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

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

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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.

16. 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.

17. 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

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

19. 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

20. 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.

21. 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

22. 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.

23. 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.

24. 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)

25. 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.

26. 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

27. 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

28. 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)

29. 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.

30. 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.

31. 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

32. 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

33. 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

34. 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

35. 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.

36. 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

37. 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).

38. 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

39. 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

40. 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.