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Child and Adolescent
Psychiatric Disorders
dvmays@wisc.edu
Kids and Mental Health
• Principles:
– Diagnosis is very complex!!!
– Treatment is difficult and often unsatisfactory.
– Families, schools, and social services are all
extremely vulnerable to social, political, and
financial pressures and emotions run high.
– It is difficult to stay focused when there is a
continual crisis.
Childhood Development
• We currently believe that each child is born with
an inborn temperament which is shaped and
molded by the family, caretakers, and
environmental experiences. In turn, the behavior
of the infant effects the environment. Happy
babies who like to be cuddled will elicit warmth
and nurturance from the caretakers. Irritable,
overly sensitive children may cause caregivers to
be impatient and withdraw.
Theories of Personality:
Trait Theories - Cloninger
• Temperament and character: 50% of personality is
attributed to temperament, 50% to character
– Temperament: biologically based, quite stable
• Novelty seeking
• Harm avoidance
• Reward dependence
• Persistence
– Character: psychosocially based, varies throughout
adulthood
• Self-directedness
• Cooperativeness
• Self-transcendence
Development of Disorders
• Temperament to Trait to Disorder
– Temperament, along with environmental influences,
inclines people to develop certain traits.
– Personality traits are emotional, cognitive, and
behavioral tendencies in which individuals vary from
each other.
– When traits become maladaptive and dysfunctional,
they lead to diagnosable personality disorders.
Environmental stressors may amplify certain traits at
certain times.
What Causes Pathology?
• Nature and Nurture: Stress-Diathesis model
– Most mental illnesses have their beginnings in childhood
• Does a bad childhood cause mental illness?
– The brain is an incredibly plastic organ. Early learning can
be reversed by later learning.
– Childhood experiences alone do not determine personality
traits.
– Adverse events in childhood do not regularly cause mental
disorders.
– Except for vision and language, the evidence for an
invariable set of developmental stages that must be
mastered at a certain time is slim.
Childhood Externalizing Disorders
• Temperamentally extroverted and impulsive
• In an unfavorable family environment, at risk for
oppositional and conduct disorder
• They effect peers, adults, and teachers quite
negatively.
• 33% will be diagnosed with antisocial personality
disorder
• Also at risk for substance abuse and mood
disorders
• ADHD with conduct disorder is risk for APD
Childhood Internalizing
Disorders
• Children with introverted temperaments
who worry a lot and are overly dependent
• Prone to depression and anxiety symptoms
in certain environments
Childhood Cognitive Disorders
• Odd affect, social isolation, poor
interpersonal skills, cognitive difficulties
• Clearly related to premorbid phase of
schizophrenia
• Children are at risk for schizophrenia,
schizoaffective disorder
Environmental Data: Amplification
Effects
• Externalizing children may be in chronic
conflict with peers, teachers, and other
adults, and may respond to conflict with
greater maladaptive behavior.
• Shy children who are overly shy may be
overly protected
Environmental Effects
• There does not seem to be a one-to-one
correspondence between particular stressors
and particular disorders.
• Abusive inconsistent parenting, sexual
abuse, early loss, trauma, lack of social
cohesion are all implicated.
Attention Deficit/
Hyperactivity Disorder
• Current theories suggest that persons with ADHD
actually have difficulty regulating their attention:
difficulty inhibiting their attention to nonrelevant
stimuli and/or focusing too intensely on specific
stimuli to the exclusion of what is relevant.
• A neurotransmitter imbalance connecting the frontal
cortex with the basal ganglia results in distortion of
six major aspects of executive functioning.
Executive Functions
• Flexibility: shifting from one strategy or mindset
to another
• Organization: anticipating needs and problems
• Planning: goal setting
• Working memory: receiving, storing and
retrieving information within short-term memory
• Separating affect from cognition: detaching one’s
emotions from one’s reason
• Inhibiting and regulating verbal and motoric
action: jumping to conclusions, difficulty waiting
ADHD
• 3-7% incidence in many Western countries
• 50-60% will have another condition, such as
learning disorder, restless-legs syndrome,
depression, anxiety, conduct disorder, obsessive-
compulsive behavior
• More frequently diagnosed in boys, but it is being
recognized more in girls.
• It is not clear how much is carried over into
adulthood. Hyperactive symptoms may decrease
with age because of increased self-control.
Attention problems may continue.
ADHD
• ADHD is the most common psychiatric disorder in
childhood. Incidence of the different subtypes: the
inattentive subtype - 4.7%, hyperactive - 3.4%,
combined - 4.4%.
• It is inheritable with concordance in monozygotic
twins of 51%, dizygotic 33%.
• Psychosocial factors do not appear to play an
etiologic role, although they may contribute to
oppositional and conduct disorders.
• It has not been proven that environmental
abnormalities contribute to ADHD.
Diagnosis
• The diagnosis is made clinically using
parent/child/teacher interviews and observations,
behavior rating scales, physical and neurological
examinations, cognitive testing. There is no
laboratory test.
• Important are past medical history including for
other psychiatric disorders (anxiety, bipolar,
conduct, depression, eating disorders, learning
disability, pervasive developmental disorder,
PTSD, psychosis, sleep disorder, AODA…)
Diagnosis
• Social history
– School performance
– Social skills
– Home and family interactions
• Disorganization of personal space
• Anger or rage reactions
• Most awake in the late evening
• Awakening child in the AM difficult
• Unable to do chores
• Homework organization and completion hard
• Family dysfunction
Diagnosis
• Medical exam
– Laboratory work
• Liver function tests possibly
• Complete blood count
• Drug screening if appropriate
• Thyroid, glucose, other metabolic screen
– Imaging - none presently
– Physical
– Other tests - impulsivity, attention deficit scales, IQ,
learning disabilities, executive functions
Problems
• “in vogue” diagnosis
• Heavy pharmaceutical marketing
• Those with diagnosis get special considerations
• Primary care MD’s have difficult time with
diagnosis - requires time and testing
• Diagnosis is unusually dependent on social and
educational circumstances
• Diagnosis has high degree of subjectivity and
testing is not specific
Treatment
• Stimulant medication has become the mainstay of
treatment. All of the medications seem to be
equally effective with about a 70% response rate.
• They have a positive effect on academic
performance, classroom behavior, and academic
productivity.
• Side effects are the same: decreased appetite,
initial sleep difficulty, headaches, stomachaches,
tics, and irritability. Growth suppression, if at all,
appears dose related. There is no evidence of
tolerance or later substance abuse.
Treatment
• Medication is useful for a large number of
children, but not all. In addition, medication
generally does not produce total remission of
symptoms.
• Psychosocial interventions such as parent support
groups, parent management training, school based
programs, behavior modification, special classes
may be helpful.
Oppositional Defiant Disorder
• A recurrent pattern of negativistic, defiant,
disobedient, and hostile behavior toward authority
figures
– Losing one’s temper
– Arguing with adults
– Actively defying requests
– Refusing to follow rules
– Deliberately annoying other people
– Blaming others for one’s own mistakes
– Being resentful, irritable, spiteful, vindictive
ODD
• Not diagnosed unless it occurs for at least 6
months and is much more frequent than in
children of the same age.
• Prevalence is 6-10%. More common in boys until
puberty.
• Lots of overlap with ADHD and CD. Some see
ODD as a precursor for CD.
• As with CD, temperament (irritability,
impulsivity, and emotional intensity) contributes
to a pattern of oppositional and defiant behaviors.
Negative cycles result.
ODD
• Milder forms may remit. More serious forms
evolve into CD.
• There is high comorbidity with ADHD, learning
disorders, CD and internalizing disorders. A
comprehensive evaluation is necessary,
• Treatment involves PMT, medication if
appropriate, social skills training, academic
support, individual counseling if needed.
Conduct Disorder
• One of the most difficult and intractable
mental health problems in children.
• Present in 2-9%, mostly boys
• Behaviors:
– Aggression toward people and animals
– Destruction of property without aggression
– Deceitfulness, lying, and theft
– Serious violations of rules
Aggression
• Bullies, threatens, or intimidates others
• Initiates physical fights
• Has used a weapon that could cause serious
physical harm
• Physically cruel to people or animals
• Stolen while confronting a victim
• Forced sexual activity
Property Destruction
• Engaged in fire setting with the intention of
causing damage
• Deliberately destroyed others’ property
Deceitfulness or Theft
• Has broken into someone’s house, building,
or car
• Often lies to obtain goods, favors, or avoid
social obligations
• Has stolen items of non-trivial value
without confronting the victim
Serious Violations of Rules
• Often stays out all night despite parental
prohibitions, beginning before 13 years old
• Has runaway from home overnight at least
twice (or once for a lengthy period)
• Is often truant from school, beginning
before 13 years old
Subtypes of CD
• Childhood onset
– Presence of 1 criteria before age 10
– Typically boys exhibiting high levels of aggression
– Often also have ADHD
– Problems tend to persist to adulthood (APD)
• Adolescent onset
– No criteria met before age 10
– Less aggressive, more normal relationships
– Most behaviors shown in conjunction with peers
– Less ADHD. Equal gender distribution
– Much better prognosis
Risks for Conduct Disorder
• Individual
– Perinatal toxicity
– Difficult temperament
– Poor social skills
– Friends who engage in problem behavior
– Innate predisposition for violence
• Family
– Poverty
– Overcrowding
– Poor housing
– Parental drug abuse
– Domestic violence
Risks for Conduct Disorder
• Family (cont)
– Inadequate, coercive parenting
– Child abuse
– Insufficient supervision
• School
– Disadvantaged school setting
– Poor school performance beginning in
elementary school
Natural History
• Signs early as age 2 (irritable temperament, poor
compliance, inattentiveness, impulsivity)
• Early disturbances lead to diagnoses of ADHD or
oppositional defiant disorder
• For some children with severe temperament
problems, even a stable home and excellent
parenting does not prevent CD. However, more
often children have unstable, stressed
environments with ineffective or abusive
parenting.
Natural History
• Negative cycle:
– Difficult temperament in the child
– Children resist complying with parental requests
– Parents either give in or become more punitive
– Child either becomes more defiant or becomes
physically aggressive
– Parents become increasingly isolated from outside
support. They are afraid to take the child out in public.
– Child receives less and less parental interaction
– Child does not have opportunities to learn more mature
behaviors
Natural History
• Elementary school
– Children lack social skills, do not recognize social cues,
cannot problem solve
– Resort to aggression and intense anger rather than
verbal problem solving
– Blame others for their actions (no self-awareness)
• Middle and high school
– Noncompliance with commands
– Emotional overreaction
– Failure to take responsibility for their actions
Natural History
• Middle and high school (cont)
– Academic failure (poor cognitive development)
– Peer group is other high risk children (other peers reject
them at a time when friendships are critically
important)
– Depression often occurs as child is alienated from
family, friends, school, other positive social groups
– The deviant peer group provides training in criminal
and delinquent behavior including substance abuse
– If arrested and incarcerated, usually the behavior will
worsen
Conduct Disorder
• Co-occurrence with ADHD is at least 50%.
It is almost impossible to distinguish these
in young children. There is also high
comorbidity with internalizing disorders
and learning disabilities.
• Children must be evaluated for academic
difficulties as well as for comorbid mental
illnesses.
Treatment
• CD is highly resistant to treatment
• Treatment must begin early and must include
mental health, medical, educational and family
components
• Because of the high degree of overlap between CD
and ADHD, stimulant medication is usually tried.
In ADHD, stimulants control specific symptoms
of inattention, impulsivity, and hyperactivity.
They do not improve relationships with parents,
teachers, or peers
• No medication is proven helpful for conduct
disorder without ADHD
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.
Treatment
• Individual psychotherapy as an individual
treatment has not proven effective
• Group therapy may have some benefit for younger
children. For adolescents, group treatment often
worsens behavior.
• Best is a comprehensive model of treatment:
behavioral PMT, social skills training, academic
support, pharmacological treatment of ADHD or
depression, individual counseling as needed.
Natural History
• Physical aggression peaks around the age of two,
then usually decreases as the child develops empathic
attachment for others.
• Adolescent risk taking is a normal transitional step to
adulthood.
• Risky behaviors include:
– Alcohol: 40% of adult alcoholics report first having
symptoms of alcoholism related behavior between 15-19.
– Gambling: 10-14% of adolescents engage in problem
gambling beginning at age 12.
Natural History
• Risky behaviors:
– Automobile accidents: drivers of both sexes
between 16-20 are twice as likely to be in
accidents than drivers between 20 and 50. It is the
leading cause of death for teens.
– Sexual activity: adolescents are more likely than
adults to engage in impulsive sexual behavior,
have multiple partners, and fail to use
contraceptives. Younger teens (12-14) are more
likely to engage in risky sexual behavior than older
teens (16-19). 3 million adolescents a year contract
an STD.
Risk Taking
• Conventional wisdom states that teens take
risks because they think they are
invulnerable, and they don’t think before
they act. Intervention programs have
typically emphasized the importance of
giving teens good information and then
expecting them to make good choices.
These programs have achieved only limited
success.
Risk Taking
• Recent studies demonstrate that teens:
– Do not think they are invulnerable any more than adults
think they are invulnerable
– Tend to overestimate the true risks of potential behavior
– After careful consideration, generally decide that the
benefits usually outweigh the risks of a choice
• Intervention programs do not address the allure of
potential benefits. They emphasize dangers.
Risk Taking
• Mature adults do not think logically in risky
situations - they use intuitively based, bottom line
thinking which yields a simple, black and white
conclusion. This type of thinking increases with
age, experience, and expertise.
• Mature decision makers will not deliberate about
risk versus benefits if there is a reasonable chance
of a catastrophic outcome, e.g. playing Russian
roulette.
Time to Decision:
Is it a good idea to drink Drano?
1,750
1,700
1,650
Reaction Time
1,600
(msec)
1,550
1,500
1,450
Adult Adolescent
Interventions
• Consider that there are risky deliberators, and
risky reactors who are too impulsive to deliberate.
• For risky deliberators, focus on reducing the
perceived benefits of risky behaviors. Encourage
teens to develop rapid, unambiguous responses to
risky situations (“I do not ride with a drinking
driver.”)
• For risky reactors, monitor and supervise as much
as possible. Remove opportunities to engage in
risky behavior. Do not rely solely on teaching
them how to think.
The Teen Brain?
• The myth: teens are inherently incompetent
and irresponsible.
• Peak age of arrest in the US for most crimes is
18. American parents and teens are in conflict
with each other 20x/ month.
• Research on 186 pre-industrialized societies:
– 60% had no word for adolescence
– Teens spent almost all their time with adults
– Teens showed almost no signs of psychopathology
– Antisocial behavior in teens was absent in >50%, or very
mild when it did occur.
The Teen Brain?
• Trouble begins to appear in other cultures soon
after the introduction of Western-style schooling,
television, and movies.
• Until 100 years ago, teens were not trying to break
away from adults, they were learning to become
adults.
• We have infantilized our teens, and isolated them
from us.
• Teens in the US are subjected to 10x as many
restrictions as adults, twice as many as active duty
marines and incarcerated felons.
Laws Restricting Behavior of
Youth Under 18
160
140
120
100
80 Laws
60
40
20
0
1700 1750 1800 1850 1900 1950 2000
The Teen Brain
• When teens are trapped in peer culture, they
learn virtually everything they know from
one another.
• When we treat teens like adults, they almost
immediately rise to the challenge.
Adolescents
• All segments of the US population have
experienced improved health throughout the
past 30 years except for adolescents, in large
part because they represent a disproportionately
large proportion of the drug abusing population.
Drug abuse has been implicated in premature
deaths of adolescents because of homicide,
suicide, and accidents.
Camel #9
• “light and luscious”
• Packaged in fuchsia, outlined with a thin red line,
designed to appeal to adolescent girls.
• $2 million for marketing in Wisconsin alone. They
must add 100 new smokers each day, because
~20,000 people overcome their addiction each year,
and 8,000 die from it, including 1,100 women.
Adolescents and
Substance Abuse
• Cigarette smoking
– Nicotine dependence begins in adolescence. 25% of
seniors smoke. Although teens smoke relatively few
cigarettes, usually under the belief that they will not
become addicted, the great majority increase their
smoking after high school.
– Smoking is increasing faster among girls than boys.
There is evidence they are more prone to develop
nicotine addiction.
Adolescents and
Substance Abuse
• Cigarette smoking
– Tobacco use in teens is associated with a wide range of
risk taking behavior, including violence, high risk
sexual activity, and drug use. There is a significant risk
of developing a major depression within one year of
starting to smoke. Children with psychiatric disorders
are also more likely to smoke.
– Teenage smoking reached a peak in Wisconsin in 1999
(38.1% of seniors) and has declined to 20.9%. Girls
(21.9%) have a slightly higher prevalence rate than
boys (19.8%).
Prevention of Cigarette Smoking
• The most effective antidote to smoking is
expensive cigarettes.
• Resistance training skills are helpful to
reduce smoking initiation.
• 75-80% of initially successful quitters
resume smoking within 6 months. If they
can stay abstinent for 5 years, risk of relapse
is negligible.
Drug and Alcohol Abuse
• Drug use increases in adolescents to young
adulthood, then generally declines. In 2005, there
has been a decline in alcohol use, LSD and
cocaine, but an increase in illicit prescription
drugs (oxycodone), marijuana, and club drugs.
The use of inhalants is rising among 8th graders.
• Teenage drinking among girls is rising faster than
boys, in large part because they are being targeted
in alcohol related ads in the magazines they read.
2005 “Monitoring
the Future” Survey
• Drinking in last month
– 8th grade 17%
– 10th grade 33.2%
– 12th grade 47%
– 28% of seniors binge drink
• Tried an illicit drug
– 8th grade 21%
– 10th grade 38%
– 12th grade 50%
Drug Abuse in Children and
Adolescents
• 1:5 teens has abused Vicodin or OxyContin. 10%
have abused a stimulant - Adderall is the most
common. 10% have abused cough medicines
• Most of the time, these prescription drugs are in the
family medicine cabinet. There are Internet sites
devoted to how to get and abuse drugs.
• Inhalant abuse can be fatal. Such agents are
commonly found in household - glue, shoe polish,
spray paints, nitrous oxide, correction fluid, etc.
Prevention in Children and
Adolescents
• The younger the child initiates alcohol and
other drug use, the higher the risk for
serious health consequences and adult
substance abuse and dependence.
• Effective prevention and intervention
programs consider cultural context, social
resistance skills, and developmental level of
the child.
Prevention in Children and
Adolescents
• Peers have been successfully used to influence, teach,
and counsel young people. Even though education
about drugs do not contribute greatly to reducing drug
use, the use of peers as facilitators works for the
average student. Adolescents believe their peers’
attitudes against drug use. The lower the perceived
acceptance rate, the less frequent the drug use.
• DARE works better than non-interactive programs,
but not as well as programs involving peer delivery of
information.
Prevention in Children and
•
Adolescents
Most promising preventive measures are:
– Assessment and treatment of psychiatric disorders
– Education that targets knowledge and attitudes
about substances
– Development of proper social and problem solving
skills
– Treatment of family problems
– Increased opportunities for prosocial activities
with peers
– Limited early access to the use of gateway drugs
such as alcohol and nicotine
Prevention in Children and
• Risk factors:
Adolescents
– Poor self-image
– Low religiousity
– Poor scholl performance
– Parental rejection
– Family dysfunction
– Abuse
– Over or under-controlling by parents
– Divorce
– Externalizing disorders (ADHD has 3x risk substance use.
Those in treatment are at less risk)
Protective Factors in Children
and Adolescents
• Nurturing home with good communication
• Teacher commitment
• Positive self-esteem
• Self-control
• Assertiveness
• Social competence
• Academic achievement
• Regular church attendance
• Intelligence
• Avoiding delinquent peers
Depression
• Depression is a constellation of symptoms
including social isolation, lack of energy,
changes in sleep and appetite, and an
inability to experience pleasure that appear
in addition to a depressed mood.
Substance Abuse and Mental Health
Services Administration
Adolescents with depression in
past year (2004)
14%
12%
10%
8%
6%
4%
2%
0%
13-14 14-15 16-17
SAMHSA - 2004
• 9% of adolescents experienced a depressive
episode over the last year.
• Girls - 13.1% Boys - 5%
• No differences in ethnic group, SES in incidence,
but those with health insurance were more likely
to get treatment.
• <50% received help for depression.
• Those with depression were twice as likely to
smoke, use alcohol and illicit drugs.
Wisconsin High School Survey
2003
• During the last 12 months, have you felt sad or
hopeless for 2 weeks or more so that you
stopped doing social activities?
– Total 25.3%
– Boys 17.6%
– Girls 33.5%
– Junior year the worst
Depression
• Depression may manifest itself as irritability and
behavior problems in children and adolescents.
• Research now indicates that substance abuse in
boys and girls, and sexual behavior in girls is a
cause for subsequent depression in adolescents.
Depression can then make teens more vulnerable
to substance abuse and other risky behaviors.
• The use of antidepressants in children and teens is
controversial.
Antidepressants and Suicide
• In the summer of 2004, two reviews by
Columbia University looked at
pharmaceutical industry data from 22
placebo controlled trials involving 4,250
pediatric patients. They found that young
people given antidepressants were 1.8x
more likely to become suicidal as young
people given placebo.
Antidepressants and Suicide
• On October 15, 2004, the FDA issued its
strongest possible warning (black box) for
all antidepressants stating that these
medications may “increase the risk of
suicidal thinking and behavior in children
and adolescents with major depressive or
other psychiatric disorders.”
Antidepressants and Suicide
• The best approach is to monitor everyone
who is started on an antidepressant closely
for the appearance of suicidal ideation,
agitation, and irritability, especially during
the initial months of therapy, and be sure
that the risk is discussed during the
informed consent process.
Self-Injurious Behavior
• SIB - the deliberate alteration or destruction of
body tissue without conscious suicidal intent
• Four types:
– Severe - extensive damage (psychotic)
– Stereotyped - rhythmic (DD, seizure disorders)
– Socially accepted/emblematic - tattooing, piercing,
etc…
– Superficial/moderate
Superficial/Moderate
• Compulsive:
– Habitual, obsessive/comp rather than impulsive. Urge is
resisted. (Ego-dystonic) Intrusive thoughts about
contamination, inadequacy, bodily shame. Nail biting,
trichotillomania, skin picking
• Episodic:
– Occasional impulsive burning and cutting in response to
stress or life events.
• Repetitive:
– Repetitive burning and cutting, rumination about self-abuse
and identification as a cutter or burner. There is little
resistance to the urge. Carefully executed. Has qualities of
addiction.
Superficial/Moderate
• Counter-dissociative:
– An attempt to re-associate self with here and
now reality
• Parasuicidal:
– “suicide gesture” reflecting ambivalence about
suicide or as attempt to communicate to others
Impulsive, Superficial/ Moderate
•
SIB followed by
Skin cutting is the most common,
burning and hitting
• Commonly comorbid with personality disorders
• Typically includes onset in adolescence, multiple
episodes, chronic, associated with depression,
despair, anger, aggression, anxiety, cognitive
constriction
• Predisposing factors include lack of social support,
male homosexuality, AODA, suicidal ideation in
women.
• Diagnosed as Impulse Control Dis NOS, or BPD
Self-Injurious Behavior
• Worldwide, nonfatal deliberate self-harm is more common in
adolescents, especially young females (11.2% girls, 3.2% boys)
Boys more frequently need medical attention.
• Self-harm in adolescents increased with consumption of
cigarettes, alcohol and drugs in one large study. Having friends
or family members self-harm was also a risk factor. Depression,
anxiety, and impulsivity was a risk for girls, who said they were
trying to punish themselves or get relief from a terrible state of
mind.
• The Internet may normalize and encourage pre-existing SIB in
adolescents.
Self-Injurious Behavior
• There is disagreement about the meaning of the
injury: symbolic, impulse disorder, serotonin deficit,
endorphin dysregulation.
• Adolescents are likely to explain their self-harm by
saying they wanted relief from unpleasant feelings
(depression, anxiety, loneliness, anger) or that the act
was impulsive.
• Childhood abuse is a factor in the descriptive and
empirical literature.
• There are also associations with AODA, PTSD,
intermittent explosive disorder, dissociative disorder.
Summary of Reasons for SIB
• Affect regulation
– Reconnection with the body
– Calming the body during periods of arousal (exhibit decreases in respiration,
skin conductance, heart rate in response to the behavior (like concentration)
– Validating inner pain
– Avoiding suicide
• Communication
– Express things which cannot be said out loud
• Control/punishment
– Trauma re-enactment
– Bargaining and magical thinking
– Self-control
– Control of others
Children and Suicide
• Suicide attempts are statistically insignificant
until the age of 12., but higher in the US in the
last 20 years.
• Suicidal children have a history of impulsive,
aggressive behavior, are taller and physically
more mature than their classmates, more were
more likely to be involved with conflict with
parents, and be in a disciplinary crisis.
Families must be involved in assessment,
prevention and treatment.
Warning Signs
• Past suicide attempts or threats
• Past violent or aggressive behavior
• Mental illness or alcohol use
• Bringing weapons to school
• Recent experience of humiliation, shame loss
• Bullying as victim or perpetrator
• Victim of abuse/neglect
• Themes of depression, death
• Vandalism, cruelty to animals, setting fires
• Poor peer relationships, cults, no supervision
Suicide first arises as a public
health problem at 12 years old.
Suicide Rates per 100,000
12
8
1.3
10yrs - 14 15yrs-19 20yrs-24
Suicide Rates: 1981-2001
30
25
20
Female
15
Male
10
5
0
81
83
85
87
89
91
93
95
97
99
01
19
19
19
19
19
19
19
19
19
19
20
Adolescent Suicidal Behavior:
2001 U.S. Data
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
Ideation Plan Attempt Complete
Wisconsin Suicides
• Suicide is the second leading cause of death in
adolescents.
• From 2000-2002, there were 323 suicides (262
homicides.)
• The annual rate is 5.7/100,000 - 36% higher than the
national average. The highest incidence is in northern
Wisconsin.
• Guns are involved in 52%.
• 27% tested positive for alcohol.
Suicidal Ideation
• In teens, suicidal ideation more strongly indicates
antisocial behavior than it does risk of suicide.
Features that may separate those who attempt
from those who don’t:
– AODA
– Severe and enduring hopelessness
– Isolation
– Reluctance to discuss suicidal thoughts
– Psychopathology
Gender Issues
• Girls
– Attempts to completions 4,000:1
– A suicide attempt is not a risk factor for suicide. Having a
depressive episode is, often with no precipitating event
– Panic attacks are a risk factor for girls
• Boys
– Attempts to completions 500:1
– Rate increased 3x since 1955 - Increased AODA?
– Dropped since 1995 - Increased antidepressants?
– Usually within hours of event, before consequences, when
anticipatory anxiety is highest. Events include legal
problems, relationship problems, humiliation.
– Aggression is a risk factor for boys
Risk Factors for Adolescents
• Mental illness
– 90% have depression, anxiety, AODA a year before
suicide. It is estimated that 1 million youths suffer from
depression, but 60-80% do not receive help. Fewer than
10% of completed suicides were on antidepressants or
in AODA treatment.
– 50% of teen suicides involve alcohol use.
– Parents frequently do not recognize signs of suicidal
behavior. Most lay people justify depressive symptoms
in themselves and others, blaming it on stress. Stressors
can mislead. It may be the mental illness that is causing
the stress.
Risk Factors for Adolescents
• Imitation
• Family history
• Sexual orientation issues
• Sexual abuse
• Other stressors
– Interpersonal losses
– Bullying (perpetrator or victim)
– Lack of affiliation
– Males after romantic breakup
Suicide Attempts (cont)
• Girls attempt mostly by ingestion (55%) or cutting
(31%). Boys by cutting (25%), ingestion (20%),
firearms (15%), hanging(11%).
• Greatest difference in mental state between an
ideater and attempter is the presence of AODA.
Suicidal teens who abuse substances are 12.8x
more likely to make an attempt.
Risk Factors
• Incarceration
– The suicide rate for adolescents in detention
centers is 57/100,000. For adolescents housed
in adult facilities is 2,041/100,000!!
Risk Assessment in Adolescents
• Although suicidal ideation is very common
in this population, suicide should be asked
about and evaluated in the context of an
accompanying mental illness. Depressed
adolescents should always be assessed for
suicidality. It is important to include data
from many sources, including parents,
school, or other significant relationships.
Risk Assessment in Adolescents
• Consider the following:
– Predictability of the youngster
– Circumstances of suicidal behavior
– Intent to die
– Psychopathology
– Coping mechanisms
– Communication
– Family support
– Environmental stress
Risk Assessment in Adolescents
• Precipitating factors in vulnerable youth
may increase immediate risk.
– Opportunity
• Access to lethal means, lack of supervision
– Altered states of mind
• Hopelessness, rage, intoxication, mental illness
– Undesirable life events
• Losses, loss of esteem, humiliation, pregnancy,
abuse
Prevention Strategies
• Suicide awareness programs
– Popular with normal teens, but they don’t seem to
increase self-referrals, help-seeking, or help-giving
in adolescents. They may activate suicidal ideation
in disturbed adolescents, whose identity is usually
not known by the instructor. They may contribute
to clustering. They also tend to minimize the role
of mental illness.
Prevention Strategies
• Screening
– Assessments of depression, AODA, recent or frequent
suicidal ideation, past suicide attempts. They identify a
number of unknown, untreated cases of depression.
– Screening programs that do not include procedures to
evaluate and refer should not be used.
• Gatekeeper training
– Teachers, counselors, MD’s, youth workers trained to
recognize teens at risk. This may work, but there is no
clear research.
•
Prevention Strategies
Crisis centers and hotlines
– There is little research about the effectiveness of these
centers. Few teenagers use them, and those that do are not
at highest risk (boys).
• Restriction of lethal means/alcohol
– A modest but statistically significant decrease in teen
firearm suicides has been associated with child access
prevention laws.
– Even adolescents without a mental disorder have 13x
greater suicide risk if there is a gun in the home and a 32x
greater risk if it is loaded.
Restriction of Lethal Means
• Firearms
17% of households purchase new guns after a child’s suicide
attempt. But if they are educated, they are 3x more likely to
remove them.
– The following reduce suicide risk in an additive manner:
• Unloading guns
• Locking guns
• Storing ammunition separately
• Locking ammunition
• Alcohol
– States that have increased the minimum drinking age have
seen a 7% suicide reduction in teens.
Prevention Strategies
• Skills training
– Teaching the problem solving and coping skills in the skills. Some
evidence of efficacy.
• Follow-up appointments
– A nighttime phone contact and next day follow-up assures 90% of
teens will stay in treatment after an ER visit.
• Antidepressants
– Caregivers need to be alert for decreasing inhibition, irritability,
change in sleep, agitation in the first weeks after an antidepressant
has been started.
Bipolar Disorder
• Bipolar disorder is a disorder of mood swings, out
of proportion with events in a person’s life. These
swings include mania and depression.
• Bipolar disorder in children is enormously
controversial! Depending on who you listen to,
there is either an epidemic, or it is virtually non-
existent.
• The diagnosis has increased 26% from 2002 to
2004!
Dr. Biederman,
Mass Gen, Boston
• Irritability is the determinant, even in the absence
of depression, elevated mood, grandiosity, or
cycles of behavior.
• These irritable episodes are not just tantrums, but
explosive, long-lasting, and often without triggers.
• This is the “Broad Phenotype” - Bipolar NOS
• Supported by parents, insurance companies, and
by the observation that many of these children
respond to medication.
Dr. Geller
Washington U, St. Louis
• Children must have alternating episodes of mania
and depression. The cycling can be complex and
very short.
• This is the “Narrow Phenotype.”
• Children exhibit:
– Excessive giddiness
– Severe irritability
– Grandiosity
– Fragmented thought
– Aggression
Making a Diagnosis
• Besides symptoms, we generally require three
important validators of a diagnosis:
– Family history
– Course of illness
• The first presentation of Bipolar Disorder is depression
• 33-50% of depressed children develop mania in 10-15 yrs.
– Treatment response
• Bad reaction to antidepressant
Bipolar vs. ADHD
• Most children diagnosed with bipolar
disorder appear to also meet ADHD criteria.
• It is rare that children with ADHD meet
bipolar criteria.
• In adults with bipolar disorder, 33% can be
diagnosed retrospectively with ADHD, with
about 10% having current ADHD
symptoms.
Bipolar vs. ADHD?
• It may be that these represent different
developmental presentations of the same
condition:
– Childhood ADHD
– Adolescent anxiety and depression
– Young adult bipolar disorder (mania)
Problems
• Children who get amphetamines may have an
earlier age of onset of mania than those who
don’t!
• Amphetamines can be harmful neurobiologically,
especially after adolescent exposure, with
hippocampal atrophy, disturbed dopaminergic
activity, enhanced corticosteroid response to
stress, and increased long-term depressive and
anxiety behaviors.
Distinguishing Bipolar Disorder
from ADHD
• Sleep problems are more common in bipolar.
• Irritability, frustration intolerance and aggression
are present in both.
• Attention problems can be the same.
• Mood symptoms distinguish the bipolar group, but
not until 7 years old.
• Hallucinations, delusions, suicidal and homicidal
behavior is more common in bipolar
Bipolar Disorder
• Treatment is usually with the mood
stabilizer Depakote. ADHD symptoms
usually do not respond to Depakote.
• The best evidence is for lithium.
• Antipsychotics are frequently used, but with
very limited data.
Severe Mood Dysregulation
• Suggested diagnosis to try to describe
children who seem to be “somewhat”
ADHD and “somewhat” Bipolar.
• Criteria:
– Abnormal mood most days (irritability)
– Hyperarousal (ADHD)
– Increased reactivity to negative stimuli
– Not manic mood, not cyclical/episodic, IQ>70
Severe Mood Dysregulation
• Treatment?
Overview
• In spite of the overall decrease in violent and property
crimes, the U.S. has the highest rate of imprisonment
in the world. 200 million Americans are incarcerated
with 4.6 million on probation or parole.
• The incarceration rate for Black males is 4,810 vs.
649 for white.
• Black females 349 vs. 68 for white females
• 13% of the population, 50% of prisons: more Black
men between 20-29 are in prison than in college.
•
Overview
Dangerous violence is almost exclusively perpetrated
by young men between the ages of 15 and 30.
• A few men are repetitively violent. 7% of young men
commit 79% of repeat violence.
• These men can be identified in early childhood. They
tend to be impulsive, have a low IQ, be hyperactive
and attention impaired, oppositional, vindictive,
easily angered, resistant to control, deliberately
annoying, and likely to blame other people for their
problems. These traits are largely inherited, although
not entirely.
Overview
• Criminal offending tends to decline with
age, even for persistent offenders. Among
non-psychopathic individuals, offending
peaks in late adolescence and declines soon
after. Among psychopaths, the decline does
not begin until 30-40 years of age. This
decline is accompanied by age-related
changes in neurotransmitters.
Neurochemical Variables of
Violence Over Time
Dopa
Seroton
Norepi
GABA
Testos
0 10 20 30 50 60 70
The Etiology of
Violent Behavior
• Prenatal risks for violent behavior include
substance abuse in the mother, low birth weight,
and prematurity.
• In the infant, neuropsychological deficits or
difficult temperament - fearlessness, lack of
prosocial activity, and hyperactivity/impulsivity.
• Environmental factors including young, single,
isolated mother, and poverty.
The Etiology of
Violent Behavior
• Lack of empathic care
• Poor parent-child attachment and bonding
• Parental loss and inconsistent care-givers.
• Abusive siblings: 40% of all juvenile perpetrated
child sexual abuse is perpetrated by siblings. Not
much is known about physical abuse and
intimidation in sibling relationships because it has
not been studied.
• Exposure to trauma and maltreatment
• Brain injury
Adolescent-Limited Conduct
Disorder
• Some externalizing disorders develop in
adolescence without the strong temperamental
predisposition. Late-onset or adolescent-limited
conduct disorder is thought to arise due to specific
adolescent contexts: having gang members in the
community, school failure, low self-esteem and
depression, or other stressful life events become
predictive. Most delinquent teens (94%) do not go
on to develop adult antisocial behavior.
Life Course
Persistent Offenders
• Comprise 5% of the population, but a
disproportionate amount of crime. They have early
conduct disorder. 50% have antisocial conduct as
adults. They have difficulty in temperament, social
alienation, poor parenting, cognitive deficits, ADHD,
impulsivity, and aggressiveness.
• It is important to identify these teens, since jail
sentences for the adolescent-limited offender may
increase the risk for becoming a chronic offender.
Risk Factors
• Conduct Disorder
– Early conduct disorder is ominous. Conduct
disorder first appearing at 6 years old doubles
the risk of criminal adult antisocial behavior
(71%), compared to those children who first
develop conduct disorder at 12 years old.
Risk Factors for Violence
• Firearms are the single greatest risk factor. 28% of
families keep guns at home, 39% are unlocked or
loaded or both.
• Alcohol - 40% of all 15-24 year old homicide victims
are intoxicated.
• Bullying/Standby Behavior - 7-16% of
schoolchildren are bullied in any given semester.
Bullying is worst in rural schools. Bullies are 6x more
likely to have a criminal conviction by 24, as well as
AODA problems. Victims experience social and
emotional isolation.
Risk Factors for Violence
• Mental illness: up to 60%are diagnosed. Also
includes violent preoccupation, chronic
humiliation, grandiosity, lack of empathy
• Media: controversial, but especially influential in
vulnerable children
• Families who are dismissive and permissive: too
much privacy, parents are afraid of the child.
Risk Factors for Violence
• Exposure to abuse: 63% of children exposed to
domestic violence don’t do well, Violence is
related to emotional development (hypersensitivity
to anger, difficulties recognizing emotions or
complex social roles, less accurate attention to
social cues, less ability to generate competent
solutions to interpersonal problems), cognitive
problems (lower IQ, poor memory and
concentration) and children who end up blaming
themselves for the violence.
Consequences of Early Exposure
to Violence
• Alcoholism 7.4%
• Drug Abuse 10.3%
• Depression 4.6%
• Suicide Attempts 12.2%
• Promiscuity 3.2%
• COPD 3.9%
• Heart Disease 2.2%
• Liver Disease 2.4%
Juvenile Gangs
• Youth gangs are present in more than 2,300 cities.
Gang membership ranges from 14-30% in samples
of at-risk youth in urban centers.
• Most gang members are between 12 and 24 years
old, and belong to a gang for one or two years.
Each gang (or subunit) generally includes from 5
to 25 members. The ethnic distribution is 47%
Hispanic, 31% African-American, 13% White,
and 7% Asian. Females constitute 4-20%.
Juvenile Gangs
• A history of antisocial behavior, early use of
marijuana, poor academic performance, and living in
a troubled neighborhood all increase the likelihood of
joining a gang.
• Gang membership is strongly associated with
violence. Gang members are more violent, commit
more offenses, and are more likely to have and use
guns than other delinquents. When a young person
quits a gang, they do not usually continue to be
violent, although they will continue drug dealing, if
that was their gang activity.
• Adult crime - Adult time
– Juveniles moved to adult court are more likely to receive prison
time than adults for the same crime. See more recidivism and
suicide.
• What doesn’t work
– Arrests for minor offenses
– Scared straight/boot camp approaches
– D.A.R.E. (Drug Abuse Resistance Education)
– Home detention, intensive parole
• What does work
– Prenatal nurse visits to high risk homes
– Head start programs
– Anti-bullying programs
– Life skills classes, programs aimed at risk factors (literacy)
