Best-Practice Assessment and Treatment of SMI in Adolescents

1. Best-Practice Assessment and Treatment of SMI in Adolescents Michael G. McDonell, Ph.D. Acting Assistant Professor Department of Psychiatry University of Washington School of Medicine Foster Care Center for Health Harborview Medical Center mikemcd@u.washington.edu

3. SED Children Any Disorder + High Level of Impairment SMI Adults Schizophrenia Bipolar MDD Axis II? SED-SMI (Alphabet Soup)

4. Why talk about SMI in Adolescents? • Disorders often present in adolescence/early adulthood • They present unique challenges to the child mental health system and child/adolescent clinicians • Focus on psychotherapy rather than case management in the youth system • Little expertise in treating these disorders in child/adolescent clinicians • Current controversies make treatment challenging • Diagnostic uncertainty • Disagreement about diagnostic criteria for children • Little data on diagnostic stability (e.g. bipolar disorder) across time • Little awareness of available treatments

5. SMI Assessment and Diagnosis Occam’s Razor: its horses not zebras • Rare cases are usually explained by • Simplicity: simplest explanation • Most reasonable: most common/obvious explanation. • SMI disorders (bipolar & schizophrenia) are zebras • Other childhood disorders are horses • Assessment is a process of Ruling Out other disorders 1st

6. Prevalence of Adolescent Onset Schizophrenia • Adult onset Schizophrenia • Lifetime prevalence of 1% • Onset mid 20-30s • Females 5 year later onset (Loranger, 1984) • Adolescent Onset: Onset <18 yoa • Rare: < 15 yoa (14/100,000) • Very EOS (VEOS) < 12 years of age • Extremely rare: (1.6/100,000) • Mostly males

7. Adolescent Onset Schizophrenia Symptoms (McDonell & McClellan, 2007) • Symptoms • Positive symptoms (more common in older adolescents) • Hallucinations • Delusion: organized delusions less common • Thought disorder • Loose associations • Illogical thinking • Impaired discourse skills • Less common: incoherence and poverty of speech/thought • Negative symptoms • Impaired social functioning, typically a change from previous functioning • Decreased self-care, motivation

8. Onset/course • Onset: • Prodromal phase • Acute onset vs. Insidious onset • Course is typically episodic and chronic

9. Best practice assessment (McDonell & McClellan, 2007) • Multi-method/multi-informant assessment • Comprehensive medical exam • Record review • Medical, psychiatric, educational • Clinician administered structured interview • With youth and parent • Mental status exam/observation • Data from collaterals (including school) • TIME, TIME, TIME

11. Epidemiology of Early Onset Bipolar Disorder (EOBD) • Adult Prevalence • Lifetime prevalence of • Bipolar I = 0.4% to 1.6% • 0.5% Bipolar II (APA, 2000) • ~ 6 % when including sub-threshold or “spectrum” cases (Judd and Akiskal, 2003) • EOBD Estimates vary widely • .6-22% (Yongstrom, 2007) • Its appears to be a US phenomenon • Onset??? • 50% of adults report first symptoms <18 yoa (Kessler et al, 1997) • Depressive symptoms typically precede mania

12. Symptoms that may differentiate based on research (Yongstrom, 2007) • Elated mood: extreme, impairing, situation inappropriate, episodic • Grandiosity: episodic and associated with mood • High energy: MUST be episodic, not hyperactivity • Decreased need for sleep, not insomnia • Mood swings: intense, with longer periods, beyond what is developmentally appropriate • Hypersexuality: R/O abuse • LOW ability to differentiate: Irritable and distractibility • Assessment: very similar to assessment of EOS • Mood diaries also helpful • Monitoring over time is important

13. Temper Dysregulation Disorder with Dysphoria (NEW DSM-V Dx) A. Severe recurrent temper outbursts in response to common stressors. 1.  The temper outbursts are manifest verbally and/or behaviorally, such verbal rages, or physical aggression towards people or property.  2.  The reaction is grossly out of proportion to the situation. 3.  The responses are inconsistent with developmental level. B. Frequency: The temper outbursts occur, on average, three or more times per week. C. Mood between temper outbursts: 1.  Nearly every day, the mood between temper outbursts is persistently negative. 2.  The negative mood is observable by others (e.g., parents, teachers, peers). D. Duration: Criteria A-C have been present for at least 12 months. E. The behaviors are present in at least 2 settings and severe in at least in one setting.  F.  Chronological age is at least 6 years (or equivalent developmental level). G. The onset is before age 10 years. H. In the past year, there has never been a distinct period lasting more than one day during which abnormally elevated or expansive mood was present most of the day for most days I.  The behaviors are not due to other disorders.

14. Just thinking about evidence based treatments gives me a headache…

15. Treatment of SMI in adolescents • There are few empirically supported treatments for this population • Most treatment options are based on evidence based adult approaches

16. Evidence based/informed txs for SMI in adolescents • Psychiatric medications: 1st line treatment, but have serious side effects with less (or more recent) evidence of efficacy, relative to adult populations. 2. Multi-informant monitoring and case management 3. Specific psychosocial interventions • Family psychoeducation (Miklowitz, Fristad, others) • Other promising approaches • Dialectical behavior therapy (DBT) • Self-harm • Emotional dysregulation • Interpersonal and social rhythm therapy for bipolar disorder (Stephanie Hlastala, Ph.D, Seattle Children’s/UW)

17. Family psychoeducaton and support interventions • Best-practice for adult schizophrenia and bipolar disorders • Have been adapted and demonstrated efficacy for adolescents with mood disorders • Focus is on: • Education about the causes, triggers of relapse, and treatments • Patients and families bring their expertise to treatment and become “experts” in the treatment of SMI. • Modification of family response to the illness to improve communication (expressed emotion) and improve problem solving • Goal: to prevent relapse and achieve and maintain recovery • Duration: from 16 weeks to 2 years • Individual family (Miklowitz bipolar disorder) (Falloon schizophrenia) • Multiple family groups (Fristad bipolar disorder) (McFarlane schizophrenia)

18. Family focused therapy for adolescents with bipolar disorder (Miklowitz et al., 2008) • Adaptation of his adult model • 21 single family sessions over 9 months • Family psychoeducation (7-10 sessions) • Develop family understanding of bipolar disorder • Formulate a family relapse prevention plan • Remaining sessions focus on • Communication training • Problem solving skills training

19. Multiple family group treatment (MFGT) for schizophrenia (McFarlane, 2002) • Designed for adults, but applicable to adolescents with EOS • Delivered by 2 clinicians to 5-8 families over 2 years • 4 phases • Joining (3-4 sessions) • Psycho-educational workshop (1 day) • Relapse prevention (24 sessions) • Social and vocational recovery (12 sessions) • Relapse prevention is promoted through • Family guidelines (set of science based principles for relapse prevention) • Problem solving skills for preventing relapse

20. MFGT Family Guidelines • Go Slow • Keep It cool • Give each other Space • Keep It Simple • Lower Expectations Temporarily • Pick Up on early Warning Signs • Set Limits • Ignore What You Can’t Change • Follow Doctor’s Orders • No Street Drugs and Alcohol • Solve Problems Step by Step • Carry on Business as Usual

21. Typical MFGT problem solving session Structure • Initial Socializing 15 minutes • Go Around 30 minutes • Select a problem to work on 5 minutes • Solving a problem 35 minutes • Final Socializing 5 minutes

22. Why might DBT work for SMI adolescents? • In SMI populations • Suicide and attempted suicide risk is high • Emotional dysregulation is a primary symptom of bipolar disorder and also an issue in schizophrenia • Interpersonal skills are impacted by SMI • Developmentally adolescents are more likely than others to have • Higher rates of suicidality • More difficulties with emotion regulation & interpersonal difficulties • Engage in other problematic risk taking behaviors (e.g., drinking/drug use, unprotected sex)

23. Adolescent DBT goals and tx targets • Goals: • Reduce Suicidal and non-suicidal self-injurious behaviors • Improve emotional regulation and interpersonal skills • Improve quality of life • Targets: • Decreasing life-threatening behaviors • Suicidal behaviors • Non-suicidal life threatening behaviors • Decreasing therapy-interfering behaviors • Not completing homework/attending appointments on time • Decreasing quality of life-interfering behaviors • High risk impulsive behaviors • Increasing behavioral skills • Interpersonal skills • Distress tolerance skills

24. Child DBT model (Miller et al, 2007) • Orientation and assessment (2 sessions) • Pretreatment/orientation and commitment stage (varies in length) • 1st Phase (16 weeks) • Individual therapy (reducing self-harm, treatment interfering behaviors, supporting skills learned in group) • Multiple family skills group (adolescent & family) • Phone consultation (adolescent = ind. therapist, family = group therapist) • Family sessions (as needed) • Team meetings (weekly) • Graduate group (16 week modules) • Graduate group (adolescents) • As needed: Phone consultation, individual therapy, family sessions, other non-DBT treatments

25. Evidence for DBT in adolescents • No randomized trials have been completed investigating DBT efficacy in adolescents. • Inpatient/residential treatment studies • Reductions in self harm, re-hospitalization, behavior problems (Katz et al. 2004; McDonell et al., in press; Rathus & Miller, 2002; Trupin et al. 2004 ) • Outpatients • Bipolar youth (Goldstien et al. 2007) • 1 year of treatment • Improved suicidality, emotional regulation and depression in 10 pilot patients.

26. Now what should I do? • Perform an accurate assessment and monitor individuals over time • Treatment • Medication management • Effective case management/coordination of care • Multidisciplinary team • Adolescent and family are an active part of the team • Consult with experts in our area • Integrate evidence based psychosocial treatments into your practice • Some tx are easier to learn/adhere to than others • Get ready for transition to adulthood • Many young do not engage in the adult mental health system

27. Resources • Assessment • Mash, E.J. & Barkley, R.A. (2007) Assessment of childhood disorders, 4th Edition. Guilford Press: New York. • AACAP (2007). Practice parameters for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder. Journal of the American Academy of Child & Adolescent Psychiatry. 46(1):107-125. • Treatment • McFarlane, W. R. (Ed.). (2002). Multiple family groups in the treatment of severe psychiatric disorders. New York: Guilford Press. • Miklowitz, D. (2007). The Bipolar Teen: What You Can Do to Help Your Child and Your Family. Guilford Press: New York. • Miller A.L., Rathus J.H., & Linehan M.M. (2007). Dialectical behavior therapy with suicidal adolescents. Guilford Press: New York.