Introduction to Mental Illness Association of School Nurses February 6, 2014

1. Introduction to Mental IllnessAssociation of School NursesFebruary 6, 2014 Presented by: Kate Mattias, MPH, JD Executive Director, NAMI-CT

2. What Is NAMI? National Alliance on Mental Illness Connecticut State Member of NAMI National

3. NAMI’s Mission Support, education & advocacy,to improve the quality of life for people in recovery from mental illnesses, their family, friends, professionals and the public 

4. Audiences We Serve • People in recovery; people living with mental illness • Family members and friends of loved ones with mental illness adults & children • Policy makers and other community stakeholders

5. Trauma Informed Care Mental Health Treatment that incorporates: • An appreciation for the high prevalence of traumatic experiences in persons who receive mental health services • A thorough understanding of the profound neurological, biological, psychological and social effects of trauma and violence on the individual (Jennings, 2004)

6. Why Trauma-Informed Care Matters • The majority of adults and children in psychiatric treatment settings have histories of trauma; • A sizeable percentage of people with substance use disorders have traumatic stress symptoms that interfere with achieving or maintaining sobriety • A sizeable percentage of adults and children in the prison or juvenile justice system have trauma histories (Hodas, 2004, Cusacket al., Mueseret al., 1998, Lipschitzet al., 1999, NASMHPD, 1998)

7. Truth about Mental Illness Prevalence of Violence No different than that of the general population while in treatment and not abusing substances Substance abuse is a major risk factor Typically drug seeking behaviors More than 25% of persons with serious mental illness are victims of violent crime 12 times the rate of the general population Steadman et. al., MacArthur Violence Risk Assessment Study, August 2001 Teplin, et.al., Archives of General Psychiatry, August, 2005

8. About Mental Illness • A disease of the brain; • Impacts children and adults; • Biologically based, with genetic links and environmental factors; • Cannot be overcome through "will power“; • Not related to a person's "character" or intelligence; • Brain chemicals that regulate our moods, thoughts, and perceptions are affected; • Situations or environment can bring on stressors that can activate or worsen conditions

9. Some Good News With the right treatment, between 70 and 90% of individuals have significant reduction of symptoms; Early identification and treatment is important; the brain is protected from further harm related to the course of illness; Advances in medication and other interventions have greatly improved the chance of recovery for many individuals

10. Who is Most Vulnerable? Mental illnesses strike individuals in the prime of their lives: • adolescence and young adulthood; • often when someone is starting higher education or employment; • the young and the old are especially vulnerable. • typically a 10 year lag between symptoms and diagnosis

11. Cultural (and age-related) Barriers That Impact Care • Language • Stigma – familial, societal, educational • For children, lack of parental/caretaker knowledge of mental illness • Parental or family perceptions of mental illness and treatments – fear of labels, treatments • Limited data about utilization patterns among population groups • Idea that depression is a normal part of aging

12. How Do We Know It’s a Mental Illness?

13. Diagnosing Mental Illnesses • No blood test • No brain scan • No “typical” behaviors or signs • No universal medication(s) • Providers have to go on: • The behavior(s) being exhibited • The person’s mood(s) • The person’s thoughts • The length of time the person has experienced unusual thoughts or behaviors

14. Childhood or Early Onset Behavioral Health Disorders

15. Common Childhood Disorders Internalizing disorders > Depression > Bipolar > Anxiety Externalizing disorders > ADHD > Oppositional Defiant Disorder > Conduct Disorder Etiology: > Stress/Trauma related to onset and course > Genetics – for most childhood disorders > Family factors related to onset and course > Symptoms may be present since infancy or early childhood, or suddenly emerge in adolescence

16. Children & Youth with Mental Illnesses

17. Early Identification and Treatment Research supported by the National Institute of Mental Health (NIMH) has found that half of all lifetime cases of mental illness begin by age 14. Studies also reveal that untreated mental disordera can lead to a more severe, more difficult to treat illness, and to the development of co-occurring mental illnesses.

18. Signs: Younger Children • Fall in school performance or poor grades despite trying hard; • Worry or anxiety; refusal to go to school, refusal to sleep or take part in activities; • Persistent disobedience or aggression and opposition to authority figures; • Frequent, unexplainable temper tantrums; • Hyperactivity; fidgeting, constant movement; • Persistent nightmares.

19. Signs: Pre-teens & Adolescents • Fall in school performance; • Abuse of alcohol or drugs; • Inability to deal with problems and daily activities; • Changes in sleeping and/or eating habits; • Persistent nightmares; • Sexual acting out; • Depression shown by continuing, prolonged negative mood and attitude, often poor appetite, difficulty sleeping or thoughts of death (or suicide).

20. Depression in Children and Youth

21. Signs that Parents Might See • Nothing pleases the child • Child hates self and everything else • Disappearance of usual happy child • Child is no fun, hard to like • Child pretends to be happy in public, sad at home • Irritability

22. Depression in Children • Major Depression • About 21% w/significant symptoms don’t meet diagnostic criteria; • More severe & acute than other depressive illnesses; • Suicidality ideation and actions more common; • Usually chronic and relapsing; • More likely to be diagnosed. • Dysthymia • Longer-term, less severe; • Chronic; usually life long; • Less likely to be diagnosed early on. • Co-Morbidity • Social withdrawal; • Conduct problems; • Often other disorders – ADHD, anxiety disorders.

23. Depression in Children and Youth • Depression is feeling sad, lonely, unloved, dumb, and worthless, along with feelings of guilt and beliefs of being mistreated; • Clinical depression is a combination of these symptoms that persist for a period of time and cause difficulties in the child’s life at home, work, school or play; • A child with depression often feels hopeless and helpless, and may wish to die. Suicide is the 2ndleading cause of death in Connecticut among that kids ages 10-14.

24. Depression in Children • Extreme irritability, aggressiveness; • Unable to have fun, won’t join in activities; • Frequent complaints of headaches, stomachaches; somatic symptoms • Refusal to attend school; causes classroom disturbances; • Drop in grades; • Need to sleep a lot; • Often co-occurs with another disorder.

25. Depression in Adolescents • Feel sad, hopeless, empty, tearful, weepy; • Develop extreme sensitivity in relationships; • Feel restless, aggressive becoming antisocial; • Think they are different and no one understands; • Can become self-destructive; high risk of self-medication or other “risky” behavior; • Stop caring about appearance and hygiene; • Have increased anxiety; • Have thoughts of death or suicide attempts.

26. Treating Depression in Children Approaches similar to that of an adult • Antidepressants regulate specific brain neurotransmitters; Selective Serotonin Reuptake Inhibitors (SSRIs) and other anti-depressants – Wellbutrin and Cymbalta - work on norapenephrine and dopamine; • Antidepressants used mainly for moderate or severe depressive symptoms; must be monitored closely especially in the first few weeks when suicidality has been evidenced • No antidepressant more effective than any other, different types have differing results in people; different side effects.

27. Treating Depression in Children & Youth • Cognitive behavioral therapy can be very effective. • Children who are depressed often have an unhealthy, negative view of themselves; • With cognitive behavioral therapy, children learn to develop a healthier, more positive outlook — which can help relieve depression. • Antidepressant medication is another option for childhood depression treatment, especially when psychotherapy is unable to effectively treat mood symptoms. Untreated mood disorders in adolescents are associated with an increased risk of suicide.

28. Treating Depression in Children & Youth • Antidepressants may be particularly helpful for children who: • Have severe symptoms that don’t respond to therapy alone • Don't have convenient or timely access to therapy • Have chronic or recurring depression • Have a family history of depression with good response to medication • Don't have active substance abuse issues • Don't have bipolar depression or an active psychotic illness

29. Bipolar Disorder

30. Bipolar Disorder in Children • A brain disorder with distinct and extreme changes in mood and behavior • Sometimes called Manic Depressive Illness • Early intervention and treatment offer the best chance • No blood test or brain scan to establish diagnosis

31. Bipolar Disorder Among Children • Overall prevalence among children is comparable to that of adults; • Significant number of children report having a distinct period of abnormal, persistent, elevated, expansive or irritable mood, although they did not fulfill criteria for bipolar I or bipolar II(Lewinsohn and colleagues) • Survey results of the membership of the National Depressive and Manic-Depressive Association (DMDA), reported the onset of illness during childhood or adolescence in 59 percent of adult respondents(Lish and coworkers)

32. Bipolar Disorder Among Children • Evidence suggests that bipolar disorder beginning in childhood or early adolescence may be a different, possibly more severe form of the illness than older adolescent- and adult-onset bipolar disorder • Symptoms may be present since infancy or early childhood, or may suddenly emerge in adolescence or adulthood. It’s only recently that doctors are able to diagnosis the disorder in childhood.

33. Bipolar Disorder Among Children • If the illness begins before or soon after puberty, it is often characterized by a continuous, rapid-cycling, irritable, and mixed symptom state that may co-occur with disruptive behavior disorders, particularly attention deficit hyperactivity disorder (ADHD) or conduct disorder (CD), or may have features of these disorders as initial symptoms • Later adolescent- or adult-onset tends to begin suddenly, often with a classic manic episode, and has an episodic pattern with relatively stable periods between episodes • Later onset - less co-occurring ADHD or CD

34. Early Identification of Bipolar Disorder • In young children it can be difficult to identify episodes of mania or depression as these conditions often mimic other childhood disorders like ADHD; • Example: Both groups present with irritability, hyperactivity and distractibility; these symptoms are not useful for the diagnosis of mania because they also occur in ADHD • But, • elated mood • grandiose behaviors • flight of ideas • decreased need for sleep and increased interest and thoughts about sexual actions occur primarily in mania and are uncommon in ADHD

35. More on Early Onset Bipolar Disorder • Children and adolescents can have cycles of normal moods, mania, and depression • During a manic phase, behavior may be impulsive, with feelings of grandiosity, poor decision-making • Suicidal thoughts, feelings of worthlessness and hopelessness often are present during the depressive phase • As the person/child moves to the manic phase, the risk of suicide can be greater

36. Treating Childhood Bipolar Disorder • Adult medications often helpful in stabilizing mood; • Mood stabilizers – lithium; anti-convulsants - valproic acid, (Depakote); more recently - lamotrigine (Lamictal); • Antidepressants for bipolar depression - mood must be stabilized first; • Stimulants and antidepressants given without a mood stabilizer (often the result of misdiagnosis) can cause potentially induce mania, more frequent cycling, and increases in aggressive outbursts; • Cognitive behavioral therapy, interpersonal therapy, and multi-family support groups are an essential part of treatment for children and adolescents with bipolar disorder. • .

37. Treatment for Early Onset Bipolar Disorder • There is some evidence that using antidepressant medication to treat depression in a person who has bipolar disorder may induce manic symptoms if it is taken without a mood stabilizer. • Using stimulant medications to treat attention deficit hyperactivity disorder (ADHD) or ADHD-like symptoms in a child with bipolar disorder may worsen manic symptoms. • There is a greater likelihood among children and adolescents who have a family history of bipolar disorder that mania will occur. If mania worsens, parents should consider getting the child evaluated for bipolar disorder. Child and Adolescent Bipolar Disorder:[NL]An Update from the National Institute of Mental Health

38. Treating Childhood Bipolar Disorder • Atypical anti-psychotics – result in less frequent and less intense mood swings or episodes of mania – typically taken with mood stabilizers; risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), and Abilify (aripiprazole); • Psychotherapy - once a child’s mood has stabilized; therapy usually supportive in nature, helping with coping skills and education about the disorder; • A support group for the child or adolescent with the disorder can also be beneficial, although few exist – some internet blogs are appearing.

39. Attention Deficit/Hyperactivity Disorder

40. Attention Deficit/Hyperactivity Disorder Characterized by three dominant features or behaviors: Inattentiveness; not paying attention Impulsivity and in many but not all cases, restlessness or hyperactivity

41. Prevalence, Gender, Comorbidity of ADHD • 2-6% meet criteria; much more if teachers or parents asked whether hyperactivity is present • boys 2.5-5.6 times more likely to have • 30-50% or higher persists into adulthood • Comorbidity – • 35-60% oppositional defiant disorder • 15-25% later - antisocial personality disorder Most children and adults with ADHD are treated with stimulants

42. Attention Deficit/Hyperactivity Disorder Inattention • seen as disorganized, distracted, forgetful • teachers/parents descriptions • problems remain relatively stable Hyperactivity/impulsivity • fidgetiness, moving about, running, climbing more than others • play noisily, talk excessively, interrupt others, less able to wait in line or take turns • parents/teachers descriptions • problems arise before inattention • decline with age

43. Children with ADHD • Awkward relationships with kids their own age; they don’t “fit in” • Seem to never perform up to their ability • May seem “accident prone;” uncoordinated or clumsy • Respond poorly to discipline • Often interrupt conversations • Their feelings get hurt easily • Have a low or high tolerance for pain

44. Poor attention span Difficulty keeping attention while playing or doing other activities or tasks Inability to listen when spoken to directly Difficulty organizing, following through or finishing tasks Avoiding or not liking tasks that require long attention spans Losing things necessary to complete tasks or activities Being easily distracted by outside stimuli Forgetfulness Symptoms of ADHD can include:

45. More Symptoms of ADHD • Fidgeting; difficulty sitting or standing still • Restlessness or excessive activity • Feeling as if “driven by a motor” • Talking excessively • Blurting out answers before questions have been completed • Impatience – difficulty waiting • Interrupting others in activities or discussions

46. Treatment for ADD/ADHD • Treatment options for children and adolescents with ADD/ADHD include • medication, (sometimes stimulants; sometimes anti-convulsives to calm the child) • psychotherapy, • behavioral therapy, and • social skills training • Neurofeedback training - individual can learn to increase EEG activity in the brain to support increased attention and decreased impulsivity • There are times when the entire family of a child with ADHD can benefit from support groups, or parenting skills training

47. Anxiety Disorders

48. Anxiety Disorders Adults & Children Most common anxiety disorders • Panic Disorder • Obsessive-Compulsive Disorder • Post-Traumatic Stress Disorder • Phobias • Generalized Anxiety Disorder • Affect about 40 million adults; about 10% of adolescents; (NIMH) • Symptoms must last at least 6 months; • Studies suggest children and adolescents more likely to have an anxiety disorder if caregivers have anxiety disorders, not shown whether biology or environment plays the greater role; • High levels of anxiety or excessive shyness in children aged 6 to 8 may be indicators of a developing anxiety disorder.

49. Anxiety Disorders – Children and Adults • Each disorder has different symptoms all of which cluster around excessive, irrational fear and dread; • Co-occurrence with bipolar disorder more common in adults than kids; • In children disorders can lead to poor school attendance, low self-esteem, deficient interpersonal skills, alcohol abuse, and adjustment difficulty.

50. Treating Anxiety Disorders – Adults and Children Medication and Therapy • Antidepressants • Anti-anxiety drugs; benzodiazepines, have calming effect on brain, usually given for a short time - can be addictive - Klonopin, Ativan, Xanax (usually adults) • Specific forms of psychotherapy (behavioral therapy and cognitive-behavioral therapy), family therapy, or a combination of these; • Cognitive behavioral treatment person learns to deal with his or her fears by modifying the way he or she thinks and behaves by practicing new behaviors.