Future of Behavioral Health Care
David Mays, MD, PhD
dvmays@wisc.edu
Childhood Wellbeing (UNICEF, 2007)
Rating
18
16
14
12
10
8
6
4
2
0
Report Card: 2011
• 75% of 18-19 year-olds are in such a poor state
that they are ineligible to even apply for
military service. This is due to obesity (33%),
no high school education (33%), or criminal
records.
• Of the rest, 23% cannot pass the military’s
basic exam for reading, math, and problemsolving.
Marriage
Education
Money
Falling Marriage Rates, Increased
Poverty
% Married Households
80
70
60
50
40
30
20
10
0
1920
1930
1940
1950
1960
1970
1980
1990
2000
2010
Marriage Money Education
• A 2011 Pew study found that while 64% of
college-educated Americans were married,
fewer than 48% of those who did not graduate
from college were married.
• Married men and women tend to be much
better off financially than unmarried people.
• Married men are more likely to work and not
engage in dangerous behaviors.
Marriage Money Education
• Women in the top 10% of earnings saw their
marriage rates increase between 1970 and
2011. Women in the bottom 65% in earnings
saw their marriage rate decline by more than
20%.
• Women have children with unemployed men,
but they do not marry them (or stay married
to them.)
% Rate of Unmarried Mothers
(Nat'l Center for Health Statistics)
45
40
35
30
25
20
15
10
5
0
1960
1970
1980
1990
2000
2009
Most Unmarried Moms are Single
Parents
• The majority of never-married mothers have
close relationships with their child’s father at
birth, but by the time the child is 5 years old,
the dad is gone. There are usually then serial
new relationships that are transient.
Children Without Fathers
• 33% live below poverty level. Studies show
that half of low income children start
kindergarten with dramatically lower
vocabularies and are less ready to learn than
peers.
• Problems with social relationships
• At risk for various emotional problems,
aggression, and addiction
Education
• At present, a child born to married, collegeeducated parents has a very good chance of living
a comfortable life. A child raised by a “lightly”
educated single parent has very little chance of
catching up to the middle class.
• If you have two college-educated parents, you’ll
have a larger vocabulary, you’ll know more about
the world, you will have a lot of adults in our life
who are there to help you and encourage you to
go to college.
Agenda
•
•
•
•
•
•
Trauma and Adverse Childhood Events
Attachment
ADHD
Bipolar Disorder
Depression
Anxiety
Adverse Childhood Events
• 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.
Nadine Harris, MD
• TED talk, Adverse Childhood Events
• I would also like to acknowledge Elizabeth
Hudson and Donna Rifkin for their materials
and graciousness in teaching me about this
area.
The ACE’s Study
• Started in 1995 by Kaiser and the CDC with
17,500 adults. Data collection is ongoing.
• The sample was 70% white, 70% college
educated.
• 67% had at least one ACE. 12.6% had four or
more.
Health Outcomes
• Even if there is no high risk behavior (drinking,
smoking, etc.)
• COPD
2.5x risk
• Hepatitis
2.5x risk
• Depression
4.5x risk
• Suicidal behavior 12x risk
Wisconsin ACE Brief: Children’s Trust Fund and
Children’s Hospital of Wisconsin
(2011-2012)
• 58% of adults reported having experienced at
least 1 ACE in childhood
• 14% experienced at least 4 ACEs
• Results
–
–
–
–
–
–
Emotional abuse – 29%
AODA in household – 27%
Separation/divorce of parents – 21%
Physical abuse – 17%
Violence between adults in household – 16%
Untreated mental illness in household – 16%
ACE’s are the single greatest public
health threat facing our nation
today.
Robert Block, MD
Former president of the Am. Acad. of
Pediatrics
Mental Illness in Youth
PBS Nova: Rampage Killers
Onset of Mental Illness (Gladstone 2011)
18
16
14
12
10
Onset
8
Diagnosis
6
4
2
0
ADHD
ODD
CD
Anxiety Depression
AODA
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.
• It seems reasonable to believe that the
interaction of genetic vulnerability and
environmental stress leads to mental illness.
Early Deprivation
• 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)
Early Abuse
• 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).
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.
PBS Nova: Rampage Killers
The Unattached
• Unattached individuals feel a deep sense of
uncertainty, that others don’t 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
The Biology
PBS: The Secret Life of the Brain
Briefly, Biology
• What the stress response is
• Stress and its effects on genetics
– Telomeres
– Epigenetics
National Geographic: Stress – Portrait
of a Killer
Telomeres
• In 1965 scientists reported that the older a
person is, the fewer times his cells divide
when cultured in a lab.
• In 1990, scientists found that each time a cell
divides in culture, telomeres shorten a bit
until they get so short that the cell is unable to
divide and dies.
Telomeres
• In 2006, scientists at Harvard found that
individuals with mood disorders have shorter
telomeres than healthy controls.
• In 2011, researchers found that children who
had been institutionalized had shorter
telomeres.
National Geographic: Stress – Portrait
of a Killer
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.
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.
Diet
Toxin
People
Gene
(on/off)
PBS Nova: Rampage Killers
Results of Early, Chronic Stress
• The student may be over-sensitized to fear
and alarm and may interpret neutral
interactions as hostile.
• Once aroused, students may lack the capacity
to self-comfort (a frontal lobe function.)
PBS: The Secret Life of the Brain
Results of Early, Chronic Stress
• Cortisol damage may impair short-term
working memory.
• Self-comforting skills, in lieu of good frontal
lobe function, may consist of lots of body
movement (fidgeting), trying to restore
familiar situations (arguing, being blamed),
avoiding being challenged to learn something
new (better to be bad than stupid.)
Brain Disorders
• It has taken us several thousand years to
understand that schizophrenia, depression,
and addiction are brain disorders, not
character flaws. We need to understand the
behaviors of children who have experienced
multiple, chronic, adverse events as also
suffering from a brain disorder.
How to Teach Children With This Kind
of Brain Disorder
• This is not a problem of designing the right
behavior modification program. It is more
complicated than that.
• I recommend the following training:
– Building Trauma Informed Skills in the School
Setting
– Trainers: Donna Rifkin PhD, Renee Wilberg MSSW,
APSW, Cory Kitt MS, LPC
– Community Care Resources: 608-827-7100
At the Very Least…
• Take care of yourself
– Wear your professional hat
– Self-calm
– Don’t get pulled into repeating the same old
situations
– Find support from colleagues
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 >50% 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.
• 1:10 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.
Overdiagnosed?
(Diller, 2014)
• For the vast majority of children, the issue
isn’t 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.
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.
The FDA
• In 2011 the FDA convened to hear testimony on
the evidence of the relationship between artificial
food colors and ADHD. AFC’s require a warning
label in the EU. The FDA ultimately decided (8-6
vote) not to recommend banning AFC’s or
requiring a warning label. (If AFC’s weren’t
already in foods in the US, they probably would
not be allowed.)
• Various studies have shown that the introduction
of AFC’s 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
child’s 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-3’s and micronutrients
(zinc, iron, magnesium, etc) are inconclusive.
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.
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. 5070% 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 can’t sit still to do homework.
Comorbidities with ADHD
40%
35%
30%
25%
20%
15%
10%
5%
0%
ODD
Lang Dis Anxiety
Learn
Mood
CD
PDD
Tics
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.
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.
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 MD’s have difficult time with diagnosis requires time and testing
• Diagnosis is unusually dependent on social and
educational circumstances
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.)
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.
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 <5 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)
• 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.
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 didn’t 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.
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
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. 301-3067070 ext. 133 or parent2parent@chadd.org
• 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 Unemotional)
• 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
conditions.
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 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.
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.
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
school
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
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
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
consequences.
• 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 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.
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.
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 Young People
• Bipolar disorder in children is enormously
controversial! Depending on who you listen to,
there is either an epidemic, or it is vastly overdiagnosed.
• 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 - doesn’t 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
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
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
adults.
• Their parents are less likely to have
psychopathology than parents with bipolar
children.
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
ADHD
DMDD
More aggressive
BIPOLAR
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 ADHD.
Bipolar
mania
ADHD
Dis.
Mood
Dysreg
Disord
Disruptive
Behavior
Disorders
Episodic
X
Euphoria, grandiosity,
hypersexuality, delusions
hallucinations
X
Mood lability
X
Insomnia
X
+/-
+/-
Pressured Speech
X
X
X
Intrusiveness
X
X
X
+/-
Irritability
X
X
X
Headstrong
Rage attacks
X
X
X
X
And Trauma!
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)
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.
Depression
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.” “I’m 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
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.)
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.
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.
Assessing Teens
• Teens do a lot of things to express their
individuality, but they don’t 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.
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.
Dr Peter Parry, child psychiatrist, editorial board
of The Carlat Child Psychiatry Report
• Reserve SSRI’s 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
Other Psychosocial Interventions
• Effective interventions share some common
features:
– Help teens increase competence in at least one selfidentified area
– Psychoeducation about depression and treatment
– Teach self-monitoring skills
– Address social, communication, problem solving skills
– Teach cognitive restructuring
– Use behavioral activation techniques
Anxiety
The Need
(Minahan 2015)
• 25% of children 13-18 have been diagnosed
with anxiety at some point. Children with
emotional behavior disorders drop out of
school by 9th grade (48%), 58% have been
arrested, and only 30% get a job after high
school.
• The typical teacher with an MA in education
has only one class in behavioral intervention.
Teachers Struggle With…
•
•
•
•
Students with anxiety
Oppositional children
Withdrawn children
Children with sexualized behavior
Behavioral Modification: Rewards and
Consequences
• One problem with using only this approach is
that it does not teach skill building.
• For instance, anxious students may be unable,
not unwilling, to complete work assignments.
They need to be taught initiation and
persistence skills.
• There are five skills that children with social
emotional disabilities frequently lack:
Self-Regulation
• Children often don’t know how to self-calm.
When we tell a child to “calm down”, we are
asking them to use cognitive skills. But when
children are very upset, they can lose the
equivalent of 13-15 IQ points. They need to
practice self-calming when they are calm.
• Techniques might include having a certain place
or chair to go to, using cognitive distractions –
word games, music, drawing
• Think of it as an anxiety first aid kit.
Social Skills
• Children who are aggressive often misread the
emotions and intentions of others. Children from
abusive, neglectful, and chaotic homes are
usually under-socialized – they don’t know how
to use verbal skills to assess the situation and get
what they want or need.
• These children can be taught how to recognize
their own feelings and the feelings of others, as
well as how their behavior effects the way others
respond to them (socialization.)
Positive Thinking
• Positive thinking is not “wishful thinking” or
fantasy. It is grounded in the belief that people
have control over many of the outcomes in
their lives, that people can learn skills, that
the brain can grow, that we can get smarter
and better by practicing skills.
Flexible Thinking
• Everybody needs a plan B. Being able to
switch strategies in the middle of a course of
action is harder for some people than others.
Children can work on skills of recognizing
when one approach to a problem is not
working and they need to try something else.
Executive Functions
•
•
•
•
•
•
1) Self-awareness
2) Non-verbal working memory
3) Verbal working memory
4) Inhibition
5) Emotional regulation
6) Self-motivation
Pre-emptively Identify Hot Spots
• There are times that are most anxiety
provoking for a child. Examples are:
– Unstructured time (cafeteria, recess)
– Transitions (waiting, stopping one activity)
– Writing, especially open-ended writing
assignments
– Social demands (partnering up with another child)
– Unexpected changes