Juvenile Offenders with Mental Health Disorders: Who They Really Are

1. Juvenile Offenders with Mental Health Disorders: Who They Really Are Jeannie Von Stultz, Ph.D. Director of Mental Health Services Bexar County Juvenile Probation

2. DSM-IV • Diagnostic and Statistical Manual of Mental Disorders • Published by American Psychiatric Association • Diagnostic Categories are proposed and determined by work groups of mental health professionals (MD and PhD) • Revisions began 2007

3. Difficult to Diagnose Children • Ongoing development • “Normal” behavior varies – Influenced by culture and/or trends • Symptoms present differently in adolescents • Childhood diagnoses share many symptoms

4. Factors Influencing Diagnosis • Psychological testing – “Snap shot” • Psychiatric Evaluation – “Snap shot”” • Behaviors occur in specific circumstances • “No problems at home” • “No problems at school”

5. Factors Influencing Diagnosis • Symptoms not observed • Sleeping Habits • Eating Habits • Undiagnosed Medical Problems • Undiagnosed Learning Problems • Medication/Drug Side Effects

6. Factors Influencing Diagnosis • Limited assessment tools • Difficult to obtain information through fill in the blank or computer tests • For a diagnosis, many symptoms must be considered – lengthy assessment (DISC) • Shorter tests are only screening tools – often misses underlying emotional problems

7. Factors Influencing Diagnosis • Collateral information is invaluable • Professionals who observe child regularly • Professionals who witness particular symptom • Diagnoses change as clinician gains knowledge • List of rule-out possibilities

8. Prevalent Diagnostic Categories • Oppositional Defiant • Conduct Disorder • Major Depressive Disorder • Bipolar Disorder • Attention Deficit Hyperactivity Disorder

9. Oppositional Defiant Disorder and Conduct Disorder • Most obvious diagnoses • Disruptive Behavior Disorders • Symptoms focus on behavior not mood • Easy to identify • Children do not recognize mood • Not going to say “I feel depressed”

10. Oppositional Defiant Disorder and Conduct Disorder • Majority of disciplinary children qualify automatically • Statistics can be misleading • Allows for treatment even if not an emotional problem (mood disorder)

11. Oppositional Defiant Disorder • Often loses temper • Argues with adults • Actively defies rules • Deliberately annoys people • Blames others for their mistake • Easily annoyed • Often angry • Vindictive

12. Oppositional Defiant Disorder • Must have 4 or more symptoms • Lasting at least 6 months • Cannot be diagnosed if only occurring during mood disorder

13. Conduct Disorder • Aggression towards people/animals • Often bullies/threatens/intimidates • Often initiates fights • Has used a weapon that can cause harm • Physically cruel to people • Physically cruel to animals • Stolen while confronting victim • Forced someone into sexual activity

14. Conduct Disorder • Destruction of property • Deliberately setting fires intending damage • Deliberately destroying property • Deceitfulness or theft • Broken into someone else’s house/car/etc • Often lies to get things or avoid obligations • Stolen items without confrontation

15. Conduct Disorder • Serious violations of rules • Stays out all night despite parental limits beginning before 13 • Run away from home overnight at least 2xs • Truant from school beginning before 13 • Must have 3 or more symptoms • Within past 12 months

16. Conduct Disorder • Can have co-occurring mood disorder • Can be CD without much criminal behavior • Cannot qualify for Antisocial Personality Disorder until 18 • Not all Conduct Disorders grow up to be Antisocial • All Antisocial Personality Disorders must have had Conduct Disorder by 15

17. ODD and CD – Treatment Options • Not effective • Medication • Traditional psychotherapy • Effective • Quality parent training programs which emphasize consistency, empathy, limit-setting • Multisystemic therapy approaches that provide intensive family-focused treatment

18. Major Depressive Disorder • Pervasive depressed mood • Loss of interest • Weight loss/gain or decreased appetite • Sleep difficulties • Psychomotor agitation/retardation • Fatigue • Feelings of worthlessness/guilt • Poor concentration/indecisiveness • Recurrent thoughts of death/suicide

19. Major Depressive Disorder • In Children vs Adults • Mood may be irritable instead of depressed • Irritability may lead to aggressive behavior • May think others are overly critical instead of being self-critical • More likely to have anxiety symptoms • More likely to have physical complaints

20. Major Depressive Disorder • At least 5 symptoms • Must be present for at least 2 weeks • Typically lasts 6 months • Dysthymic Disorder • Lower grade depression – 2 symptoms • Longer duration – 1 year • Not caused by medical condition • Not induced by substance use • May initiate substance use

21. MDD – Treatment Options • Evaluation of treatment in infancy stage • Research on meds is limited in children • SSRIs supported effectiveness • Paxil, Prozac, Luvox, Zoloft • Several newer meds with limited research • Wellbutrin, Lexapro, Effexor, Celexa, Cymbalta

22. MDD – Treatment Options • Cognitive behavioral approach seems to be promising • Intensive • Social skills training • Assertiveness training • Relaxation training • Family therapy

23. Bipolar Disorder • Manic Episode • Elated Mood • Inflated self-esteem • Decreased need for sleep • More talkative or pressured talk • Flight of ideas • Distractibility • Increase in activity or physical agitation • Excessive involvement in pleasurable activities

24. Bipolar I Disorder • Must have history of manic episode • Manic episodes often precede or follow a major depressive episode • Several variations of the disorder depending on frequency and patterns of mood

25. Bipolar II Disorder • Lower intensity hypomanic episode • Similar symptoms as manic • Not as impairing • “Not so manic” episode • Major depressive episode

26. Bipolar Disorder • Children vs Adults • Elated mood • Exceptionally silly behavior or laughing • Irritability • Grandiosity • Believes rules/consequences do not apply to them • Smarter than others • Capable of doing things without risk of injury • Difficult to determine in children

27. Bipolar Disorder • Children vs Adults • Flight of ideas • Jumping from topic to topic • Cycles quickly • Irritable or elated • Depressed

28. Bipolar – Treatment Options • Research in infancy stage • Psychotropic medication in conjunction with cognitive therapy most promising • Mood Stabilizers • Abilify • Lithium • Depakote - anticonvulsant • Tegretol - anticonvulsant

29. Bipolar – Treatment Options • Atypical Antipsychotics • Respirdal • Clozaril • Zyprexa • Geodon • Seroquel

30. Attention Deficit Hyperactivity Disorder • Inattention • Fails to attend to details • Difficulty sustaining attention • Doesn’t seem to listen when spoken to • Doesn’t follow through with instructions • Difficulty organizing tasks

31. Attention Deficit Hyperactivity Disorder • Inattention • Avoids tasks that require sustained attention • Loses things necessary for tasks • Easily distracted by stimuli • Forgetful in daily activities

32. Attention Deficit Hyperactivity Disorder • Hyperactivity • Often fidgets/squirms • Often leaves seat • Runs around or feels restless • Difficulty playing quietly • Often “on the go”

33. Attention Deficit Hyperactivity Disorder • Hyperactivity • Talks excessively • Blurts out answers before question finished • Difficulty waiting turn • Often interrupts

34. Attention Deficit Hyperactivity Disorder • Must have 6 or more symptoms from at least one of the categories • Type will be based on predominant symptoms • Can have 6 or more from both categories • Must last longer than 6 months

35. Bipolar vs ADHD • Difficult to differentiate • Symptoms shared • Irritability • Hyperactivity • Distractibility

36. Bipolar vs ADHD • Symptoms more common in Bipolar • Elated mood • Grandiose behaviors • Flight of ideas • Decreased need for sleep • Hypersexuality

37. ADHD – Treatment Options • Psychotropic Medication • Strattera • Vyvanse • Daytrana • Adderall • Cylert • Concerta • Ritalin

38. ADHD – Treatment Options • Medication side effects • Sleep disturbance • Eating disturbance • Weight loss

39. ADHD – Treatment Options • Therapy • Parent training • Social skills training • Educational support

40. Irritability Aggressiveness Inattentiveness Fatigue Sleep disturbance Eating disturbance Blaming Others Distractibility Talkativeness Hyperactivity Unable to follow instructions Argumentative Impulsivity (criminal behavior) Shared Symptoms