EMOTIONAL HEALTH IN CHILDREN WHAT WE KNOW ABOUT … · When do we see Depression? Depression more common with higher age but described even in infants. Bowlby‐depression in institutionalized

EMOTIONAL HEALTH IN CHILDRENWHAT WE KNOW ABOUT SUICIDE;

DEPRESSION; BIPOLAR DISORDER

Shiva Mansourkhani, M.D. Child and Adolescent Psychiatry

Department of Psychiatry Texas Tech University Health Science Center; Paul

Foster School of Medicine

Jan 2018

DEPRESSION

IN CHILDREN AND ADOLESCENTS

Depression

In 2015, an estimated 3 million adolescents aged 12 to 17 in the United States had at least one major depressive episode in the past year.

This number represented 12.5% of the U.S. population aged 12 to 17.

DEPRESSION

Prevalence• 2% in children• 4%‐8% in adolescentsLifetime prevalence by age of 18 is approximately 20%Male : female ratio• 1:1 during childhood• 1:3 during adolescence

DEPRESSION

More than 70% of children and adolescents with depressive disorders do not get diagnosed or treated

Percentage of High School Students Who Felt Sad or Hopeless,* 1999‐2015†

*Almost every day for 2 or more weeks in a row so that they stopped doing some usual activities during the 12 months before the survey†No change 1999‐2015 [Based on linear and quadratic trend analyses using logistic regression models controlling for sex, race/ethnicity, and grade (p < 0.05). Significant linear trends (if present) across all available years are described first followed by linear changes in each segment of significant quadratic trends (if present).]Note: This graph contains weighted results.

National Youth Risk Behavior Surveys, 1999‐2015

28.3 28.3 28.6 28.5 28.526.1

28.5 29.9 29.9

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20

40

60

80

100

1999 2001 2003 2005 2007 2009 2011 2013 2015

Percen

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Factors that can increase risk of childhood depression‐ Family history of depression‐ Children of parents that suffer from depression tend to develop their first episode of depression earlier thanChildren whose parents do not chaotic or conflicted families ‐Children and teens who abuse substances like alcohol and drugs, are also at greater risk of depression.

Depression in children

The symptoms of depression in children vary.

It is often undiagnosed and untreated because they are passed off as normal emotional and psychological changes that occur during growth.

Symptom variation based on age. Childhood Clinical PresentationLook for symptoms within appropriate developmental contextsChildren have fewer melancholic symptoms, fewer suicide attempts, andfewer delusional symptoms

IrritabilityLow frustration toleranceTemper tantrumsSomatic complaintsSocial withdrawal“Acting out”School refusalFailure to make expected weight gain

Symptom variation based on age. Adolescent Clinical PresentationAngerAcademic difficultiesBehavioral changesReckless or hostile behaviorSocial withdrawalGiving away valued possessionsFrequent school absencesCo‐morbidities50%‐90% of depressed kids have other psychiatric disorders50% have 2 or more other psychiatricDisorders

Depression DiagnosisOne or more major depressive episodes I the absence of mania or hypomania not due to medical

condition and not substance induced or another mental disorder

5 or more symptoms have been presented during the same 2‐week period and represent change from previous functioning where at least 1 of the symptoms is either 1) depressed mood OR 2) loss of interest/pleasure

• Depressed mood most of the day, nearly daily• Diminished interest• Significant weight loss/ gain• Insomnia/hypersomnia nearly daily• Psychomotor agitation/ retardation• Fatigue• Feelings of worthlessness• Difficulty concentrating• Thoughts of death

Most Frequent Comorbidities

• Anxiety• Oppositional behavior disorders• Attention deficit hyperactivity disorder (ADHD)• Substance use disorders

Differential Diagnosis

Medical disorders• Hypothyroidism• Mononucleosis• Anemia• Cancers• Autoimmune diseases• Premenstrual dysphoric disorder

Other Differential Diagnosis

• Bereavement • Depressive reactions to stressors• Substance/medication‐induced depression (Stimulants, Steroids,

Contraceptives)

Bipolar disorder• Significant family history• Psychotic symptoms• History of pharmacologically induced mania• Hypomanic symptoms

When do we see Depression?

Depression more common with higher age but described even in infants.

Bowlby ‐ depression in institutionalized infants had sleep disturbance, feeding, listless, withdrawn, protest, anxiety, despair, detachment.

Is depression in children & adolescents the same illness as in adults? Recent studies show it is continuous with the adult disease with high relapse rates for those with 1stepisode in childhood

Important to address early. Depression untreated affects social, emotional, cognitive and interpersonal skills.

Any episode 7‐9 months is a long time in adolescent’s life.

High risk for nicotine & substance dependence, early teen pregnancy, physical illness.

As adults, higher suicide rates, more medical & psychiatric hospitalization, more impairment in work, family and social life.

AACAP Recommendations for Depression

• Confidentiality between child and MH professional• Routinely screen children and adolescents for symptoms

of depression, if positive screen for comorbidities• ASSESMENT FOR SUICIDE, SELF‐HARM OR OTHERS HARM• Social evaluation

AACAP Recommendations for Depression

• Always treat depression for acute, continuous and maintenance phase

• Psychoeducation, supportive management, and family and school involvement

• Manage comorbidities• High Risk should have access to early services

interventions

Multimodal Treatment

• Therapy• Medications• Family therapy• School/learning interventions• Community

Psychotherapies with EmpiricalSupport

• Cognitive behavioral therapy (CBT) For children• Interpersonal therapy (IPT) For adolescents• CBT for adolescents

References:

U.S. Department of Health and Human Services, NIH publication: Teen Depression AACAP American Academy of Child and Adolescent Psychiatry

SUICIDE

Rather Than Ask “Which of My Patients Will Die By Suicide?”

Ask “ How Do I Decrease Suicide Potential For All My Patients?”

Suicide

Major public health concern.

Among the leading causes of death in the United States.

Four out of Five teens who attempt suicide have given clear warning signs.

Suicide

Suicide was the third leading cause of death among individuals between the ages of 10 and 14, and the second leading cause of death among individuals between the ages of 15 and 34.

Each day in our nation, there are an average of over 3,470 attempts by young people grades 9‐12. (2.4 each minute)

Suicide attempts often impulsive in nature

Scope of the Problem• Suicide affects many, many people– Suicide affects those at risk who do not die by suicide– Suicide affects survivors: loved ones and professionals

• Suicide prediction is poor (and likely will remain so)– Suicide is rare while risk factors are common• Suicide prevention remains inadequate– Suicide rates have increased over last 15 years‐ Weakness is present at every level ofidentification and care– But interventions are available to interveneto decrease rates

Scope of Suicide in 2014

• Number of individuals dying by suicide– 1,000,000+ individuals annually world‐wide– 42,773 individuals in USA– Comparison: 836,000 ER visits for self‐inflictedinjury– Comparison: 32,657 MVA deaths, 18,893painkiller overdose deaths, 14,294 murders

Thoughts about suicide and suicide attempts are often associated with depression. In addition to depression, other risk factors include:Gender‐ MaleFamily history of suicide attemptsExposure to violenceImpulsivityAggressive or disruptive behaviorAccess to firearmsBullyingFeelings of hopelessness or helplessnessAcute loss or rejection

Risk Factors

Elevated Risk Factors

Perfectionist PersonalitiesGLBTQLearning DisabledLonersLow Self‐ EsteemDepressed YouthStudents in TroubleAbused, Molested or NeglectedAbusers of Drugs and Alcohol

Mental & Medical Conditions That IncreaseSuicide Risk

Mental & Medical Conditions That IncreaseSuicide Risk

Dramatic Differences in Suicide Rates By Gender,Race, Age, Location, and Time• Gender– Males account for ≈ 78% of all suicides‐ M:F ratio in 2014: 3.5, M:F in 1999: 4.4• Race / ethnic background– White, American Indian / Alaska Nativemales: ≈ 27/100,000– White males account for ≈ 70% of all suicides

Non‐Modifiable Baseline Risk Factors for Suicide

• Male sex• Middle and older age• Race/ethnicity: Caucasian, Native American• Incarceration• Prior suicide attempts, especially in the last year• Family history of suicide• History of abuse / trauma• Local epidemics of suicide or suicide of family / friend

Modifiable Baseline Risk Factors• Presence of mental disorder(s)• Presence of alcohol and substance abuse• Feelings of hopelessness• Impulsive or aggressive tendencies• Cultural and religious beliefs (e.g., believe suicide is noble)• Isolation, a feeling of being cut off from other people

Modifiable Baseline Risk Factors

• Unmarried or living alone• Loss (relational, social, work, or financial)• Physical illness / chronic pain• Easy access to lethal methods, esp. firearm• Barriers to accessing mental health treatment• Unwillingness to seek help because of stigma

• And suicide management works!

– Decrease risk of dying by suicide for ALL your at‐risk patients!

Percentage of High School Students Who Seriously Considered Attempting Suicide,* 1991‐2015†

*During the 12 months before the survey†Decreased 1991‐2015, decreased 1991‐2009, increased 2009‐2015 [Based on linear and quadratic trend analyses using logistic regression models controlling for sex, race/ethnicity, and grade (p < 0.05). Significant linear trends (if present) across all available years are described first followed by linear changes in each segment of significant quadratic trends (if present).]Note: This graph contains weighted results.


29.024.1 24.1

20.5 19.3 19.0 16.9 16.914.5 13.8 15.8 17.0 17.7

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20

40

60

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100

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015

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Decrease Suicide Potential in AllDecrease Suicide Potential in All

How Suicide Management Works

• Assess ALL your at‐risk patients to identify factors affecting suicide risk– Then modify identified risk and protective factors to decrease psychopathology, distress, and suicide potential in all patients• Rate level of suicide risk (low, moderate,severe, imminent

How Suicide Management Works cont’d– Based on risk level, provide the appropriate level of care and supervision to maintain safety in least restrictive environment• Anticipate and divert from suicidal crises– Conduct crisis analysis in at‐risk patients to help them, their families/friends….of potential future crisis

SuicideSuicide is defined as death caused by self‐directed injurious behavior with intent to die as a result of the behavior.Suicide attempt is a non‐fatal, self‐directed, potentially injurious behavior with intent to die as a result of the behavior. A suicide attempt might not result in injury.Suicidal ideation refers to thinking about, considering, or planning suicide.Self‐directed violence: Behavior that is self‐directedand deliberately results in injury or thepotential for injury to oneself

Effective Interventions for Suicidal IdeationReduction

• Cognitive behavioral therapy (CBT)• Problem‐solving therapy (PST)• Psychodynamic interpersonal therapy (PIT)• Collaborative assessment and management of suicide (CAMS)• Attachment‐based family therapy: in adolescents• Promoting Access to Collaborative Treatment (PACT): in older adults in primary care settings• Prevention of Suicide in Primary Care Elderly

Effective Psychotherapies for Suicide AttemptReduction

• Cognitive therapy for suicide prevention (CT‐SP)• Cognitive behavioral therapy (CBT)• Dialectical behavioral therapy (DBT)• Metallization‐based therapy (MBT)• Problem‐solving therapy (PST)• Psychodynamic interpersonal therapy (PIT)• Multi‐systemic therapy (MST): in adolescents

How to help

Don't Forget ‐Youth Suicide Prevention is Everyone's Business

If you notice any of these warning signs, you can help!

By taking the time to notice and reach out to a peer, you can be the beginning

of a positive solution

FACTS about Suicide • Feeling: Expressing hopelessness about future• Actions: Displaying severe pain/ distress/ overwhelming

• Changes: In behavior, withdrawal from friends, anger, hostility, sleep changes

• Threats: Talking, writing, making plan for suicide, posting on social media

• Situations: Stressful situations loss, breakups, getting in trouble with law, at school, home, triggers for suicide

If you notice any of these warning signs, you can help!

1. Express your concern about what you are observing in their behavior 2. Ask directly about suicide 3. Encourage them to call the National Suicide Prevention Lifeline at 800‐273‐TALK (8255) 4. Involve an adult they trust

Remember, if you have IMMEDIATE concern about someone’s safety, call 911 right away!

Resolving Suicide

• Prediction is poor!– You will not be able predict which of your patients will die by suicide or when they will do so– Presence of a psychiatric disorder or any other risk factor is not enough to identify which at‐risk patients will die by suicide– No structured interview, assessment tool, or laboratory test, nor any combination, can predict which patient will die by suicide– Although we can rate the level of risk (low, moderate, severe, imminent) we cannot predict when a person will die by suicide

Why is Suicide Prevention Poor• Research remains inadequate• Suicide‐related surveillance data remains inadequate• Public health measures remain inadequate• Many suicide decedents had not sought treatment• Among suicide victims who saw primary care clinician, many had not disclosed suicidal symptoms or plan• Among suicide victims who received psychiatric treatment, treatment received was often inadequate• Clinician suicide training is perceived as inadequate

Percentage of High School Students Who Seriously Considered Attempting Suicide,* by Sex,† Grade, and Race/Ethnicity,† 2015

*During the 12 months before the survey†F > M; H > B (Based on t‐test analysis, p < 0.05.)All Hispanic students are included in the Hispanic category. All other races are non‐Hispanic.Note: This graph contains weighted results.

National Youth Risk Behavior Survey, 2015

17.712.2

23.418.2 18.3 17.7 16.3 14.5

18.8 17.2

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Total Male Female 9th 10th 11th 12th Black Hispanic White

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13.410.7

20.3 19.7

16.0 15.1

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Range and Median Percentage of High School Students Who Seriously Considered Attempting Suicide,* Across 36 States and 19 Cities, 2015

*During the 12 months before the survey

State and Local Youth Risk Behavior Surveys, 2015

No Data

13.4% - 15.2%

15.3% - 16.0%

16.1% - 17.6%

17.7% - 20.3%

Percentage of High School Students Who Seriously Considered Attempting Suicide*


State Youth Risk Behavior Surveys, 2015

Percentage of High School Students Who Made a Plan About How They Would Attempt Suicide,* by Sex,† Grade, and Race/Ethnicity, 2015

*During the 12 months before the survey†F > M (Based on t‐test analysis, p < 0.05.)All Hispanic students are included in the Hispanic category. All other races are non‐Hispanic.Note: This graph contains weighted results.


14.69.8

19.415.0 15.4 13.9 13.8 13.7 15.7 13.9

0

20

40

60

80

100


Percen

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Percentage of High School Students Who Made a Plan About How They Would Attempt Suicide,* 1991‐2015†

*During the 12 months before the survey†Decreased 1991‐2015, decreased 1991‐2009, increased 2009‐2015 [Based on linear and quadratic trend analyses using logistic regression models controlling for sex, race/ethnicity, and grade (p < 0.05). Significant linear trends (if present) across all available years are described first followed by linear changes in each segment of significant quadratic trends (if present).]Note: This graph contains weighted results.


18.6 19.0 17.7 15.7 14.5 14.8 16.513.0 11.3 10.9 12.8 13.6 14.6

0

20

40

60

80

100

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015

Percen

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11.08.7

18.2 19.3

14.3 13.8

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10

20

30

40

50

States Cities

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Range and Median Percentage of High School Students Who Made a Plan About How They Would Attempt Suicide,* Across 34 States and 16 Cities, 2015



No Data

11.0% - 12.6%

12.7% - 14.3%

14.4% - 15.4%

15.5% - 18.2%

Percentage of High School Students Who Made a Plan About How They Would Attempt Suicide*



Percentage of High School Students Who Attempted Suicide,* by Sex,† Grade,† and Race/Ethnicity,† 2015

*One or more times during the 12 months before the survey†F > M; 9th > 11th, 9th > 12th, 10th > 12th; H > W (Based on t‐test analysis, p < 0.05.)All Hispanic students are included in the Hispanic category. All other races are non‐Hispanic.Note: This graph contains weighted results.


8.65.5

11.6 9.9 9.4 8.0 6.28.9

11.36.8

0

20

40

60

80

100


Percen

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Percentage of High School Students Who Attempted Suicide,* 1991‐2015†

*One or more times during the 12 months before the survey†Decreased 1991‐2015 [Based on linear and quadratic trend analyses using logistic regression models controlling for sex, race/ethnicity, and grade (p < 0.05). Significant linear trends (if present) across all available years are described first followed by linear changes in each segment of significant quadratic trends (if present).]Note: This graph contains weighted results.


7.3 8.6 8.7 7.7 8.3 8.8 8.5 8.4 6.9 6.3 7.8 8.0 8.6

0

20

40

60

80

100

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015

Percen

t

5.9 6.4

12.7

20.7

9.6 9.9

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10

20

30

40

50

States Cities

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Range and Median Percentage of High School Students Who Attempted Suicide,* Across 35 States and 19 Cities, 2015

*One or more times during the 12 months before the survey


No Data

5.9% - 7.8%

7.9% - 9.5%

9.6% - 10.4%

10.5% - 12.7%

Percentage of High School Students Who Attempted Suicide*

*One or more times during the 12 months before the survey


Percentage of High School Students Who Attempted Suicide That Resulted in an Injury, Poisoning, or Overdose That Had to Be Treated by a Doctor or Nurse,* by Sex,†

Grade,† and Race/Ethnicity,† 2015

*During the 12 months before the survey†F > M; 9th > 12th, 10th > 12th; H > W (Based on t‐test analysis, p < 0.05.)All Hispanic students are included in the Hispanic category. All other races are non‐Hispanic.Note: This graph contains weighted results.


2.8 1.9 3.7 3.2 3.1 2.6 1.9 3.8 3.7 2.1

0

20

40

60

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100


Percen

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Percentage of High School Students Who Attempted Suicide That Resulted in an Injury, Poisoning, or Overdose That Had to Be Treated by a Doctor or Nurse,* 1991‐

2015†

*During the 12 months before the survey†No change 1991‐2015 [Based on linear and quadratic trend analyses using logistic regression models controlling for sex, race/ethnicity, and grade (p < 0.05). Significant linear trends (if present) across all available years are described first followed by linear changes in each segment of significant quadratic trends (if present).]Note: This graph contains weighted results.


1.7 2.7 2.8 2.6 2.6 2.6 2.9 2.3 2.0 1.9 2.4 2.7 2.8

0

20

40

60

80

100

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015

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1.9 1.9

9.3

7.4

3.2 3.5

0

5

10

15

20

States Cities

Perc

ent

Range and Median Percentage of High School Students Who Attempted Suicide That Resulted in an Injury, Poisoning, or Overdose That Had to Be Treated by a Doctor or

Nurse,* Across 33 States and 17 Cities, 2015



No Data

1.9% - 2.6%

2.7% - 3.1%

3.2% - 3.8%

3.9% - 9.3%

Percentage of High School Students Who Attempted Suicide That Resulted in an Injury, Poisoning, or Overdose That Had to Be Treated by a Doctor or

Nurse*



References:

U.S. Department of Health and Human Services, NIH publication: Suicide.

The Parent Resource Project, The Jason foundationSuicide Assessment and Management Course: Scope of the Problem of Suicide

Jack Krasuski, MD © 2016 MasterPsych.com 877‐225‐8384 11

BIPOLAR DISORDER

IN CHILDREN AND ADOLESENTS

Bipolar Disorder

Bipolar disorder (formerly called manic‐depressive illness) is an illness of the brain that causes extreme cycles in:a person’s mood, energy level, thinking, and behavior.

A person with bipolar disorder may have manic episodes, depressive episodes, or “mixed” episodes.

These mood episodes cause symptoms that last a week or two or sometimes longer.

During an episode, the symptoms last every day for most of the day.

BIPOLAR DISORDER

Epidemiology• Preschool validity has NOT been established• Childhood prevalence estimates 0.1% – 1%• Episodes of mania 0.1%• General population prevalence• Bipolar I disorder: 1.6 %• Bipolar II disorder: 0.5 %• Combined bipolar I and II: 2.6%• Genetics 4‐6 fold increased

Bipolar disorder

‐ Not the same as the normal ups and downs every kid goes through.

‐Symptoms are more powerful

‐Mood swings are more extreme accompanied by changes in sleep, energy level, and the ability to think clearly.

Manic Episode DSM‐V A distinct period of Abnormally and persistently elevated, expansive or

irritable mood And persistently increased goal directed activity or energy (added to DSM‐5)

• Presence ≥ 3 symptoms (4 if mood irritable)• Inflated self‐esteem or grandiosity• Decreased need for sleep• More talkative• Flight of ideas or subjective racing thoughts• Distractibility• Increase in goal‐directed activity• Activities with high potential for bad consequencesDuration: 1 week or hospitalization

Hypomanic Episode

• Symptoms of mania • Duration: at least 4 consecutive days• Change in function uncharacteristic when individual is

not symptomatic• Change is observable by others• No marked impairment or need for hospitalization

Bipolar symptoms are so strong, they can make it hard for a child to do well in school or get along with friends and family members.

Illness can also be dangerous. Some young people with bipolar disorder try to hurt themselves or attempt suicide.

Who develops bipolar disorder?

Anyone can develop bipolar disorder, including children and teens.

However, most people with bipolar disorder develop it in their late teen or early adult years.

The illness usually lasts a lifetime.

Bipolar In Young Children

• The diagnostic validity of bipolar disorder in young children has yet to be established.

• Caution must be taken before applying this diagnosis in preschool children

What are the symptoms of bipolar disorder?

‐unusual mood changes along with unusual sleep habits, activity levels, thoughts, or behavior.

‐In a child, these mood and activity changes must be very different from their usual behavior and from the behavior of other children.

Manic episode‐ unusual mood changes. ‐ very happy or “up,” and are much more energetic and active than usual, or than other kids their age.

Depressive episode‐ feel very sad and “down,” and are much less active than usual.

Mixed episode has both manic and depressive symptoms.

Children and teens having a manic episode may:

‐Feel very happy or act silly in a way that’s unusual for them and for other people their age ‐ Have a very short temper ‐ Talk really fast about a lot of different things ‐ Have trouble sleeping but not feel tired ‐ Have trouble staying focused ‐ Talk and think about sex more often ‐ Do risky things

Children and teens having a depressive episode may:

‐ Feel very sad ‐ Complain about pain a lot, such as stomachaches and headaches ‐ Sleep too little or too much ‐ Feel guilty and worthless ‐ Eat too little or too much ‐ Have little energy and no interest in fun activities ‐ Think about death or suicide

AACAP Recommendations for Bipolar

• Screen children with mood symptoms fro bipolar• Youths with suspected bipolar disorder must also be

carefully evaluated for other associated problems, including suicidality, comorbid disorders (including substance abuse), psychosocial stressors, and medical problems

Bipolar Treatment

• For mania in well‐defined bipolar I disorder, pharmacotherapy is the primary treatment.

• Most youths with bipolar I disorder will require ongoing medication therapy to prevent relapse

Children and teens with bipolar disorder should get treatment.

With help, they can manage their symptoms and lead successful lives

Psychotherapeutic Interventions

• Psychotherapeutic interventions are an important component of a comprehensive treatment plan for early‐onset bipolar disorder

• 1. Psychoeducational therapy• 2. Relapse prevention• 3. Individual psychotherapy• 4. Social and family functioning• 5. Academic and occupational functioning• 6. Community consultation

References:

U.S. Department of Health and Human Services, NIH publication: Bipolar Disorder in Children and Teens 2015

AACAP American Academy of Child and Adolescent Psychiatry

Documents

EMOTIONAL HEALTH IN CHILDREN WHAT WE KNOW ABOUT … · When do we see Depression? Depression more common with higher age but described even in infants. Bowlby‐depression in institutionalized