Future of Behavioral Health Care

David Mays, MD, PhDdvmays@wisc.edu

Childhood Wellbeing (UNICEF, 2007)

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Report Card: 2011• 75% of 18-19 year-olds are in such a poor state

that they are ineligible to even apply for military service. This is due to obesity (33%), no high school education (33%), or criminal records.

• Of the rest, 23% cannot pass the military’s basic exam for reading, math, and problem-solving.

Marriage

MoneyEducation

Falling Marriage Rates, Increased Poverty

1920 1930 1940 1950 1960 1970 1980 1990 2000 20100

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% Married Households

Marriage Money Education

• A 2011 Pew study found that while 64% of college-educated Americans were married, fewer than 48% of those who did not graduate from college were married.

• Married men and women tend to be much better off financially than unmarried people.

• Married men are more likely to work and not engage in dangerous behaviors.

Marriage Money Education

• Women in the top 10% of earnings saw their marriage rates increase between 1970 and 2011. Women in the bottom 65% in earnings saw their marriage rate decline by more than 20%.

• Women have children with unemployed men, but they do not marry them (or stay married to them.)

% Rate of Unmarried Mothers (Nat'l Center for Health Statistics)

1960 1970 1980 1990 2000 20090

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Most Unmarried Moms are Single Parents

• The majority of never-married mothers have close relationships with their child’s father at birth, but by the time the child is 5 years old, the dad is gone. There are usually then serial new relationships that are transient.

Children Without Fathers

• 33% live below poverty level. Studies show that half of low income children start kindergarten with dramatically lower vocabularies and are less ready to learn than peers.

• Problems with social relationships• At risk for various emotional problems,

aggression, and addiction

Education

• At present, a child born to married, college-educated parents has a very good chance of living a comfortable life. A child raised by a “lightly” educated single parent has very little chance of catching up to the middle class.

• If you have two college-educated parents, you’ll have a larger vocabulary, you’ll know more about the world, you will have a lot of adults in our life who are there to help you and encourage you to go to college.

Agenda

• Trauma and Adverse Childhood Events• Attachment• ADHD• Bipolar Disorder• Depression• Anxiety

Adverse Childhood Events

• These experiences include physical, sexual and emotional abuse; neglect; violence between parents of caregivers; alcohol and substance abuse; mental health issues for caregivers; incarceration of a household member; divorce; and peer and community violence.

Nadine Harris, MD

• TED talk, Adverse Childhood Events

• I would also like to acknowledge Elizabeth Hudson and Donna Rifkin for their materials and graciousness in teaching me about this area.

The ACE’s Study

• Started in 1995 by Kaiser and the CDC with 17,500 adults. Data collection is ongoing.

• The sample was 70% white, 70% college educated.

• 67% had at least one ACE. 12.6% had four or more.

Health Outcomes

• Even if there is no high risk behavior (drinking, smoking, etc.)

• COPD 2.5x risk

• Hepatitis 2.5x risk• Depression 4.5x risk• Suicidal behavior 12x risk

Wisconsin ACE Brief: Children’s Trust Fund and Children’s Hospital of Wisconsin

(2011-2012)

• 58% of adults reported having experienced at least 1 ACE in childhood

• 14% experienced at least 4 ACEs• Results– Emotional abuse – 29%– AODA in household – 27%– Separation/divorce of parents – 21%– Physical abuse – 17%– Violence between adults in household – 16%– Untreated mental illness in household – 16%

ACE’s are the single greatest public health threat facing our nation today.

Robert Block, MDFormer president of the Am. Acad. of

Pediatrics

Mental Illness in Youth

PBS Nova: Rampage Killers

Onset of Mental Illness (Gladstone 2011)

ADHD ODD CD Anxiety Depression AODA0

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OnsetDiagnosis

What Causes Pathology?

• Most mental illnesses have their beginnings in childhood. But adverse events in childhood do not regularly cause mental disorders. Most children are resilient.

• It seems reasonable to believe that the interaction of genetic vulnerability and environmental stress leads to mental illness.

Early Deprivation

• Effects of early deprivation– Cognitive delays– Motor delays– Language delays– Absence of crying– Failure to seek nurturance– Repetitive, stereotyped behaviors– Problems in school– Impulsivity, difficulty with peers– Genetic changes (shortened telomeres)

Early Abuse

• Physical abuse, and sexual abuse have immediate and long-term effects on child development. We see higher rates of psychiatric disorder, increased rates of substance abuse, and relationship difficulties.

• Children who are sexually abused are at significant risk for developing anxiety disorders (2x), major depression (3.4x), alcohol abuse (2.5x), drug abuse (3.8x) and antisocial behavior (4.3x).

Attachment• The effects of secure attachment include trust,

intimacy, self-esteem, impulse management, autonomy and resilience. Individuals with secure attachment feel comfortable with intimacy and desire to be close to others during times of threat. They perceive their adult partners as a source of support and love. They report a sense of contentment and meaning in life.

• The attachment circuitry remains plastic and we are able to form very strong attachments even late in life. Ask any grandparent how they feel about their grandchildren! We are never too old to fall in love.

PBS Nova: Rampage Killers

The Unattached

• Unattached individuals feel a deep sense of uncertainty, that others don’t give enough and are not reliable. They have difficulty with bonds and show greater dissatisfaction, cynicism, and distrust. They are more likely to suffer from eating disorders, maladaptive drinking, and substance abuse.

Comorbidities With Attachment Problems

• Oppositional Defiant Disorder• Conduct Disorder• Attention Deficit Hyperactivity Disorder• Bipolar Disorder• Major Depressive Disorder• Substance Abuse

Differential DiagnosisADHD Bipolar Unattached

Course may improve worsens Conduct disorder, antisocial

Attention impaired varies hypervigilant

Mood friendly irritable charming, phony

Conscience remorse limited devious

Peers makes friends but loses them

Mood dependent none

Anxiety uncommon “wired” appears invulnerable

The Biology

PBS: The Secret Life of the Brain

Briefly, Biology

• What the stress response is• Stress and its effects on genetics– Telomeres– Epigenetics

National Geographic: Stress – Portrait of a Killer

Telomeres

• In 1965 scientists reported that the older a person is, the fewer times his cells divide when cultured in a lab.

• In 1990, scientists found that each time a cell divides in culture, telomeres shorten a bit until they get so short that the cell is unable to divide and dies.

Telomeres

• In 2006, scientists at Harvard found that individuals with mood disorders have shorter telomeres than healthy controls.

• In 2011, researchers found that children who had been institutionalized had shorter telomeres.

National Geographic: Stress – Portrait of a Killer

The Epigenome

• Our genome is the instruction book for making a human body. But the genes themselves need instructions for what to do, and when and where to do it. These chemical markers and switches are located along the double helix and are known as the epigenome. They are the software code that induces the DNA hardware to manufacture a variety of proteins and cell types.

• Epigenetics provides the link between nature and nurture.

The Epigenome

• The epigenome is as critical as the actual DNA for the development of healthy organisms. During development, it determines which cells become heart, which bone, which the brain.

• In recent years, it has been discovered that the epigenome is very sensitive to its chemical environment, and vitamins, toxins, even affectionate mothering can effect the epigenome, and thereby change DNA production, sometimes reversibly, sometimes for life.

Gene (on/off

)

Toxin

Diet

People

PBS Nova: Rampage Killers

Results of Early, Chronic Stress

• The student may be over-sensitized to fear and alarm and may interpret neutral interactions as hostile.

• Once aroused, students may lack the capacity to self-comfort (a frontal lobe function.)

PBS: The Secret Life of the Brain

Results of Early, Chronic Stress

• Cortisol damage may impair short-term working memory.

• Self-comforting skills, in lieu of good frontal lobe function, may consist of lots of body movement (fidgeting), trying to restore familiar situations (arguing, being blamed), avoiding being challenged to learn something new (better to be bad than stupid.)

Brain Disorders

• It has taken us several thousand years to understand that schizophrenia, depression, and addiction are brain disorders, not character flaws. We need to understand the behaviors of children who have experienced multiple, chronic, adverse events as also suffering from a brain disorder.

How to Teach Children With This Kind of Brain Disorder

• This is not a problem of designing the right behavior modification program. It is more complicated than that.

• I recommend the following training:– Building Trauma Informed Skills in the School

Setting– Trainers: Donna Rifkin PhD, Renee Wilberg MSSW,

APSW, Cory Kitt MS, LPC– Community Care Resources: 608-827-7100

At the Very Least…

• Take care of yourself– Wear your professional hat– Self-calm– Don’t get pulled into repeating the same old

situations– Find support from colleagues

ADHD Incidence and Prevalence

• ADHD is the most common psychiatric disorder in childhood. The CDC recently reports that 11% of all school-aged children and 20% of high school boys are diagnosed with ADHD!!! 66% are on meds.

• It is inheritable with concordance in monozygotic twins of 51%, dizygotic 33%.

• Psychosocial factors do not appear to play an etiologic role, although they may contribute to oppositional and conduct disorders.

ADHD Incidence and Prevalence

• More frequently diagnosed in boys, but it is being recognized more in girls, who may have more of the inattention subtype.

• 50-60% will have another condition, such as learning disorder, restless-legs syndrome, depression, anxiety, conduct disorder, obsessive-compulsive behavior.

• It is not clear how much is carried over into adulthood. NCR estimates persistence into adolescence in 40-60%, into adulthood in 36%. Hyperactive symptoms may decrease with age because of increased self-control. Attention problems may continue. A recent review of 1,500 showed >50% lost their diagnosis 2 years later.

A Growing Problem

• Express Scripts, the biggest prescription manager in the US reports that the number of young American adults taking medication for ADHD doubled from 2008-2012.

• 1:10 adolescent boys take medication for this disorder.

• Many experts agree that the disorder is being diagnosed and treated with medication in children far beyond reasonable rates.

Overdiagnosed?(Diller, 2014)

• For the vast majority of children, the issue isn’t so much hyperactivity and impulsivity. The issue is that some children have a personality that makes it difficult to do things they are not interested in. This is being called ADHD in this country. In North Carolina, for example, 30% of parents have been told by someone that their son has ADHD.

Etiology

• There are multiple causes of ADHD. 65-75% of the variance is believed to be from genes with another 15% caused by maternal cigarette smoking, alcohol use, premature birth, maternal respiratory infections, maternal anxiety, and high maternal phenylalanine levels.

• Post-natal risk include head trauma, hypoxia, infection, lead poisoning, etc.

The FDA

• In 2011 the FDA convened to hear testimony on the evidence of the relationship between artificial food colors and ADHD. AFC’s require a warning label in the EU. The FDA ultimately decided (8-6 vote) not to recommend banning AFC’s or requiring a warning label. (If AFC’s weren’t already in foods in the US, they probably would not be allowed.)

• Various studies have shown that the introduction of AFC’s have negative effects on the behavior of children with and without ADHD.

Chemicals and ADHD

• A British study and meta-analysis by Columbia and Harvard suggests that removing artificial coloring agents from children with ADHD would likely be 1/3 to ½ as effective as stimulants, for some children.

• A follow-up study in 2010 suggests that children with a variation of a histamine gene represent the sensitive group. Histamine effects activity levels in animals and there is strong evidence that artificial colors can trigger histamine release. The gene in question weakens the child’s ability to clear histamine from the blood.

The Bottom Line

• Parents can try removing the major sources of artificial colors and additives – junk food, candy, brightly colored cereals, fruit drinks, soda – for a few weeks to see if their behavior improves. The difficulty is parents are not good evaluators. (When mothers think their children are getting high levels of sugar, they routinely rate them as “hyper.”)

• Studies concerning omega-3’s and micronutrients (zinc, iron, magnesium, etc) are inconclusive.

Neurology

• Identified are disruptions of circuits in the frontal lobe, pre-central motor cortex, and locus ceruleus.

• Brain structures mediating executive functions undergo continuous development into adulthood. There appears to be a 3 year lag time in brain development at age 16 in ADHD children.

Executive Functions and ADHD

• 1) Self-awareness: the ability to see yourself and monitor your actions. ADHD patients do not monitor their actions and are less aware of their failures. They also tend to have a “positive illusory bias.”

• 2) Non-verbal working memory: the ability to remember the past and predict the future. People with ADHD are terrible at time management and making predictions.

• 3) Verbal working memory: using internal language to reason with and guide yourself

Executive Functions and ADHD

• 4) Inhibition: inhibit initial reactions and responses to situations and things.

• 5) Emotional regulation: tools to regulate feelings when they occur. These children come across as very emotional, quick to anger, silliness, overly affectionate. People forgive the silliness, but not the hostility. 50-70% of ADHD children have no friends by the 3rd grade.

• 6) Self-motivation: People with ADHD are very dependent on immediate feedback, If there are no consequences, they fall apart. They can pay attention to video games, but can’t sit still to do homework.

Comorbidities with ADHD

ODD Lang Dis Anxiety Learn Mood CD PDD Tics0%

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35%

40%

ADHD and Substance Abuse

• The long-term Multimodal Treatment Study of ADHD (MTA) at 8 year follow-up shows that children with ADHD are at significant risk for substance abuse by adolescence. Marijuana and nicotine were especially problematic.

• Rates of abuse were neither increased or decreased related to treatment with medication.

Diagnosis

• The diagnosis is made using parent/child/teacher interviews and observations, behavior rating scales, physical and neurological examinations, cognitive testing. There is no laboratory test.

• Symptoms may be absent when the child is receiving frequent rewards for an activity, is under close supervision, is in a novel setting, is interested, is in a one-on-one situation.

Problems Diagnosing ADHD• Complicated diagnosis: inattention and impulsivity

are seen with bipolar disorder, depression, anxiety, oppositional defiant disorder, conduct disorder, learning disabilities

• Heavy pharmaceutical marketing• Those with diagnosis get special considerations• Primary care MD’s have difficult time with diagnosis -

requires time and testing• Diagnosis is unusually dependent on social and

educational circumstances

Treatment

• Stimulant medication is the mainstay treatment. These medications seem to be equally effective. Studies of efficacy beyond 2 years are rare. Core symptoms seem to benefit, but associated domains (social skills, achievement, family function) do not.

• Also required are psychoeducation, behavioral interventions, parent training, and school support (daily report cards, homework assistance, contingency management, etc.)

Why Do Stimulants Work?

• In healthy volunteers, methylphenidate reduces brain fatigue associated with effortful attention and suppresses the emergence of the default brain network (mind wandering, task-irrelevant thinking.)

• The effect is more than just “keeping you awake.”

• You do not have to have ADHD to benefit from a stimulant.

Side Effects of Stimulants

• Side effects of all the stimulants are the same: decreased appetite (25%), initial sleep difficulty, headaches, stomachaches, tics, and irritability.

• Cardiovascular effects include a slight increase in blood pressure and heart rate. Children should be screened for cardiac problems.

• Growth suppression, if at all, appears dose related during the first year of treatment (~ 2 cm).

• Preschoolers also show the side effects of listlessness and social withdrawal. Children <5 do not show benefit.

• The question of stimulants leading to substance use disorders remains unsettled. Controlling for conduct disorder is difficult.

Multimodal Treatment Study of Children With ADHD (MTA)

• MTA is a large (579 children) study that has been ongoing for 8 years. Initially, each child received 14 months of treatment: medication alone, psychosocial therapy alone, both together, or treatment as usual in the community.

• At 14 and 24 months, the best results occurred in children on medication alone or with psychosocial treatment.

• At 36 months, after the children had resumed care in the community, the advantage of being on medication had completely disappeared.

Multimodal Treatment Study of Children With ADHD (MTA)

• At 8 years, long-term outcomes show, that while treatment reduces ADHD symptoms, it does not enable children to function as well as their healthy classmates. They lag behind on 91% of the outcome variables.

• The best outcomes were for children with the mildest symptoms at outset and the most stable, well-off families. Type of treatment didn’t matter.

• The conclusion is that a flexible, individualized approach is best with periodic discontinuation of the medication to see if it is helping.

• Improvement in ADHD is difficult to sustain.

Non-FDA Approved Medicines for ADHD

• bupropion (Wellbutrin) – antidepressant• imipramine, nortriptyline – tricyclic

antidepressants• clonidine – similar to guanfacine, an alpha2 -

adrenergic agonist (now approved)• modafinil (Provigil) – works, but at higher

doses than used for fatigue

Nutritional Supplements

• Omega-3 fatty acids: limited evidence, little downside in a trial. Fish oil is inexpensive, 1000-2000 mg/day for 3-6 months for a trial.

• L-Carnitine: no evidence of efficacy• Zinc: no evidence of efficacy• Iron: only if there is iron deficiency• Megavitamins: no efficacy and possibility of

harm. A multivitamin might be useful if the child is not eating a balanced diet.

Behavioral Treatments

• Parent training• Educational interventions or classroom or

contingency management• Social skills training• Intensive summer programs

Resources for Parents

• Parent to Parent: help and education for parents with children with ADHD. 301-306-7070 ext. 133 or parent2parent@chadd.org

• Your Child in the Balance– Kevin Kalikow, New York: CDS Books, 2006.

Disruptive, Impulse Control, and Conduct Disorders

• Oppositional Defiant Disorder– Symptoms now in 3 types: angry/irritable, argumentative/defiant,

vindictiveness– May co-occur with conduct disorder– Severity scale

• Intermittent Explosive Disorder– Now must be older than 6, no longer requires physical aggression, may

also have ADHD, conduct disorder, ODD, ASD• Conduct Disorder

– childhood or adolescent onset specifier– Limited Prosocial specifier (Callous and Unemotional)

• Kleptomania• Pyromania

Lack of Research

• Despite the frequency of these disorders, they have been relatively understudied. Controlled trials are usually non-existent, and there are no FDA-approved medications for any of these conditions.

Oppositional Defiant Disorder

• A recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures– Losing one’s temper– Arguing with adults– Actively defying requests– Refusing to follow rules– Deliberately annoying other people– Blaming others for one’s own mistakes– Being resentful, irritable, spiteful, vindictive

ODD

• Not diagnosed unless it occurs for at least 6 months and is much more frequent than in children of the same age.

• Prevalence is 6-10%. More common in boys until puberty.• Lots of overlap with ADHD and Conduct Disorder. Some

see ODD as a precursor for CD.• As with CD, temperament (irritability, impulsivity, and

emotional intensity) contributes to a pattern of oppositional and defiant behaviors. Negative cycles result.

ODD

• Milder forms may remit. More serious forms evolve into CD.

• There is high comorbidity with ADHD, learning disorders, CD and internalizing disorders. A comprehensive evaluation is necessary,

• Treatment involves Parent Management Training, medication if appropriate, social skills training, academic support, individual counseling if needed.

Conduct Disorder

• One of the most difficult and intractable mental health problems in children.

• Present in 2-9%, mostly boys• 50% will also be diagnosed with ADHD. Co-occurs

with mood disorders, PTSD, and learning problems.• Behaviors:– Aggression toward people and animals– Destruction of property without aggression– Deceitfulness, lying, and theft– Serious violations of rules

Risks for Developing Conduct Disorder

• Individual– Perinatal toxicity– Difficult temperament– Poor social skills– Friends who engage in problem behavior– Innate predisposition for violence

• Family– Poverty– Overcrowding– Poor housing– Parental drug abuse– Domestic violence

Risks for Conduct Disorder

• Family (cont.)– Inadequate, coercive parenting– Child abuse– Insufficient supervision

• School– Disadvantaged school setting– Poor school performance beginning in elementary

school

Presentation

• Elementary school– Children lack social skills, do not recognize social cues,

cannot problem solve– Resort to aggression and intense anger rather than

verbal problem solving– Blame others for their actions (no self-awareness)

• Middle and high school– Noncompliance with commands– Emotional overreaction– Failure to take responsibility for their actions

Presentation

• Middle and high school (cont.)– Academic failure (poor cognitive development)– Peer group is other high risk children (other peers reject

them at a time when friendships are critically important)– Depression often occurs as child is alienated from family,

friends, school, other positive social groups– The deviant peer group provides training in criminal and

delinquent behavior including substance abuse– If arrested and incarcerated, usually the behavior will

worsen

Subtypes of CD

• Childhood onset– Presence of 1 criteria before age 10– Typically boys exhibiting high levels of aggression, may also be

diagnosed as ADHD. – Problems tend to persist to adulthood (APD)

• Adolescent onset– No criteria met before age 10– Less aggressive, more normal relationships– Most behaviors shown in conjunction with peers (e.g. gang members)– Less ADHD. Equal gender distribution.– Much better prognosis

• Limited Prosocial Specifier

Limited Prosocial Specifier

• Lack of remorse or guilt• Callous, lack of empathy• Unconcerned about performance• Shallow or deficient affect

Limited Prosocial

• These youth are less likely to show empathy to others in distress, although they are capable of cognitively recognizing distress in others (unlike some autism).

• They are less sensitive to punishment and tend to be thrill-seeking and uninhibited.

• These youth are more likely to show both “instrumental” and “reactive” aggression.

Reactive Aggression

• Reactive aggression is characterized by impulsive defensive responses to perceived provocation. Over-reaction to minor threats is also seen.

• Such children may selectively attend to negative social cues, fail to consider alternative explanations for behavior, fail to consider alternative responses, and fail to consider the consequences.

• Most reactive aggression is associated with anxiety and depression.

Treatment of Reactive Aggression

• These youth generally are poorly socialized and have difficulty with emotional modulation:– Deal with hostile-attributional biases and

hypervigilance to hostility– Promote self-control mechanisms– Work with managing intense anger– Treat depression and anxiety

Instrumental Aggression

• In instrumental, or predatory, aggression, violence is used as a means to an end. These youth often show emotional detachment rather than emotional dysregulation.

• They do not focus on the negative effects of their behavior on others and resistant to punishment.

• Instrumental aggression in pre-adolescence predicts delinquency, violence, disruptive behavior during mid-adolescence, and criminal behavior with psychopathy in adults.

• Instrumental aggression is very difficult to treat.

Pharmacological Approaches

• Conduct disorder and oppositional defiant disorder do not respond to medications alone.

• The most difficult to treat patients have long-standing anxiety or learning disabilities.

• In children with autism, developmental disabilities, or traumatic brain injury often respond to rapid dose changes by becoming aggressive.

• Start with adrenergic agents (guanfacine, clonidine) which are safe and work quickly. They may give the child a few extra seconds to get control by slowing agitation.

Treating Conduct Disorder

• Sometimes stimulants can help. If depression and anxiety are present, treat those.

• Individual psychotherapy as a treatment has not proven effective because young people with Conduct Disorder resist it.

• Group therapy may have some benefit for younger children. For adolescents, group treatment often worsens behavior.

• Of the 16 treatments likely to be effective for disruptive behavior in children and adolescents, the most effective interventions involve parents or caregivers.

Treatment of Limited Prosocial CD

• Conduct disordered youth with these traits respond less well to treatment. They are more likely to respond to reward-oriented interventions than punishment.

• It is not clear whether CU traits are the result of inherited temperament, or whether the CU results from lack of good quality attachment and bonding, but CU traits may decrease somewhat when the quality of parental care improves.

• In addition, sometimes a change in peers (a friend made at school vs. friends in the neighborhood) can make a difference.

Family-Based Treatment

• Helping the Noncompliant Child is most appropriate for children 3-8. Therapists coach parents in how to reward positive behaviors and give clear instructions. The goal is to improve interactions between parent and child.

Family-Based Treatment

• Parent Management Training has the strongest evidence base. PMT offers parents training on how to become more effective in giving positive, specific feedback, how to employ the use of natural and logical consequences, and how to use brief, nonaversive punishments when appropriate. It is most effective for 3-12 year olds.

Other Treatments

• Boot camp type treatments are usually ineffective and may worsen problems. Weaker youths may learn more criminal behaviors from older kids. Long-term data show high arrest records for youth who have been in boot camps.

Bipolar Disorder in Young People

Bipolar Disorder in Young People

• Bipolar disorder in children is enormously controversial! Depending on who you listen to, there is either an epidemic, or it is vastly over-diagnosed.

• The problem is that there is little agreement on: – the validity of symptoms such as elated mood and

grandiosity in children– the role of irritability – whether symptoms must be episodic

Classic Bipolar Symptoms in Children

• Mania– Hyperactivity– Irritability– Psychosis/grandiosity– Elated/expansive mood– Rapid speech/racing

thoughts– Sleep - doesn’t need it or

want it

• Depression– Personality change– Drop in grades– Morbid/suicidal– Pessimistic– Somatic

Bipolar Disorder or ADHD?

• Most children diagnosed with bipolar disorder also appear to meet ADHD criteria. Overlapping symptoms include distractibility, pressured speech, psychomotor agitation, racing thoughts, and increased goal-directed activity.

• However, it is unusual that a child with ADHD will meet strict bipolar criteria for mania.

Distinguishing Bipolar Disorder from ADHD

• Symptoms specific to mania and not ADHD in children:– Decreased need for sleep (not insomnia)– Hypersexuality– Flight of ideas, pressured speech, racing thoughts– Grandiosity and euphoria (is not amusing,

inappropriate)– Hallucinations, delusions– Suicidal and homicidal behavior

The “Narrow” Definition

• A young person meeting the classic criteria would be said to fit the “narrow phenotype.” They would be likely to be genetically related to another person with bipolar disorder. They will most likely continue to have bipolar disorder symptoms as an adult.

• There is little controversy about this group among clinicians.

The “Broad” Definition

• These are children who are described by parents as having “mood swings,” who have explosive outbursts of extreme intensity and duration. Parents have to “walk on eggshells.”

• They are not particularly at risk for developing becoming bipolar adults. They are more likely to have problems with depression and anxiety as adults.

• Their parents are less likely to have psychopathology than parents with bipolar children.

Disruptive Mood Dysregulation Disorder

• Severe recurrent temper outbursts 3+ times/week

• General mood is irritable and angry• Present for 12 or more months• Between 6 and 18, onset before 10• Not better explained by another disorder

(autism, PTSD)• Cannot be comorbid with ODD, intermittent

explosive disorder, or bipolar disorder

ADHD

Disruptive Behavior Disorders

BIPOLAR

More aggressive More continuous

More labile

DMDD

Long-Term Prognosis(Am J Psych April 2014)

• A prospective study of 1,400 youth followed children and adolescence into adulthood. Youth who met the criteria for DMDD had elevated rates of anxiety and depression and were more likely to meet criteria for more than one disorder relative to children without DMDD, even if they had a different psychiatric disorder. They were also more likely to have adverse health outcomes, be impoverished, have reported police contact, and have low educational attainment.

A bit more…

• The patterns of increased psychopathology and poor adaptive functioning seen in this study of DMDD reflect risks often seen in ADHD. Some preliminary research is pointing to EEG findings that distinguish ADHD children who have chronic irritability versus those who have ADHD alone. It is possible that it is the chronic irritability that leads to the worst ADHD outcomes, not the ADHD.

Bipolar mania

ADHD Dis. Mood Dysreg Disord

Disruptive Behavior Disorders

Episodic X

Euphoria, grandiosity, hypersexuality, delusions hallucinations

X

Mood lability X X

Insomnia X +/- +/-

Pressured Speech X X X

Intrusiveness X X X +/-

Irritability X X X Headstrong

Rage attacks X X X

And Trauma!

Differential Diagnosis of DMDD

• DMDD and bipolar: irritability in bipolar is episodic, and varies with euthymia, depression, and mania

• DMDD and intermittent explosive disorder: outbursts are 2x week for 3 months, DMDD are 3x week for 1 year

• DMDD and ODD: outbursts only 1x/week in ODD, over 6 months in ODD, no impairment required and must be severe in only 1 setting for ODD (impairment in 2 of 3 settings for DMDD)

Treatment

• The distinction between DMDD and bipolar disorder may be important. For bipolar disorder, the first-line treatment would be mood stabilizers (second generation antipsychotics.) For DMDD, which evolves to anxiety and depression in adulthood, the first-line treatment maybe stimulants and antidepressants.

• The only treatment trial for this group of children completed to date is a small negative trial of lithium.

Depression

Depression in Children

• Depression effects up to 2.5% of children and 8.3% of adolescents. (Lifetime prevalence in adults is 16%.)

• Among preschoolers, anhedonia is the most specific symptom of depression, accompanied by sadness, social withdrawal, guilt, fatigue, cognitive problems. Irritability may or may not be present.

• Children may also show depression by high levels of self-criticism and somatic complaints. “Nobody likes me.” “I’m no good at sports.” “My head aches.” “My stomach hurts.”

Treatment of Depression in Children

• Antidepressants should not be used as first or second-line treatment for preschool or younger school-aged children due to lack of efficacy and problems with side effects. Family therapy is the treatment of choice, with an emphasis on mood regulation.

• In older school-aged children, fluoxetine is the only approved antidepressant, although other antidepressants are often prescribed. (In children 12 or older, escitalopram is also FDA approved.)

Depression in Adolescents

• By adolescence, depression rates have started to climb and young people are more able to describe themselves as depressed, apathetic, or suicidal. The average age of onset is 15.

• Adolescent depression frequently is persistent and recurring.

• Suicidality first arises as a public health problem in adolescence. In 2009, 13.8% seriously considered suicide and 6.3% made a suicide attempt.

Depression in Youth

• Depression may also manifest itself as boredom, recklessness, obsessive-compulsive behavior, and behavior problems in young people.

• Substance abuse in boys and girls, and sexual behavior in girls is a cause for subsequent depression in adolescents. Depression can then make teens more vulnerable to more substance abuse and other risky behaviors.

Assessing Teens

• Teens do a lot of things to express their individuality, but they don’t usually quit their sports and hobbies. If the teen is hanging around in her room all day, this is a worrisome sign. The same is true with falling grades. Look for functional impairment and vague, somatic complaints, or comments from third parties.

• Some teens may be insulted if you ask them if they are depressed. Ask instead if they are irritable.

Helping Families

• Arguing, refusal to participate in family activities, being embarrassed to be seen with the family may all be normal separation. Parents need to be firm and reasonable about limits, and not take it all too personally. Teenagers need to know they are loved and the parents are there for them.

• By the time families come in for help, everyone is feeling helpless and angry. One of the best things the therapist can do is instill some confidence that things will get better, and appreciate how much work the family has been doing to try to make things better.

Dr Peter Parry, child psychiatrist, editorial board of The Carlat Child Psychiatry Report

• Reserve SSRI’s for youth with severe OCD, anxiety not responding to CBT, severe depression.

• Treat mild to moderate depression with:– Behavioral activation (exercise, sleep hygiene,

socialization)– Breathing relaxation exercises– Healthier diet– Omega-3 fatty acids– Reduced substance abuse– Addressing school, bullying, family issues

Other Psychosocial Interventions

• Effective interventions share some common features:– Help teens increase competence in at least one self-

identified area– Psychoeducation about depression and treatment– Teach self-monitoring skills– Address social, communication, problem solving

skills– Teach cognitive restructuring– Use behavioral activation techniques

Anxiety

The Need(Minahan 2015)

• 25% of children 13-18 have been diagnosed with anxiety at some point. Children with emotional behavior disorders drop out of school by 9th grade (48%), 58% have been arrested, and only 30% get a job after high school.

• The typical teacher with an MA in education has only one class in behavioral intervention.

Teachers Struggle With…

• Students with anxiety• Oppositional children• Withdrawn children• Children with sexualized behavior

Behavioral Modification: Rewards and Consequences

• One problem with using only this approach is that it does not teach skill building.

• For instance, anxious students may be unable, not unwilling, to complete work assignments. They need to be taught initiation and persistence skills.

• There are five skills that children with social emotional disabilities frequently lack:

Self-Regulation

• Children often don’t know how to self-calm. When we tell a child to “calm down”, we are asking them to use cognitive skills. But when children are very upset, they can lose the equivalent of 13-15 IQ points. They need to practice self-calming when they are calm.

• Techniques might include having a certain place or chair to go to, using cognitive distractions – word games, music, drawing

• Think of it as an anxiety first aid kit.

Social Skills

• Children who are aggressive often misread the emotions and intentions of others. Children from abusive, neglectful, and chaotic homes are usually under-socialized – they don’t know how to use verbal skills to assess the situation and get what they want or need.

• These children can be taught how to recognize their own feelings and the feelings of others, as well as how their behavior effects the way others respond to them (socialization.)

Positive Thinking

• Positive thinking is not “wishful thinking” or fantasy. It is grounded in the belief that people have control over many of the outcomes in their lives, that people can learn skills, that the brain can grow, that we can get smarter and better by practicing skills.

Flexible Thinking

• Everybody needs a plan B. Being able to switch strategies in the middle of a course of action is harder for some people than others. Children can work on skills of recognizing when one approach to a problem is not working and they need to try something else.

Executive Functions

• 1) Self-awareness• 2) Non-verbal working memory• 3) Verbal working memory• 4) Inhibition• 5) Emotional regulation• 6) Self-motivation

Pre-emptively Identify Hot Spots

• There are times that are most anxiety provoking for a child. Examples are:– Unstructured time (cafeteria, recess)– Transitions (waiting, stopping one activity)– Writing, especially open-ended writing

assignments– Social demands (partnering up with another child)– Unexpected changes