Introduction to Mental Illness Association of School Nurses
February 6, 2014 Presented by: Kate Mattias, MPH, JD Executive
Director, NAMI-CT
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2 What Is NAMI? National Alliance on Mental Illness Connecticut
State Member of NAMI National
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3 NAMIs Mission Support, education & advocacy, to improve
the quality of life for people in recovery from mental illnesses,
their family, friends, professionals and the public
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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
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5 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) Trauma
Informed Care
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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, Cusack et al., Mueser et al., 1998,
Lipschitz et al., 1999, NASMHPD, 1998)
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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
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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
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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
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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
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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
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How Do We Know Its a Mental Illness? 12
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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 persons mood(s)
The persons thoughts The length of time the person has experienced
unusual thoughts or behaviors 13
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14 Childhood or Early Onset Behavioral Health Disorders
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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
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Children & Youth with Mental Illnesses
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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. 17
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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. 18
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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).
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Depression in Children and Youth
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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 21
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22 Depression in Children Major Depression About 21%
w/significant symptoms dont 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.
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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 childs life at home, work, school or
play; A child with depression often feels hopeless and helpless,
and may wish to die. Suicide is the 2 nd leading cause of death in
Connecticut among that kids ages 10-14. 23
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Depression in Children Extreme irritability, aggressiveness;
Unable to have fun, wont 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. 24
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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. 25
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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.
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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.
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Treating Depression in Children & Youth Antidepressants may
be particularly helpful for children who: Have severe symptoms that
dont 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
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Bipolar Disorder
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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
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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)
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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. Its only recently that doctors are able
to diagnosis the disorder in childhood.
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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
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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
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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
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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. ..
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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 HealtChild and Adolescent Bipolar Disorder:[NL]An Update
from the National Institute of Mental Health
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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 childs 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.
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Attention Deficit/Hyperactivity Disorder
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Characterized by three dominant features or behaviors:
Inattentiveness; not paying attention Impulsivity and in many but
not all cases, restlessness or hyperactivity
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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
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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
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Children with ADHD Awkward relationships with kids their own
age; they dont 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
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Symptoms of ADHD can include: 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
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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
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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
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47 Anxiety Disorders
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48 Anxiety Disorders Adults & Children 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.
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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.
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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.
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51 Issues Associated with Mental Illness in Children and
Adolescents
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52 Physical Health & Mental Illness Current NIMH data:
adults with SMI die, on average, 25 years earlier than their
counterparts w/o mental illness* Key Health Challenges: Lack of
health insurance; Suicide; Smoking (41% of population with SMI vs
22% in general pop.)** Obesity; Undiagnosed/under treated die
younger; Heart disease (44%)*; (some medications increase
cholesterol) Stroke (68%);* High blood pressure; Cancer; Diabetes
(280%) * Journal of American Medical Association **Harvard School
of Public Health
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53 Co-occurring Substance Abuse Often self-medication Alcohol,
marijuana, cocaine, ecstasy, ketamine (tranquilizer most commonly
used on animals; has become popular among teens and young adults)
Alcohol and drug abuse inhibit the ability of neurotransmitters to
work effectively Provide temporary relief Can make many symptoms
worse; Can negate effectiveness of prescribed medications; Can be
dangerous when combined with certain drugs Tobacco impacts dopamine
in the brain and is also considered a drug of abuse
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54 Stigma: What People Experience Erodes confidence that mental
disorders are real, treatable health conditions; Promotes thinking
that theres something wrong with the person and stops people from
getting treatment; erects attitudinal, structural and financial
barriers to effective treatment and recovery; people dont want to
disclose their illness Perpetuates damaging myths that further
isolate persons with mental illness from social networks and the
workforce.
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55 Whats Possible? HOPE and RECOVERY Increasing research on
childrens mental illness; Early identification and early
intervention preliminary research show positive outcomes ;
Increasing awareness among childrens providers pediatricians, other
clinicians, school personnel - about early onset mental
illness
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56 Connecticuts Network of Care www.ctnetworkofcare.org
