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Understanding Mental Health Disorders


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Title: Understanding Mental Health Disorders

Understanding Mental Health Disorders
  • David Mays, MD, PhD
  • dvmays_at_wisc.edu

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

Wisconsins Office of Childrens Mental
HealthCoordinating and Integrating Services to
improve the lives of children and families
Office of Childrens Mental Health
The Good News
  • WI is better than the national average when it
    comes to
  • Insuring kids
  • Identifying kids with emotional distress (EBD) in
  • 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

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
  • Those in Poverty
  • Twice the rate of severe emotional disturbance
    as non-poor kids

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
  • Studies show that half of low income children
    start kindergarten with dramatically lower
    vocabularies and are less ready to learn than

Almost Half of WIs Children have Experienced any
46 have at least one Adverse Childhood
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.

WI has 1,033 residents per provider (vs. 7501
nationally) Mental Health America WI is 42nd
Nationally in Mental Health Workforce capacity
  • Rate of hospitalizing in state facility is 4.5
    times the national average and the highest in the
  • 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

  • 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)

  • 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

  • Students with any form of disability are at an
    increased risk of suspensions
  • Suspensions have been decreasing for all students
  • 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

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Kids with Emotional/Behavioral Challenges Have
Low Graduation Rates
  • .

Shift Our Perspectivefrom a primarily Clinical
Approach to a Public Health Approach
Onset of Mental Illness (Gladstone 2011)
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.

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.

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)

  • 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

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

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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  • 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.

  • 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.)

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.

Comorbidities With Attachment Problems
  • Oppositional Defiant Disorder
  • Conduct Disorder
  • Attention Deficit Hyperactivity Disorder
  • Bipolar Disorder
  • Major Depressive Disorder
  • Substance Abuse

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
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.

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.

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
  • Many experts agree that the disorder is being
    diagnosed and treated with medication in children
    far beyond reasonable rates.

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.

  • 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.

  • 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
  • Various studies have shown that the introduction
    of AFCs have negative effects on the behavior of
    children with and without ADHD.

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.

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.

  • Identified are disruptions of circuits in the
    frontal lobe, pre-central motor cortex, and locus
  • 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.

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

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.

Comorbidities with ADHD
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.

  • 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.

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

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

  • 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
  • Also required are psychoeducation, behavioral
    interventions, parent training, and school
    support (daily report cards, homework assistance,
    contingency management, etc.)

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
  • The effect is more than just keeping you awake.
  • You do not have to have ADHD to benefit from a

  • 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

Side Effects of Stimulants
  • Side effects of all the stimulants are the same
    decreased appetite (25), initial sleep
    difficulty, headaches, stomachaches, tics, and
  • 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
  • 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.

Multimodal Treatment Study of Children With ADHD
  • 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
  • At 36 months, after the children had resumed care
    in the community, the advantage of being on
    medication had completely disappeared.

Multimodal Treatment Study of Children With ADHD
  • 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
  • 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.

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

Treatment Efficacy (Effect Size)
  • Methylphenidate 0.78
  • Clonidine 0.58
  • Atomoxetine 0.64
  • Omega-3 fatty acids 0.31

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.

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

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

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
  • Kleptomania
  • Pyromania

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

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

  • 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
  • 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.

  • 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.

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

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

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

  • 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

  • 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.

  • 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
  • Middle and high school
  • Noncompliance with commands
  • Emotional overreaction
  • Failure to take responsibility for their actions

  • 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

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
  • Child receives less and less parental interaction
  • Child does not have opportunities to learn more
    mature behaviors

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

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

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.

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
  • Most reactive aggression is associated with
    anxiety and depression.

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

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
  • 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

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
  • 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.

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.

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.

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.

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.

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.

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
  • 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

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

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.

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

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.

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
  • Their parents are less likely to have
    psychopathology than parents with bipolar

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,
  • Cannot be comorbid with ODD, intermittent
    explosive disorder, or bipolar disorder

More aggressive
More continuous
More labile
Disruptive Behavior Disorders
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.

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

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
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.

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)

  • 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.

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

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.

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
  • 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

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

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.

  • 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

  • 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
  • The most recent survey suggests that 66 of teens
    get less than 8 hours sleep during weekdays.

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

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
  • 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.

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,
  • Breathing relaxation exercises
  • Healthier diet
  • Omega-3 fatty acids
  • Reduced substance abuse
  • Addressing school, bullying, family issues

Other Psychosocial Interventions
  • Effective interventions share some common
  • 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
  • Teach cognitive restructuring
  • Use behavioral activation techniques

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.

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.

  • 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.)

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.

Do Violent Video Games Create Violent Children?
  • Peek (2014)

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
  • What is the evidence?

  • 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.

  • 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.

  • 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.

  • 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
  • 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.

  • 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.

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

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

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.
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