of rage attacks are time-limited.
  Commentators emphasize the importance of the
  frequency, persistence and duration criteria.

96
Differential Diagnosis of DMDD

• DMDD and bipolar irritability in bipolar is
  episodic, and varies with euthymia, depression,
  and mania
• DMDD and intermittent explosive disorder
  outbursts are 2x week for 3 months, DMDD are 3x
  week for 1 year
• DMDD and ODD outbursts only 1x/week in ODD, over
  6 months in ODD, no impairment required and must
  be severe in only 1 setting for ODD (impairment
  in 2 of 3 settings for DMDD)

97
Treatment

• The distinction between DMDD and bipolar disorder
  may be important. For bipolar disorder, the
  first-line treatment would be mood stabilizers
  (second generation antipsychotics.) For DMDD,
  which evolves to anxiety and depression in
  adulthood, the first-line treatment maybe
  stimulants and antidepressants.
• The only treatment trial for this group of
  children completed to date is a small negative
  trial of lithium.

98
DMDD

• 1) Stimulants
• 2) Psychosocial intervention (parent training
  or CBT)
• 3) Addition of valproate or a second-generation
  antipsychotic

99
Depression in Children

• Depression effects up to 2.5 of children and
  8.3 of adolescents. (Lifetime prevalence in
  adults is 16.)
• Among preschoolers, anhedonia is the most
  specific symptom of depression, accompanied by
  sadness, social withdrawal, guilt, fatigue,
  cognitive problems. Irritability may or may not
  be present.
• Children may also show depression by high levels
  of self-criticism and somatic complaints. Nobody
  likes me. Im no good at sports. My head
  aches. My stomach hurts.

100
Treatment of Depression in Children

• Antidepressants should not be used as first or
  second-line treatment for preschool or younger
  school-aged children due to lack of efficacy and
  problems with side effects. Family therapy is the
  treatment of choice, with an emphasis on mood
  regulation.
• In older school-aged children, fluoxetine is the
  only approved antidepressant, although other
  antidepressants are often prescribed. (In
  children 12 or older, escitalopram is also FDA
  approved.)

101
Depression in Adolescents

• By adolescence, depression rates have started to
  climb and young people are more able to describe
  themselves as depressed, apathetic, or suicidal.
  The average age of onset is 15.
• Adolescent depression frequently is persistent
  and recurring.
• Suicidality first arises as a public health
  problem in adolescence. In 2009, 13.8 seriously
  considered suicide and 6.3 made a suicide
  attempt.

102
Depression in Youth

• Depression may also manifest itself as boredom,
  recklessness, obsessive-compulsive behavior, and
  behavior problems in young people.
• 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 more substance
  abuse and other risky behaviors.

103
Sleep

• A recent review found the following health risk
  associations with too little sleep
• Increased soda consumption
• Lack of physical activity
• More hours spent watching TV, playing video games
• More recreational computer use
• More smoking, alcohol, marijuana
• More incidents of sexual intercourse
• More depression/ suicidal ideation

104
Sleep

• It is difficult to assess sleep in teenagers
  because they normally sleep an enormous amount.
  up to 14 hours a day! Look at how they are
  functioning.
• The most recent survey suggests that 66 of teens
  get less than 8 hours sleep during weekdays.

105
Assessing Teens

• Teens do a lot of things to express their
  individuality, but they dont usually quit their
  sports and hobbies. If the teen is hanging around
  in her room all day, this is a worrisome sign.
  The same is true with falling grades. Look for
  functional impairment and vague, somatic
  complaints, or comments from third parties.
• Some teens may be insulted if you ask them if
  they are depressed. Ask instead if they are
  irritable.

106
Helping Families

• Arguing, refusal to participate in family
  activities, being embarrassed to be seen with the
  family may all be normal separation. Parents need
  to be firm and reasonable about limits, and not
  take it all too personally. Teenagers need to
  know they are loved and the parents are there for
  them.
• By the time families come in for help, everyone
  is feeling helpless and angry. One of the best
  things the therapist can do is instill some
  confidence that things will get better, and
  appreciate how much work the family has been
  doing to try to make things better.

107
Dr Peter Parry, child psychiatrist, editorial
board of The Carlat Child Psychiatry Report

• Reserve SSRIs for youth with severe OCD, anxiety
  not responding to CBT, severe depression.
• Treat mild to moderate depression with
• Behavioral activation (exercise, sleep hygiene,
  socialization)
• Breathing relaxation exercises
• Healthier diet
• Omega-3 fatty acids
• Reduced substance abuse
• Addressing school, bullying, family issues

108
Other Psychosocial Interventions

• Effective interventions share some common
  features
• Help teens increase competence in at least one
  self-identified area
• Psychoeducation about depression and treatment
• Teach self-monitoring skills
• Address social, communication, problem solving
  skills
• Teach cognitive restructuring
• Use behavioral activation techniques

109
Generation Wired

• This generation prefers texting to talking. (Each
  text triggers a dopamine release.) Some parents
  continually text their children.
• Young people also need to learn the skills of
  being alone, reading body language, negotiation,
  communication one on one, etc.

110
Generation Wired

• The average teen sends more than 50 texts/day.
  51 log onto a social network site more than once
  a day. 22 log in more than 10x/day. The amount
  of time all children spend online daily has
  tripled in the last 10 years.
• You have to be 13 to join Facebook, but children
  should learn about not sharing personal
  information before then. Pre-teens are very
  rule-focused, but they can forget what theyve
  learned when they become teens.

111
Facebooked

• Facebook can be a like a high school cafeteria on
  steroids. For some kids, its great. For others,
  they may feel like everybody else is having all
  the fun. For still others, they may be targeted
  by cyber-bullying. (If your child is acting blue
  and avoiding the phone or computer, ask if
  anything upsetting happened recently online.)

112
Video Games

• 90 of American young people play video games,
  average age 33
• Boys are the heaviest users and almost always
  play with others. It is a social activity.
  Non-participation may be a marker for pathology.
• M-rated video play is common among all teens.

113
Do Violent Video Games Create Violent Children?

• Peek (2014)

114
What Is The Research?

• Television, movies, and video games have been
  extensively studied over the last several
  decades. Six prominent medical groups have
  commented upon the negative effects of violent
  media.
• What is the evidence?

115
History

• Video games were first developed in the 1970s.
  Violent video games became popular in the 1990s.
  These games have become increasingly realistic.
  As mentioned earlier, nearly every child plays
  video games, on average 65 minutes/day for 8-10
  year olds.

116
Data

• Studies demonstrate that exposing a child to
  violent video games increases the likelihood that
  they will behave aggressively immediately after.
• Most studies find a correlation between the
  amount of time playing violent video games and
  the likelihood of getting into fights, arguing
  with teachers, and poor school performance.

117
Theory

• Social-cognitive models of behaviors point to
  priming (we are more likely to do what we see),
  arousal, and desensitization. This model posits
  that children eventually build aggression related
  schema in their view of the world. Each exposure
  to violent media is a learning trial,
  contributing to more and more aggressive behavior.

118
Theory

• Critics argue that the relationship between
  violent media and aggressive behavior is not
  causal. It does not take into account genetics,
  temperament, and family environment. These
  critics argue that violence is largely innate.
  Exposure to violent media modulates this
  tendency.
• Evidence for this point of view is based on
  studies that show that male gender, trait
  aggression, and family violence are better
  predictors of aggression than media exposure.

119
Conclusions

• All children are affected in some way by media
  violence. Some are more susceptible than others.
  It is a risk factor that is more controllable.
• 90 of teen parents do not check ratings before
  purchasing video games.

120
Pathologic Video Game Play

• Feeling agitated when not playing
• Not being able to decrease time playing
• Not sleeping because of play
• Missing meals because of play
• Being late because of play
• Having arguments at home because of play
• Games interfere with social relationships
• Games interfere with schoolwork

121
Advice for Parents

• For children who are not doing well in school, or
  have other emotional problems, parents should
  minimize media in the bedroom. 20 of middle
  school students with media in the bedroom have
  problematic use. Girls may be especially
  vulnerable to maladaptive online relationships.
• Know what your child is playing. Watch them play.
  Join in if appropriate for a few rounds.
• Clarify limits and house rules. Many children
  benefit from specific limits.
• Info on games www.commonsensemedia.org

122
Advice to Parents

• A young person is not addicted to the Internet
  simply because they enjoy it. Recognize the
  importance of online communication to youth.