Childhood Mental Illnesses: Overview of Disorders & Treatment Lynn Baer, RN, MSN, CS BJC Behavioral Health

Overview of Presentation Mental Illness ADHD Major Depression Bipolar Disorder Anxiety Disorders Behavior Disorders (ODD, CD)

Mental Illness Normal /Abnormal Behavior The difference between normal & abnormal behavior is not always clear. Children vary greatly in their temperament, development & behaviors. It is normal for young children to have occasional outbursts.

Normal Behavior Depends on a number of factors, including: Child’s level of development The context in which the behavior occurs The child’s family values & expectations The cultural, social background

Abnormal Behavior Actions harmful to the physical, emotional, or social well-being of the child, family members or others Behavior interfering with the child’s intellectual development Behavior forbidden by law, ethics, destructive behavior Generally, if behavior is consistently interfering with academics & relationships, there may be a mental illness involved

Mental Illness: Classification Diagnostic and Statistical Manual (DSM) Pros -Communication -Effective Treatment -Increased objectivity & common terminology Cons -Stigma (stereotyping, labeling, etc.) -Overconfidence -Diagnostic Overlap, Co-morbidity

Attention Deficit Hyperactivity Disorder ADHD is a persistent pattern of developmentally inappropriate degree of gross motor activity, impulsivity, & inattention in the school and home. Core Symptoms: -Inattention- distractibility & poor sustained attention to task -Hyperactivity- excessive activity & physical restlessness -Impulsivity- impaired impulse control & delay of gratification

DSM Criteria / ADHD Six of the inattention symptoms and/or six of the hyperactive and impulsivity symptoms Some symptoms that caused impairment were present before age 7 Some symptoms were chronic- present more than not, persisting for 6 months Significant impairment from the symptoms is present in 2 or more settings; home, school, social settings Types of ADHD: Inattentive Hyperactivity/Impulsivity Combined

Cause & Prevalence Cause is unknown although there seems to be a strong genetic component ADHD associated with weaknesses in ‘executive function’ area of brain Prevalence has been estimated at 3-7% of school age children ADHD more prevalent in males than females with a 4:1 ratio

Comorbidity 31% of children with ADHD have no other mental illness 40% of children with ADHD have Oppositional Defiant Disorder 34% of children with ADHD have an Anxiety Disorder 4% of children with ADHD have a Mood Disorder 14% of children with ADHD have Conduct Disorder 11% of children with ADHD have a Tic Disorder

The Evaluation is critical Rule out: Other disorders (Anxiety, Depression, etc.) Health problems (lead poisoning, etc.) Environmental difficulties (stressful home situations- divorce, loss, etc.) Appropriate developmental behavior

The strengths of children with ADHD High energy Creativity Innovative Resourcefulness Intuitiveness Tenacity Hardworking Trusting attitude Forgiving attitude Sensitivity Ability to take risks Flexibility Good sense of humor Loyalty

Treatment Medication -Benefits: Increases focus, reduces motor activity & impulsivity. Secondary benefit- improves academic performance Therapy -Individual and/or family therapy -Social skills training -Behavior modification

Major Depression A mood and behavioral disorder in which the child’s mood is depressed. Other Depressive Disorders: Dysthymic Disorder Depressive Disorder not otherwise specified

DSM Criteria Major Depression Depressed or irritable mood most of the day, nearly every day, as indicated by either subjective report or observation. Markedly diminished interest or pleasure at almost all activities. Change in appetite and weight. Change in sleep pattern (insomnia, hypersomnia) nearly every day. Psychomotor agitation or retardation.

DSM criteria, continued Fatigue or loss of energy nearly everyday. Feelings of worthlessness or excessive guilt. Poor concentration. Recurrent thoughts of death or suicidal ideation. Symptoms must cause significant impairment in all major areas of life.

Major Depression Causes Prevalence Genetic Environmental 5 to 10% of children, adolescents Those with learning disorders have a higher prevalence Equal incidence in boys and girls

Steps to Treatment Evaluation Diagnosis Hospitalization (crisis stabilization) Medication Outpatient Therapy Play Therapy, Cognitive Behavioral Therapy Family Therapy / Psycho-Education

When is medication necessary? The child is suicidal and needs immediate intervention. The depression is affecting several areas of the child’s life. Due to severity of illness, the child is unable to benefit from therapy. Research suggests that the combination of medication & therapy leads to better results

Bipolar Disorder A mood disorder characterized by the existence of both depressive and manic moods. Children usually have an ongoing, continuous mood disturbance that is a mix of mania and depression. This rapid cycling produces irritability with periods of wellness.

Symptoms of Childhood Bipolar Disorder An expansive or irritable mood Depression Rapidly changing mood shifts Separation anxiety Hyperactivity, agitation, and distractibility Sleep disturbance Bed wetting and night terrors Impulsivity, poor judgement, racing thoughts Risk taking behavior Inappropriate sexual behavior Grandiose belief in own abilities

Causes Researchers believe bipolar disorder is caused by an imbalance in brain chemicals, (neurotransmitters). Areas of the brain involved: prefrontal (processing), amygdala (emotions), stem (regulations). Bipolar disorder can be brought on by medical illness, medications, stress, hormonal changes, substance use. If a child has a parent with a mood disorder, there is a 10-30% risk; if sibling = 20% risk; if both parents = 75% risk.

Prevalence Bipolar disorder affects more than 2.5 million adults. About 1 in 10 will experience symptoms during adolescence or younger. Diagnosis can be as young as 5 years of age. It occurs equally in genders, races, ethnic groups and social classes.

Treatment: Stabilize Mood First Due to safety concerns, medication is usually the first step in treatment. Once the child is calmer, additional medications may be added for mood stabilization, anxiety or impulsivity symptoms. Once the mood is more stable, various therapies can be helpful (education for child & parents, individual and family therapy)

Anxiety Disorders Anxiety is the fearful anticipation of further danger of problems accompanied by unpleasant feelings or physical symptoms. Anxiety is normal and is experienced many times in a person’s lifetime. Anxiety Disorders occur when the anxiety interferes with one’s daily life. They are classified based on the nature of the symptoms and whether there is something particular that triggers them.

Anxiety Disorders Panic Disorder with / without Agoraphobia Specific Phobia Social Phobia Obsessive-Compulsive Disorder Posttraumatic Stress Disorder Acute Stress Disorder Generalized Anxiety Disorder Separation Anxiety Disorder Anxiety Disorder due to medical condition Substance-Induced Anxiety Disorder

Obsessive-Compulsive Disorder Repeated, intrusive and unwanted thoughts that cause anxiety, often accompanied by ritualized behavior that relieves this anxiety. Obsessions: Persistent ideas, thoughts, impulses, or images that are experienced as inappropriate and that cause marked anxiety and stress These are not simply excessive worries The person attempts to ignore or suppress these ideas, thoughts, impulses or images or to neutralize them with some other thoughts The person recognizes the obsessional ideas, thoughts, etc. are a product of his/her own mind

Compulsions Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) the person feels driven to perform in response to the obsession The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation (however these behaviors or acts are either not connected realistically, or are clearly excessive)

DSM Criteria Obsessive-Compulsive Disorder Children don’t necessarily recognize that the obsessions or compulsions are excessive or unreasonable (they may lack the cognitive awareness to make this judgement). The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hr. a day), or significantly interfere with the child’s normal routine, social activities or relationships.

Causes, Prevalence Genetic Environmental More common in boys than girls. Boys develop OCD at an earlier age than girls. Usually begins in adolescence, but is seen in as many as 1 in 200 children. Children with a parent with OCD have 10 times the risk of developing OCD themselves.

Treatment Treatment for Anxiety Disorders can be very successful with a combination of medications & therapy. Medications can include Antidepressants, Anxiolytics or Antipsychotics Behavior Therapy Exposure, Response Therapy Cognitive Behavioral Therapy Relaxation Therapy Family Therapy

Oppositional Defiant Disorder A recurrent pattern of negative, defiant, disobedient, and hostile behavior toward authority figures. Evaluation is critical to rule out other disorders, health problems, environmental issues, or developmentally age-appropriate behaviors

DSM criteria Oppositional Defiant Disorder Must have at least four of the following symptoms lasting 6 months or longer: Often loses temper Often argues with adults Often actively defies or refuses to comply with adult request or rules (won’t compromise or negotiate) Often deliberately annoys people Often blames others for his / her mistakes Often is touchy, angry, resentful of restrictions Often is spiteful or vindictive

Causes Genetic: ODD more common where at least 1 parent has a history of a mood disorder, ODD, Conduct Disorder, ADHD, Antisocial Personality Disorder, Substance Abuse Environment: Occurs more in families with parental discord, different caregivers, or if the parenting style is harsh, inconsistent or neglectful

Prevalence Rates vary from 2- 16% of the population. ODD frequently coexists with ADHD and Learning Disabilities. The disorder usually becomes evident by the age of 8, and usually not later than early adolescence. In some cases, ODD develops into Conduct Disorder.

Treatment Medications: None specifically for ODD, but child may be taking tenex (guanfacine), or clonidine (catapres), or an antipsychotic (such as risperdal), or a stimulant (such as ritalin) Behavior Therapy: Behavior charts / reward systems for home, school Parenting techniques Anger management

Conduct Disorder Conduct Disorder (CD) is a repetitive & persistent pattern of behavior in which the basic rights of others are violated (and is not simply a one time reaction to the immediate social context).

DSM Criteria for CD At least 3 of the following criterion present in the past 12 months (with at least one present in the past 6 months): -Aggressive to people and animals -Destroys property -Deceitful or stealing -Violates the rules or laws

Causes, Prevalence Genetic Environmental Rates of CD range from 1-10% of population Higher rate in males Frequently diagnosed Symptoms usually emerge from middle childhood to middle adolescence

Treatment Treatment involves several approaches including therapy for the student & family, as well as medication to decrease aggression. Therapy: -Anger Management Techniques (ART) -Problem Solving Skills Training -Parent Management Training -Behavior Management Plans Prognosis is poor.