Adolescent Mental
Health
Hope and Healing
Mickey Curtis, LPCC, LADAC, LMSW
Mickey Curtis, LPCC, LADAC, LMSW
Clinical Supervisor, MST Program
La Frontera NM
The Road to Success
Growing from adolescence to
adulthood is like traveling a long
winding road,
…filled with highs and lows, sudden
stops, potholes and other obstacles.
The youth experiencing behavioral
health concerns have experienced
more obstacles in their paths than
have others.
They need assistance in better
navigating the road or finding their
own paths …
M Curtis
Adolescent Development
Challenging Characteristics
Stages
Early (10-14)
Mid (15-17)
Intellectual/
Cognition
Concrete thought dominates
Cause-effect relationships
underdeveloped
Very self-absorbed
Growth in abstract thought
Reverts to concrete thinking
under stress
Autonomy
Challenges Authority
“anti-parent”
Mood Swings
Argumentative and
disobedient
Conflict with family
Ambivalence about
emerging independence
Identity
Development
Questions about being
“normal”
Goals change frequently
Feels “no one understands”
Desire for privacy
Experimentation; sex, drugs,
risk-taking behaviors
Strong peer allegiances
Challenges/ Obstacles
 Trauma
 Family/ Parental stressors
 Mental illness
 Substance Abuse
 Eating Disorders
40 Development Assets - Support
1. Family support—Family life provides high levels of love and
support.
2. Positive family communication—Young person and her or his
parent(s) communicate positively, and young person is willing to seek
advice and counsel from parents.
3. Other adult relationships—Young person receives support from
three or more nonparent adults.
4. Caring neighborhood—Young person experiences caring
neighbors.
5. Caring school climate—School provides a caring, encouraging
environment.
6. Parent involvement in schooling—Parent(s) are actively involved
in helping young person succeed in school.
40 Development Assets - Empowerment
 7. Community values youth—Young person
perceives that adults in the community value youth.
 8. Youth as resources—Young people are given
useful roles in the community.
 9. Service to others—Young person serves in the
community one hour or more per week.
 10. Safety—Young person feels safe at home, school,
and in the neighborhood.
40 Development Assets: Boundaries and
Expectations
 11. Family boundaries—Family has clear rules and
consequences and monitors the young person’s whereabouts.
 12. School Boundaries—School provides clear rules and
consequences.
 13. Neighborhood boundaries—Neighbors take responsibility for
monitoring young people’s behavior.
 14. Adult role models—Parent(s) and other adults model positive,
responsible behavior.
 15. Positive peer influence—Young person’s best friends model
responsible behavior.
 16. High expectations—Both parent(s) and teachers encourage
the young person to do well.
40 Development Assets: Constructive
Use of Time
 17. Creative activities—Young person spends three or more
hours per week in lessons or practice in music, theater, or other
arts.
 18. Youth programs—Young person spends three or more hours
per week in sports, clubs, or organizations at school and/or in the
community.
 19. Religious community—Young person spends one or more
hours per week in activities in a religious institution.
 20. Time at home—Young person is out with friends “with nothing
special to do” two or fewer nights per week.
40 Development Assets: Commitment
to Learning
 21. Achievement Motivation—Young person is motivated to do
well in school.
 22. School Engagement—Young person is actively engaged in
learning.
 23. Homework—Young person reports doing at least one hour of
homework every school day.
 24. Bonding to school—Young person cares about her or his
school.
 25. Reading for Pleasure—Young person reads for pleasure
three or more hours per week.
40 Development Assets:
Positive Values
 26. Caring—Young person places high value on helping other
people.
 27. Equality and social justice—Young person places high value
on promoting equality and reducing hunger and poverty.
 28. Integrity—Young person acts on convictions and stands up for
her or his beliefs.
 29. Honesty—Young person “tells the truth even when it is not
easy.”
 30. Responsibility—Young person accepts and takes personal
responsibility.
 31. Restraint—Young person believes it is important not to be
sexually active or to use alcohol or other drugs
40 Development Assets:
Social Competencies
 32. Planning and decision making—Young person knows how to
plan ahead and make choices.
 33. Interpersonal Competence—Young person has empathy,
sensitivity, and friendship skills.
 34. Cultural Competence—Young person has knowledge of and
comfort with people of different
 cultural/racial/ethnic backgrounds.
 35. Resistance skills—Young person can resist negative peer
pressure and dangerous situations.
 36. Peaceful conflict resolution—Young person seeks to resolve
conflict nonviolently.
40 Development Assets:
Positive Identity
 37. Personal power—Young person feels he or she has control
over “things that happen to me.”
 38. Self-esteem—Young person reports having a high selfesteem.
 39. Sense of purpose—Young person reports that “my life has a
purpose.”
 40. Positive view of personal future—Young person is optimistic
about her or his personal future.
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Mental illness: The Facts*
 Mental illnesses are brain disorders, not defects in
personality or a sign of poor moral character.
 Major brain disorders include schizophrenia, bipolar
disorder, major depression, anxiety disorders, and
obsessive-compulsive disorders
 Many degrees of recovery are possible with
medication, therapy, good coping skills, and a strong
support system
* adapted from National Alliance on Mental Illness (NAMI)
www.nami.org
Mental illness: The Causes *
 Imbalance of brain chemicals.
 Genetics play a role. Some people inherit, through
their genes, a tendency to develop these illnesses
 Life events, such as a serious loss, another chronic
illness, or other serious problems can trigger the
beginning of a severe mental illness. Chronic stress or
abuse may also cause the onset of these illnesses.
* adapted from National Alliance on Mental Illness (NAMI)
www.nami.org
What is under the surface ?
Prevalence of Exposure to Trauma
 51% of women and 61% of men in the general
population report exposure to trauma
 90% of public mental health clients report
exposure to trauma
 Although studies vary in actual numbers,
inmates in jails and prisons report a higher
incidence of traumatic experiences relative to
the general population
Annual Incidence = 60%
Lifetime prevalence = 80%
What is Trauma?
 Intense and overwhelming experience that
involves serious loss, threat, or harm to a
person’s physical and or emotional wellbeing
 May occur at any time in a person’s life and
may involve an isolated traumatic event or
recurrent incidents over time
 Traumatic events overwhelm the person’s
usual coping resources
Examples of Traumatic Life Experiences
 Physical or sexual assault
 Child physical or sexual abuse
 Domestic violence (victim or witness)
 Exposure to combat, war, or torture
 Accident (including witness)
 Serious medical illness or disability
 Natural disaster
 Witnessing violence
Trauma Related Disorders
 Post-traumatic Stress Disorder





The presence of a traumatic event
Re-experiencing
Avoiding/numbing
Increased arousal
The duration is more than one month and causes significant
distress or impairment in social or occupational functioning
 Acute Stress Disorder
 The same general criteria as PTSD; symptoms last a minimum
of two days and a maximum of four weeks
 The onset occurs within four weeks of the traumatic event
Key Question to Ask
For Trauma Informed Care
What Happened to You ?
NOT
What’s Wrong with You ?
Principles of Trauma Informed Care
 Create a safe and calm environment
 Convey that the individual is important
 Promote dignity and respect
 Demonstrate cultural competency
 Work from a Recovery Oriented strength based framework
 Collaborate with consumers; offer choices whenever
possible
 Include the family and/ or support system
Behavioral Problems
Internalizing:
depression, anxiety, withdrawal, school failure
Externalizing:
aggression, destructiveness and disruptiveness
Adolescent Behavioral/ Mental
Health Disorders
 Depressive Disorders
 Anxiety Disorders
 Trauma and Stress Related Disorders
 Disruptive, Impulse Control and Conduct Disorders
 Substance-Related and Addictive Disorders
 Bipolar and Related Disorders
 Eating Disorders
Trauma /Substance Abuse
While most adolescents and many
adults use chemicals to get high,
trauma survivors use them to just get
by.
Adolescent Substance Abuse
in Dona Ana County
 Alcohol Abuse
 Marijuana
 Prescription Drug Abuse
 Inhalants
 Methamphetamine
 Heroin
 Other
Treatment “Levels of Care”
 Outpatient Therapy
 Medication Management (usually in combination with
other therapies)
 Intensive Outpatient Services
 Drug Courts
 Residential Treatment (includes Treatment Foster
Care)
 Acute Hospitalization
Evidence-Based Practices*
in Dona Ana County
 Trauma-Focused Cognitive Behavioral Therapy
 Multisystemic Therapy (MST)
 Matrix Model Substance Abuse Treatment (IOP)
 Seven Challenges Substance Abuse Treatment (IOP)
 Cognitive Behavioral Therapy
 Motivational Interviewing
 EMDR (Eye Movement Desensitization and Reprocessing)
 Parenting Programs (Nurturing, Triple P, Strengthening Families

* proven effective by research
What is Needed?
 School-Based Health Clinics with Mental Health
Services
 Early Intervention
 Youth Mental Health First Aid
 Anti-Stigma and Awareness Campaigns – Youth and
Parent Involvement
 Prevention of Adverse Childhood Experiences
ADVERSE CHILDHOOD EXPERIENCES
STUDY
Centers for Disease Control and Kaiser Permanente in
San Diego, CA.
17,100 Adults
Tracked health outcomes based on childhood ACEs
30
WHAT ARE THE
ADVERSE CHILDHOOD EXPERIENCES
(ACEs)?
1. Child physical abuse
2. Child sexual abuse
3. Child emotional abuse
4. Neglect
5. Mentally ill, depressed or suicidal person in the home
6. Drug addicted or alcoholic family member
7. Witnessing domestic violence against the mother
8. Loss of a parent to death or abandonment, including
abandonment by divorce
9. Incarceration of any family member
31
ACE Study: a Paradigm shift
Mechanisms by which Adverse Childhood Experiences influence health and
well-being throughout life
32
KEY VARIABLES IN BRAIN OUTCOMES
CRITICAL TIME:
AGE OF
MALTREATMENT
TYPE OF ABUSE
Different types of
maltreatment activate
different processes
that shape the brain,
such as chemicals &
hormones, electrical
activity, cell growth, &
specialization of
cells.
The brain develops over
time. The effects of
maltreatment
correspond to the
region and/or
function that is
developing at the
time of maltreatment.
GENDER
Although both boys & girls are affected
by maltreatment the effects of sexual
abuse are more profound in girls
while the effects of neglect are more
profound in boys.
33
CORPUS CALLOSUM
HIPPOCAMPUS
The center for:
• Controlling emotional
reactions
• Constructing verbal memory
• Constructing spatial memory
VULNERABLE TO:
All forms of maltreatment in the
first 2-3 years of life.
Integrates hemispheres &
facilitates:
• Language development
• Proficiency in math
• Processing of social cues,
such as facial expression
VULNERABLE TO:
Neglect in infancy.
Sexual abuse in the
elementary school years.
RIGHT TEMPORAL GYRUS
Center for spoken language.
VULNERABLE TO:
Emotional abuse, especially between
ages 7 and 9.
34
INTEGRATING BRAIN & EPIDEMIOLOGY RESEARCH
Epidemiology
Findings
Brain Research Findings
Maltreatment,
trauma & Adverse
Childhood
Experiences
Predictable
adaptation during
brain development
cause cognitive,
social, & behavioral
traits
Cognitive, social,
behavioral & health
outcomes
Poor health &
excessive use of
healthcare systems
(Brain Research &
Epidemiological
Findings)
Early Death
Resilience is the key to countering this scenario! 35
2013
Winning Art Poster
Mental Health
Awareness
Katie LaPage
Mayfield HS
Art Student
CONSEQUENCES OF BIOLOGICAL OUTCOMES
COGNITIVE
•
•
•
•
•
Slowed language development
Attention problems (ADD/ADHD)
Speech delay
Poor verbal memory/recall
Loss of brain matter/IQ
SOCIAL
•
•
•
•
Aggression & violent outbursts
Poor self-control of emotion
Can’t modify behavior in response to social cues
Social isolation—can’t navigate friendship
MENTAL HEALTH
• Poor social/emotional development
• Alcohol, tobacco & other drug abuse—vulnerable to early initiation
• Adolescent & adult mental health disorders—especially depression, suicide,
dissociative disorder, borderline personality disorder, PTSD
37
ACES ARE HIGHLY INTERRELATED,
SELF-PERPETUATING,
& HAVE A CUMULATIVE STRESSOR
EFFECT
The number of different categories of ACEs (ACE score) was found to
determine health outcomes, not the intensity or frequency of a single
category.
The evidence suggests that ACEs are a causal agent for many health
challenges. Without interruption, ACEs escalate across generations.
38
A SIGNIFICANT PORTION OF DISEASE ACROSS
THE POPULATION IS ATTRIBUTABLE TO ACES
54% of depression,
58% of suicide attempts
39% of ever smoking,
26% of current smoking
65% of alcoholism,
50% of drug abuse
78% of IV drug use is attributable to ACEs
48% of promiscuity (having more than 50 sexual partners)
…are attributable to ACEs
39
LIFE LONG PHYSICAL, MENTAL &
BEHAVIORAL OUTCOMES OF ACEs
 Alcoholism & alcohol abuse
 Chronic obstructive pulmonary
disease & ischemic heart disease
 Depression

 Fetal death

 High risk sexual activity

 Illicit drug use

 Intimate partner violence

 Liver disease
Obesity
Sexually transmitted disease
Smoking
Suicide attempts
Unintended pregnancy
The higher the ACE Score, the greater the incidence of
co-occurring conditions from this list.
40
ACE STUDY DOSE RESPONSE FINDINGS
Intravenous Drug Use
Attempted Suicide
4
25
3
4+
2.5
2
3
1.5
2
1
0.5
0
% Ever Attempting Suicide
% Reporting IV Drug Use
3.5
20
4+
15
10
3
5
1
0
ACE Score
1
2
ACE Score
41
PROBABILITY OF SAMPLE OUTCOMES
GIVEN 1,000 AMERICAN ADULTS
330
Report No ACEs
510
Report 1-3 ACES
160
Report 4-8 ACEs
WITH 0 ACEs
WITH 3 ACEs
WITH 7+ ACEs
1 in 16 smokes
1 in 69 are alcoholic
1 in 480 uses IV drugs
1 in 14 has heart disease
1 in 9 smokes
1 in 9 are alcoholic
1 in 43 uses IV drugs
1 in 7 has heart disease
1 in 6 smokes
1 in 6 are alcoholic
1 in 30 use IV drugs
1 in 6 has heart disease
1 in 96 attempts suicide
1 in 10 attempts suicide
1 in 5 attempts suicide
42
43
ACES TEND TO
CO-OCCUR / CLUSTER
In the lives of Washingtonians
•Among adults exposed to physical abuse,
84% reported at least 2 additional ACEs
•Among adults exposed to sexual abuse, 72%
reported at least 2 additional ACEs
44
What we see in this research…
ACEs drive:
•
•
•
•
•
Health outcomes & healthcare costs
Special education needs
Rates of school failure
Intergenerational patterns of high-cost social problems
Caseloads for the highest-cost social problems
We also see that we can prevent and protect children from ACEs.
We have the power to reduce ACEs in the next generation, and
the privilege of helping people with many ACEs to live joyful and
fulfilling lives.
45
www.resiliencetrumpsaces.org
What is RESILIENCE?
Adapted from research of Masten, Boss, Brooks & Goldstein
The ability to recover from or adjust to change
How?
Give choices
Give chores/affirmation
Give opportunity for mastering skills
Give sense of connecting to the world
47
Three basic building blocks to success:
Adapted from the research of Dr. Margaret Blaustein
Attachment - feeling connected, loved, valued, a part
of family, community, world
Regulation - learning about emotions and feelings and
how to express them in a healthy way
Competence - acting rather than reacting, accepting
oneself and making good choices
48
When dealing with a child:
Know your own “triggers” and emotional
state to respond with:
Consistency
Predictability
Routines and Rituals
49
SKILL BUILDING
Children aren’t born knowing this, we
have to teach it
Instead of “NO!”, brainstorm together:
“What are you trying to accomplish? “
“What do you think might happen if you
do this or… ?
50
SKILL BUILDING
Think: lack of skill not intentional
misbehavior
Think: building missing skills not shaming
for lack of skills
Think: nurture not criticize
Think: teach not blame
Think: discipline not punishment
51
Survival Mode Response
Stressed
Brains
• Respond
• Learn or
• Process effectively
Can’t:
Allow time to de-escalate
52
One strategy
for helping
child identify
emotional
state
Great for role
modeling too!
53
CHANGE STARTS WITH A CHOICE
• Think: teaching and learning
• Punishment creates anger, resentment,
exclusion, intolerance
• Supportive discipline (“to teach”)
builds missing skills that lead to success
54
Summary
3 Points:
• Our brains adapt to experiences in daily life
• The more trauma a child experiences, the greater
the chance of negative effects on thinking, mental
health and social factors as the brain is developing
• Resilience can be built into the daily life experience
of a child or adolescent !
55
From the individual to the collective:
lessons being learned
• Community mental health models can be shifted to
emphasize understanding and sensitivity to trauma
history
• Providers, parents and community members can move
from shame and blame to positive healing, which can
then lead to social support and, ultimately, to positive
change
• A community can come together to work collectively
to build resilience into the daily life experience of a
child, adolescent, or adult - it is never too late !
56
Everyday Matters
 “You treat a disease, you win,
you lose. You treat a person, I
guarantee you, you’ll win, no
matter what the outcome.” –
Patch Adams
Thank You !
 Resources:
SAMHSA www.samhsa.gov
National Child Traumatic Stress Network www.nctsn.org
The Body Keeps the Score: Brain, Mind, and Body in the Healing of
Trauma by Bessel Van Der Kolk, M.D.
National Alliance on Mental Illness: www.nami.org
www.search-institute.org
www.resiliencetrumpsaces.org