Transcript Depression in Children - Association of School Nurses of Connecticut

Introduction to
Mental Illness
Association of School Nurses
February 6, 2014
Presented by: Kate Mattias, MPH, JD
Executive Director, NAMI-CT
What Is NAMI?
National Alliance on
Mental Illness Connecticut
State Member of NAMI National
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NAMI’s Mission
Support,
education
& advocacy,
to improve the quality of life for people in
recovery from mental illnesses, their
family, friends, professionals and the
public
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Audiences We Serve
 People in recovery; people living with mental
illness
 Family members and friends of loved ones with
mental illness adults & children
 Policy makers and other community stakeholders
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Trauma Informed Care
Mental Health Treatment that incorporates:
– An appreciation for the high prevalence of
traumatic experiences in persons who
receive mental health services
– A thorough understanding of the profound
neurological, biological, psychological and
social effects of trauma and violence on the
individual
(Jennings, 2004)
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Why Trauma-Informed Care Matters
 The majority of adults and children in
psychiatric treatment settings have
histories of trauma;
 A sizeable percentage of people with
substance use disorders have
traumatic stress symptoms that
interfere with achieving or
maintaining sobriety
 A sizeable percentage of adults and
children in the prison or juvenile
justice system have trauma histories
(Hodas, 2004, Cusack et al., Mueser et al., 1998, Lipschitz et al.,
1999, NASMHPD, 1998)
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Truth about Mental Illness
 Prevalence of Violence
 No different than that of the general
population while in treatment and not abusing
substances
 Substance abuse is a major risk factor
 Typically drug seeking behaviors
 More than 25% of persons
with serious mental illness are
victims of violent crime
 12 times the rate of the general population
Steadman et. al., MacArthur Violence Risk Assessment Study, August 2001
Teplin, et.al., Archives of General Psychiatry, August,
7 2005
About Mental Illness
 A disease of the brain;
 Impacts children and adults;
 Biologically based, with genetic links
and environmental factors;
 Cannot be overcome through "will power“;
 Not related to a person's "character" or
intelligence;
 Brain chemicals that regulate our moods,
thoughts, and perceptions are affected;
 Situations or environment can bring on
stressors that can activate or worsen conditions
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Some Good News
• With the right treatment, between
70 and 90% of individuals have
significant reduction of symptoms;
• Early identification and treatment is
important; the brain is protected
from further harm related to the
course of illness;
• Advances in medication and other
interventions have greatly improved
the chance of recovery for many
individuals
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Who is Most Vulnerable?
Mental illnesses strike individuals in
the prime of their lives:
 adolescence and young adulthood;
 often when someone is starting
higher education or employment;
 the young and the old are especially
vulnerable.
 typically a 10 year lag between
symptoms and diagnosis
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Cultural (and age-related) Barriers
That Impact Care
 Language
 Stigma – familial, societal, educational
 For children, lack of parental/caretaker
knowledge of mental illness
 Parental or family perceptions of mental illness
and treatments – fear of labels, treatments
 Limited data about utilization patterns among
population groups
 Idea that depression is a normal part of aging
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How Do We Know It’s a
Mental Illness?
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Diagnosing Mental Illnesses
No blood test
No brain scan
No “typical” behaviors or signs
No universal medication(s)
Providers have to go on:
The behavior(s) being exhibited
The person’s mood(s)
The person’s thoughts
The length of time the person has
experienced unusual thoughts or behaviors13
Childhood or Early Onset
Behavioral Health
Disorders
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Common Childhood Disorders
Internalizing disorders
> Depression
> Bipolar
> Anxiety
Externalizing disorders
> ADHD
> Oppositional Defiant Disorder
> Conduct Disorder
Etiology:
> Stress/Trauma related to onset and course
> Genetics – for most childhood disorders
> Family factors related to onset and course
> Symptoms may be present since infancy or early childhood, or
suddenly emerge in adolescence
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Children & Youth with
Mental Illnesses
Early Identification and Treatment
Research supported by the National
Institute of Mental Health (NIMH) has
found that half of all lifetime cases of
mental illness begin by age 14.
Studies also reveal that untreated
mental disordera can lead to a more
severe, more difficult to treat illness,
and to the development of cooccurring mental illnesses.
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Signs: Younger Children
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Fall in school performance or poor grades despite
trying hard;
Worry or anxiety; refusal to go to school,
refusal to sleep or take part in activities;
Persistent disobedience or
aggression and opposition to
authority figures;
Frequent, unexplainable temper tantrums;
Hyperactivity; fidgeting, constant movement;
Persistent nightmares.
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Signs: Pre-teens & Adolescents
 Fall in school performance;
 Abuse of alcohol or drugs;
 Inability to deal with problems
and daily activities;
 Changes in sleeping and/or
eating habits;
 Persistent nightmares;
 Sexual acting out;
 Depression shown by continuing, prolonged
negative mood and attitude, often poor appetite,
difficulty sleeping or thoughts of death (or suicide).
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Depression in Children
and Youth
Signs that Parents Might See
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Nothing pleases the child
Child hates self and everything else
Disappearance of usual happy child
Child is no fun, hard to like
Child pretends to be happy in public,
sad at home
 Irritability
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Depression in Children
 Major Depression
 About 21% w/significant symptoms don’t meet diagnostic criteria;
 More severe & acute than other depressive illnesses;
 Suicidality ideation and actions more common;
 Usually chronic and relapsing;
 More likely to be diagnosed.
 Dysthymia
 Longer-term, less severe;
 Chronic; usually life long;
 Less likely to be diagnosed early on.
 Co-Morbidity
 Social withdrawal;
 Conduct problems;
 Often other disorders – ADHD, anxiety disorders.
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Depression in Children and Youth
 Depression is feeling sad, lonely, unloved, dumb, and
worthless, along with feelings of guilt and beliefs of being
mistreated;
 Clinical depression is a combination
of these symptoms that persist for
a period of time and cause difficulties in the
child’s life at home, work, school or play;
 A child with depression often feels hopeless and helpless,
and may wish to die.
Suicide is the 2nd leading cause of death in
Connecticut among that kids ages 10-14.
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Depression in Children
 Extreme irritability, aggressiveness;
 Unable to have fun, won’t join in
activities;
 Frequent complaints of headaches,
stomachaches; somatic symptoms
 Refusal to attend school; causes
classroom disturbances;
 Drop in grades;
 Need to sleep a lot;
 Often co-occurs with another
disorder.
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Depression in Adolescents
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Feel sad, hopeless, empty, tearful, weepy;
Develop extreme sensitivity in relationships;
Feel restless, aggressive becoming antisocial;
Think they are different and no one understands;
Can become self-destructive; high risk of
self-medication or other “risky” behavior;
 Stop caring about appearance and
hygiene;
 Have increased anxiety;
 Have thoughts of death or suicide attempts.
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Treating Depression in Children
Approaches similar to that of an adult
 Antidepressants regulate specific brain
neurotransmitters; Selective Serotonin Reuptake
Inhibitors (SSRIs) and other anti-depressants –
Wellbutrin and Cymbalta - work on norapenephrine and
dopamine;
 Antidepressants used mainly for moderate or severe
depressive symptoms; must be monitored closely
especially in the first few weeks when suicidality has
been evidenced
 No antidepressant more effective than any other, different
types have differing results in people; different side
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effects.
Treating Depression in
Children & Youth
 Cognitive behavioral therapy can be very effective.
 Children who are depressed often have an unhealthy,
negative view of themselves;
 With cognitive behavioral therapy, children learn to develop
a healthier, more positive outlook — which can help relieve
depression.
 Antidepressant medication is another option for childhood
depression treatment, especially when psychotherapy is
unable to effectively treat mood symptoms. Untreated mood
disorders in adolescents are associated with an increased
risk of suicide.
Treating Depression in
Children & Youth
 Antidepressants may be particularly helpful for
children who:
 Have severe symptoms that don’t respond to therapy
alone
 Don't have convenient or timely access to therapy
 Have chronic or recurring depression
 Have a family history of depression with good response
to medication
 Don't have active substance abuse issues
 Don't have bipolar depression or an active psychotic
illness
Bipolar Disorder
Bipolar Disorder in Children
 A brain disorder with distinct and
extreme changes in mood and
behavior
 Sometimes called Manic
Depressive Illness
 Early intervention and treatment
offer the best chance
 No blood test or brain scan to
establish diagnosis
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Bipolar Disorder Among Children
 Overall prevalence among children is comparable to
that of adults;
 Significant number of children report having a distinct
period of abnormal, persistent, elevated, expansive or
irritable mood, although they did not fulfill criteria for
bipolar I or bipolar II (Lewinsohn and colleagues)
 Survey results of the membership of the National
Depressive and Manic-Depressive Association
(DMDA), reported the onset of illness during childhood
or adolescence in 59 percent of adult respondents (Lish
and coworkers)
Bipolar Disorder Among Children
 Evidence suggests that bipolar disorder beginning
in childhood or early adolescence may be a
different, possibly more severe form of the illness
than older adolescent- and adult-onset bipolar
disorder
 Symptoms may be present since infancy or early
childhood, or may suddenly emerge in
adolescence or adulthood. It’s only recently that
doctors are able to diagnosis the
disorder in childhood.
Bipolar Disorder Among Children
 If the illness begins before or soon after puberty, it is
often characterized by a continuous, rapid-cycling,
irritable, and mixed symptom state that may co-occur
with disruptive behavior disorders, particularly attention
deficit hyperactivity disorder (ADHD) or conduct
disorder (CD), or may have features of these disorders
as initial symptoms
 Later adolescent- or adult-onset tends to begin
suddenly, often with a classic manic episode, and has
an episodic pattern with relatively
stable periods between episodes
 Later onset - less co-occurring
ADHD or CD
Early Identification of Bipolar
Disorder
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In young children it can be difficult to identify episodes of
mania or depression as these conditions often mimic other
childhood disorders like ADHD;
Example: Both groups present with irritability, hyperactivity
and distractibility; these symptoms are not useful for the
diagnosis of mania because they also occur in ADHD
But,
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elated mood
grandiose behaviors
flight of ideas
decreased need for sleep and increased interest and thoughts about
sexual actions occur primarily in mania and are uncommon in ADHD
More on Early Onset Bipolar
Disorder
 Children and adolescents can have cycles of
normal moods, mania, and depression
 During a manic phase, behavior may be
impulsive, with feelings of grandiosity, poor
decision-making
 Suicidal thoughts, feelings of worthlessness
and hopelessness often are present during
the depressive phase
 As the person/child moves to the manic
phase, the risk of suicide can be greater
Treating Childhood Bipolar Disorder
 Adult medications often helpful in stabilizing mood;
 Mood stabilizers – lithium; anti-convulsants - valproic acid,
(Depakote); more recently - lamotrigine (Lamictal);
 Antidepressants for bipolar depression - mood must be
stabilized first;
 Stimulants and antidepressants given without a mood
stabilizer (often the result of misdiagnosis) can cause
potentially induce mania, more frequent cycling, and
increases in aggressive outbursts;
 Cognitive behavioral therapy, interpersonal therapy,
and multi-family support groups are an essential part of
treatment for children and adolescents with bipolar disorder.
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Treatment for Early Onset
Bipolar Disorder
 There is some evidence that using antidepressant
medication to treat depression in a person who has
bipolar disorder may induce manic symptoms if it is taken
without a mood stabilizer.
 Using stimulant medications to treat attention deficit
hyperactivity disorder (ADHD) or ADHD-like symptoms in
a child with bipolar disorder may worsen manic
symptoms.
 There is a greater likelihood among children and
adolescents who have a family history of bipolar disorder
that mania will occur. If mania worsens, parents should
consider getting the child evaluated for bipolar disorder.
Child and Adolescent Bipolar Disorder:[NL]An Update from the National Institute
of Mental Health
Treating Childhood Bipolar Disorder
 Atypical anti-psychotics – result in less frequent and less
intense mood swings or episodes of mania – typically taken
with mood stabilizers; risperidone (Risperdal), olanzapine
(Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), and
Abilify (aripiprazole);
 Psychotherapy - once a child’s mood has stabilized; therapy
usually supportive in nature, helping with coping skills and
education about the disorder;
 A support group for the child or adolescent with the disorder
can also be beneficial, although few exist – some internet
blogs are appearing.
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Attention Deficit/Hyperactivity
Disorder
Attention Deficit/Hyperactivity
Disorder
Characterized by three dominant
features or behaviors:
Inattentiveness; not paying
attention
Impulsivity and in many but not
all cases,
restlessness or hyperactivity
Prevalence, Gender,
Comorbidity of ADHD
 2-6% meet criteria; much more if
teachers or parents asked whether
hyperactivity is present
 boys 2.5-5.6 times more likely to have
 30-50% or higher persists into adulthood
 Comorbidity –
 35-60% oppositional defiant disorder
 15-25% later - antisocial personality disorder
Most children and adults with ADHD are
treated with stimulants
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Attention Deficit/Hyperactivity
Disorder
Inattention
– seen as disorganized, distracted, forgetful
– teachers/parents descriptions
– problems remain relatively stable
Hyperactivity/impulsivity
– fidgetiness, moving about, running, climbing
more than others
– play noisily, talk excessively, interrupt others, less able to
wait in line or take turns
– parents/teachers descriptions
– problems arise before inattention
– decline with age
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Children with ADHD
 Awkward relationships with kids
their own age; they don’t “fit in”
 Seem to never perform up to their ability
 May seem “accident prone;” uncoordinated
or clumsy
 Respond poorly to discipline
 Often interrupt conversations
 Their feelings get hurt easily
 Have a low or high tolerance
for pain
Symptoms of ADHD can include:
 Poor attention span
 Difficulty keeping attention while playing or
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doing other activities or tasks
Inability to listen when spoken to directly
Difficulty organizing, following through or
finishing tasks
Avoiding or not liking tasks that require long
attention spans
Losing things necessary to complete tasks or
activities
Being easily distracted by outside stimuli
Forgetfulness
More Symptoms of ADHD
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Fidgeting; difficulty sitting or standing still
Restlessness or excessive activity
Feeling as if “driven by a motor”
Talking excessively
Blurting out answers before
questions have been completed
 Impatience – difficulty waiting
 Interrupting others in activities
or discussions
Treatment for ADD/ADHD
 Treatment options for children and adolescents
with ADD/ADHD include
 medication, (sometimes stimulants; sometimes anticonvulsives to calm the child)
 psychotherapy,
 behavioral therapy, and
 social skills training
 Neurofeedback training - individual can learn to
increase EEG activity in the brain to support
increased attention and decreased impulsivity
 There are times when the entire family of a child with
ADHD can benefit from support groups, or parenting
skills training
Anxiety Disorders
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Anxiety Disorders Adults & Children
Most common anxiety disorders
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Panic Disorder
Obsessive-Compulsive Disorder
Post-Traumatic Stress Disorder
Phobias
Generalized Anxiety Disorder
 Affect about 40 million adults; about 10% of adolescents; (NIMH)
 Symptoms must last at least 6 months;
 Studies suggest children and adolescents more likely to have an
anxiety disorder if caregivers have anxiety disorders, not shown
whether biology or environment plays the greater role;
 High levels of anxiety or excessive shyness in children aged 6 to 8
may be indicators of a developing anxiety disorder.
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Anxiety Disorders – Children
and Adults
 Each disorder has different
symptoms all of which cluster around
excessive, irrational fear and dread;
 Co-occurrence with bipolar disorder
more common in adults than kids;
 In children disorders can lead to poor
school attendance, low self-esteem,
deficient interpersonal skills, alcohol
abuse, and adjustment difficulty.
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Treating Anxiety Disorders –
Adults and Children
Medication and Therapy
 Antidepressants
 Anti-anxiety drugs; benzodiazepines, have calming effect
on brain, usually given for a short time - can be addictive Klonopin, Ativan, Xanax (usually adults)
 Specific forms of psychotherapy (behavioral therapy and
cognitive-behavioral therapy), family therapy, or a
combination of these;
 Cognitive behavioral treatment person learns to deal with
his or her fears by modifying the way he or she thinks and
behaves by practicing new behaviors.
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Issues Associated with Mental
Illness in Children and
Adolescents
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Physical Health & Mental Illness
 Current NIMH data: adults with SMI die, on average, 25 years
earlier than their counterparts w/o mental illness*
 Key Health Challenges:
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Lack of health insurance;
Suicide;
Smoking (41% of population with SMI vs 22% in general pop.)**
Obesity;
Undiagnosed/under treated die younger;
Heart disease (44%)*; (some medications increase cholesterol)
Stroke (68%);*
High blood pressure;
Cancer;
Diabetes (280%)
* Journal of American Medical Association
**Harvard School of Public Health
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Co-occurring Substance Abuse
 Often “self-medication”  Provide temporary relief
 Can make many
 Alcohol, marijuana,
symptoms worse;
cocaine, ecstasy,
ketamine (tranquilizer most  Can negate effectiveness
commonly used on animals; has
of prescribed medications;
become popular among teens
 Can be dangerous when
and young adults)
combined with certain
 Alcohol and drug abuse
drugs
inhibit the ability of
 Tobacco impacts
neurotransmitters to
dopamine in the brain and
work effectively
is also considered a drug
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of “abuse”
Stigma: What People Experience
 Erodes confidence that mental disorders
are real, treatable health conditions;
 Promotes thinking that there’s something
“wrong” with the person and stops people
from getting treatment;
 erects attitudinal, structural and financial
barriers to effective treatment and recovery;
people don’t want to disclose their illness
 Perpetuates damaging myths that further
isolate persons with mental illness from
social networks and the workforce.
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What’s Possible?
• HOPE and RECOVERY
• Increasing research on children’s
mental illness;
• Early identification and early
intervention preliminary research show
positive outcomes ;
• Increasing awareness among
children’s providers – pediatricians,
other clinicians, school personnel about early onset mental illness
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Connecticut’s Network of Care
www.ctnetworkofcare.org
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Questions and Answers
NAMI-CT
www.namict.org
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