adolescent mental health - acofp...isolation”. -john lennon “everybody’s on the phone we’re...
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Adolescent Mental Health
Ron Marino, DO, MPH, FACOP
Associate Chairman, Pediatrics
Winthrop University Hospital
Professor of Clinical Pediatrics
NYIT College of Osteopathic Medicine
Stony Brook University Medical School
Disclosures
I do not intend to discuss an unapproved/investigative use of a commercial product or device in my presentation.
I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or providers of commercial services discussed in this presentation.
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Goals and Objectives
• Appreciate the magnitude and types of mental health problems occurring in adolescents
• Cite socio cultural factors that impact on mental health
• Utilize mental health screening techniques in primary care
• Implement primary care management strategies
• Appropriately refer for mental health services
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Typical Adolescent Development
Mood swings
Black and White thinking
Risk Taking
Peer Group Dominance
Explore sexuality
Family time
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Today’s Context
Digital Generation
Social Media
Cyber bullying
Sexting
Nature Deficit Disorder
Hurried Child
More than 1 America!
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The Neighborhood Context of Adolescent Mental Health*
CAROLS.ANESHENSELUniversity of California, Los Angeles
CLEA A. SUCOFFRAND Corporation
Journal of Health and Social Behavior 1996. Vol. 37 (December):293-310
Mental health disorders in adolescence are pervasive, often carry into adulthood, and
appear to be inversely associated with social status. We examine how structural aspects of neighborhood context, specifically, socioeconomic stratification and racial/ethnic segregation, affect adolescent emotional well-being by shaping subjective perceptions of their neighborhoods. Using a community-based sample of 877 adolescents in Los Angeles County, we find that youth in low socioeconomic status (SES) neighborhoods perceive greater ambient hazards such as crime, violence, drug use, and graffiti than those in high SES neighborhoods. The perception of the neighborhood as dangerous. in turn, influences the mental health of adolescents: (the more threatening the neighborhood, the more common the symptoms of depression, anxiety, oppositional defiant disorder, and conduct disorder. Social stability and, to a lesser extent, social cohesion, also emerge as contributors to adolescent disorder. This investigation demonstrates that research into the mental health of young people should consider the socioeconomic and demographic environments in which they live.
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I feel that others don’t care about
me
I feel powerless, and not in control of
my life
I don’t like
myself I feel good about the
future
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Mental Health Issues of Adolescents
Anxiety
ADHD
Depression
Substance Abuse
Gender Issues
Internet Addiction
Prevalence of the Mental Health Challenges in US Children and
Adolescents
2724211815129630
Autism Suicide ADHD Depression Anxiety
Prevalence % of Children
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CC: I think I have ADHD
My friends Adderall really helped my guitar playing.
School history – honor student. Freshman in College
P.E.: Vitals WNL
Negative Physical
Assessment Plan?
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#1 Mental Health Disorder of Adolescents Lifetime Prevalence 25% 13 – 18 year olds
Incidence tripled between 2003-2011
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• Separation Anxiety
• Phobias
• Panic Disorders
• Generalized Anxiety Disorder
DSM-V
Disruptive mood dysregulation disorder
Major Depressive Disorder
Persistent depression
Premenstrual dysphoric disorder
Substance induced depressive
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Scope of Problem
• 1/5 teens have a hx of depression at some point during adolescence
• In PC setting, point prevalence rate of depression is as high as 28%
• 2-3 times higher in girls
• Between 2010-2016 incidents increased by 20%
Suicide
2nd leading cause of death.
Rate increasing in females.
Intention vs. gesture
2000 Deaths/yr
16 % high school students report thoughts of self harm 8 % attempt.
WHS 2015
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Sexual Orientation
Paradigm of Sexuality
Gender Identity
SexualBehavior
Sexual Attraction
Biological Sex
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The Williams Institute and The American Foundation for Suicide Prevention 2011
Substance AbuseIn the last 30 days,
LGBTQ youth are more likely to have used:
Tobacco
59.3% vs. 35.2%
Alcohol
89.4% vs. 52.8%
Cocaine
25.3% vs. 2.7%
LGBTQ youth are more likely to have used
substances before the age of 13:
Tobacco
47.9% vs. 23.4%
Alcohol
59.1% vs. 30.4%
Cocaine
17.3% vs. 1.2%
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61%
56%
25%
5%
LGBT Teens Who Are “Out”
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“We’re afraid of everyone, afraid of the sun, Isolation”. -John Lennon
“Everybody’s on the phone we’re all connected but we’re all alone.” -Jimmy Buffet
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80% of households had 1
32% of children < 18 had 1
JAOA 105:85, 2/05
Empirical Article Clinical Psychological Science 1-15The Authors (s) 2017Reprints and permissions:Sagepub.com/journalsPermissions .navDO1: 10.1177/2167702617723376222.psychologicalscience.org/CPS
®SAGE
Increases in Depressive Symptoms, Suicide-Related Outcomes, and Suicide Rates Among U.S. Adolescents After 2010 and Links to Increased New Media Screen Time
Jean M. Twenge', Thomas E. Joiner", Megan L. Rogers", andGabrielle N. Martin''San Diego State University and "Florida State University
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“….Results show a clear pattern linking screen activities with higher levels of depressive symptoms/suicide related outcomes and non screen activities with lower levels”
Twenge .et al. 2017
Tyler Clementi
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• 2-6 year olds spend 4 hours a day watching screens
• 6 to 8 year olds spend 7.5 hours a day watching screens
• 40% of 3 month olds watch TV regularly
• 25% of 2 year olds have TV in their rooms
• 90% of 2 year olds watch TV regularly
Some Scary Statistics
Computer Play
A rapidly evolving culture
Not going away
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Bizarre Computer Behaviors
• Swatting
• Digital Self Harm
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Challenges of Computer Play
Sedentary
Time consuming
Addicting
Isolating
Commercial
↑ Violence
Cognitive Overload
↓Contemplation, reflection
Anonymous
Potential Good of Computer Play
Opportunities to share
Virtual creativity
↑ Scanning and skimming skills
Potential parental involvement
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The Teenage Brain
Media Multitasking Matter volume in ACC
Social Media Use Dopamine
Finding Balance
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Longitudinal humanistic relationship based primary care!
The Primary Care Advantage
Longitudinal, trusting, and empowering therapeutic
relationships
Family‐centered medical home
Opportunities for prevention
Understanding of common social, emotional, and educational problems in the context of a child’s development and environment
Experience working with specialists and serving as a Care Coordinator
Familiarity with chronic care principles and practice improvement methods
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Surveillance Screening Evaluation
Check in on
Abuse
Gender identity
Internet gaming
Substances
Lifestyle
Bullying
School Attendance
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Warning Symptoms
School Functioning or Attendance
Change in eating pattern
Social isolation
Temper outbursts
Screening
a brief process
designed for those thought to be developing normally (asymptomatic)
identifies those in need of further assessment
does not provide a diagnosis,
helps to formulate referral questions
Barbara Ward‐Zimmerman, Ph.D. (August, 2012). The Integration of Routine Behavioral Health Screening Into
Pediatric Primary Care. Unpublished paper presented at APA Annual Convention, Orlando, Florida.
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PSC 17PHQ – 9Columbia Depression ScaleScaredStrengths and Difficulties QuestionnaireVanderbilt Rating Scales
Interview Logistics
• Parents Role
• Confidentiality
• Physical Environment
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Clinical Approaches
It’s in the Rapport!
Do Ask!
Depression
Sleep disturbance
Interests (anhedonia)
Guilt – self esteem
Energy
Concentration
Appetite
Psychomotor agitation/retardation
Suicidal ideation
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Open Ended Questions
Understanding
Compassion
Commitment
Connections
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“Everybody feels sad”
Screening questions:
Have you lost interest in things you used to enjoy?
Have you had any change in your sleep patterns?
Have you had any thoughts about hurting yourself?
Have you been feeling sad, down, or depressed much of the time?
Questions to ask Regarding Suicide Risk
Do you have thoughts of death or dying?
Do you wish you were dead?
Do you believe that things would be better if you were dead?
Do you have any intent to kill yourself or any plan to do so?
If you have a plan, what is it?
Do you have the means necessary to carry out your plan?
Have you ever tried to kill yourself or hurt yourself before?
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Initial Management
Educate and Counsel patient and families about
depression and options for treatment, including a discussion of confidentiality
Develop a treatment plan, set goals in key areas of functioning: home, peer, school
Share info about community links
Establish a safety plan
Treatment
Mild: Consider active support and monitoring first
Mod‐Severe: Consider consultation with MH Professional
Recommend scientifically tested and proven treatments (psychotherapies such as CBT,IPT), SSRIs
Monitor for adverse effects during SSRI treatment
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Help Prevent Suicide!
Make the home safe: remove firearms, lock up or remove alcohol, medications, poisons
Ask about suicide: asking will NOT promote the idea
Watch for suicidal behavior: expressing self‐destructive thoughts; obsessed with death in drawings, music, video games, books, TV, internet; giving away possessions
Watch for signs of drinking
Develop a suicide emergency plan: exactly what to do if adolescent IS feeling suicidal – don’t leave alone
Active Monitoring
Appropriate first choice for new‐onset mild‐mod depression
Schedule frequent visits
Prescribe regular exercise and leisure activities
Recommend a peer support group
Review self‐management goals
FU with patient via telephone
Provide patient and family with educational materials
Taper with improvement, consider referral if no improvement
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Mental Health Apps
Aura
Calm
Relax Melodies
Take a Chill
Head Space
Calm Counter
The Relational virtues of a Healer
Genuine Compassion Respect Attentive Listening
“Listening is a magnetic and strange thing, a creative force. The friends who listen to us are the ones we move toward. When we are listened to, it creates us, makes us unfold and expand.”
Karl Menninger, MD
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Karl Menninger, MD
Touch releases Oxytocin
Oxytocin Trust and Tranquility
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Rx for Adolescents
Service
Outdoor Experiences
Adults who care
Pro Social Peers
Referral
•Know your resources
•Get written permission from patient and parent/guardian
•Have a clear plan tocommunicate information
•Have a clear plan to receive follow up information
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Co-Management
Stay actively involved – do not abandon your patient!
Have a clear plan (and patient/parental permission) to
exchange essential information
Establish your own PCP Chronic Care Management
Plan with the patient and family
I’ll tell you what this means, Norm… no size restrictions and screw
the limit
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• Lack of comfort/Training
• Lack of Time
• Lack of Adequate payment
10 ways to Improve Mood Naturally
1. Lighten up
2. Get plenty of sleep
3. Connect with someone
4. Eat wisely
5. Go for gratitude
6. Step it up!
7. Be kind
8. Turn off the TV
9. Address stress
10. Ask your doctor about supplements
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Medications
SSRI Starting Dose (mg/d)
Increments Effective Dose
Maximum Dose
Fluoxetine* 10 10-20 20 60
Setraline(zoloft)
25 12.5-25 50 200
Citalopram(Celexa)
10 10 20 60
Escitalopram(Lexapro)
5 5 10 20
Paroxetine(Paxil)
10 10 20 60
Fluvoxamine(Luvox)
25-50 25-50 150 300
Black Box Warning
In 2004, FDA reviewed reports of 23 clinical trials involving more than 4,400 children and adolescents who had been prescribed any of 9 antidepressants for treatment of major depression, anxiety or OCD.
No suicides occurred in any of these trials. But more who were receiving an antidepressant medication (4/100) spontaneously reported suicidal thoughts than those on placebo (2/100)
The medicine did not increase suicidality that had been present at the start of the study, and it did not induce new suicidality in those without prior suicidal ideation.
All studies showed a reduction in suicidality over the course of treatment
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Side Effects
Dry mouth
Constipation
Diarrhea
Sweating
Sleep disturbance
Sexual dysfunction
Irritability
“Disinhibition”
Agitation or jitteriness
Headache
Appetite changes
Rashes
More Serious Side Effects
Serotonin syndrome : fever, hyperthermia, restlessness,
Confusion
Akathisia
Hypomania
Discontinuation syndrome: dizziness, drowsiness,
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Preventing Adolescent Mental Health Problems
• Select your Parents Carefully!• Avoid Toxic Stress and ACE’s• Develop Pro Social Relationships• Avoid the technology trap• Pray!
Support Resilience!
• Lifestyle• Diet• Sleep• Social Connections
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Thank You
CC: Palpitations, Shakiness, Sweaty Palms and Hyperventilation. This occurs in anticipation of tests at college. Calls mother for emotional support.
No depression or Suicidality. Boyfriend in Army in Japan. Up late to Skype with him.
PE: Aesthenic appearing socially appropriate, H.R. 90 B.P. 124/70
Labs: WNL Including Thyroid
Assessment & Plan?
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CC: Wants to talk. Grades Falling. Bullied at school and on-line. Sad but no Suicidal. Gender identity female No ABUSE
SIGECAPS
Exam: Tearful Articulate
L Leg Hemimelia
Assessment and Plan?
L
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