Mental Illness and Suicidal Behaviour in Children and Youth

Dr Phil Ritchie, Psychologist

Children’s Hospital of Eastern Ontario

Mental Illness in Children and Youth

• Statistics suggest that by the time students graduate from high school, 1 in 5 will have met criteria for a diagnosable mental illness.

• Unfortunately, only 1 in 6 of these will have received appropriate treatment for this.

AdolescenceAdolescence

• The period of life when your child kicks you off the The period of life when your child kicks you off the pedestal they’d put you on only to step up onto it pedestal they’d put you on only to step up onto it themselves.themselves.

• That period that immediately follows your child’s first That period that immediately follows your child’s first sleeping through the night in which they decide to sleeping through the night in which they decide to stay up all night and sleep through the day.stay up all night and sleep through the day.

Adolescence – A Series of Crises (with Adolescence – A Series of Crises (with thanks to Dr. Tracy Vaillancourt)thanks to Dr. Tracy Vaillancourt)

– Identity – increasingly self-conscious, who do they Identity – increasingly self-conscious, who do they want to affiliate with, sexualitywant to affiliate with, sexuality

– Autonomy – move away from parental influence to Autonomy – move away from parental influence to that of peersthat of peers

– Intimacy – relationships no longer based on Intimacy – relationships no longer based on common activities, now focuses on meeting common activities, now focuses on meeting emotional needsemotional needs

A Series of Crises cont’dA Series of Crises cont’d

– Sexuality – biologically drivenSexuality – biologically driven– Risk-taking – stimulation-seekingRisk-taking – stimulation-seeking– Egocentrism – concerned with how others Egocentrism – concerned with how others

perceive themperceive them

The Adolescent BrainThe Adolescent Brain

• Brain develops to mid-20sBrain develops to mid-20s• At puberty, pruning processAt puberty, pruning process• Motor and sensory areas are quite sophisticated Motor and sensory areas are quite sophisticated

while decision-making (important for impulse-control while decision-making (important for impulse-control and emotional regulation) centres remain and emotional regulation) centres remain underdevelopedunderdeveloped

The Adolescent Brain cont’dThe Adolescent Brain cont’d

• In short, adolescents are physically capable of In short, adolescents are physically capable of complex feats, but psychologically ill-prepared to complex feats, but psychologically ill-prepared to make good decisionsmake good decisions

• One giant, tingly nerve looking to get stimulated but One giant, tingly nerve looking to get stimulated but little judgment about the dangers such stimulation little judgment about the dangers such stimulation might entailmight entail

The Adolescent Brain, cont’dThe Adolescent Brain, cont’d•

        

                                                                                                    

Anxiety Disorders in Youth Anxiety Disorders in Youth – A Pattern of False Alarms– A Pattern of False Alarms

• Anxiety is a good thing – anticipating future danger or Anxiety is a good thing – anticipating future danger or misfortune is helpfulmisfortune is helpful

• Keeps us from diving into unknown waters or walking Keeps us from diving into unknown waters or walking in a dangerous neighbourhood late at nightin a dangerous neighbourhood late at night

• When anxiety becomes extreme or irrational, it goes When anxiety becomes extreme or irrational, it goes from adaptive to maladaptivefrom adaptive to maladaptive

• Most common Mental Illness affecting 12% of Most common Mental Illness affecting 12% of population, half of which will develop as children or population, half of which will develop as children or youthyouth

Anxiety Disorders in Youth cont’dAnxiety Disorders in Youth cont’d

• Panic DisorderPanic Disorder• Specific PhobiaSpecific Phobia• Social Phobia (Social Anxiety Disorder)Social Phobia (Social Anxiety Disorder)• Obsessive Compulsive Disorder)Obsessive Compulsive Disorder)• PTSD (the only 1 that requires a “trigger” event)PTSD (the only 1 that requires a “trigger” event)• Generalized Anxiety DisorderGeneralized Anxiety Disorder• Separation Anxiety DisorderSeparation Anxiety Disorder• Anxiety Disorder NOSAnxiety Disorder NOS

Anxiety Disorders in Youth cont’dAnxiety Disorders in Youth cont’d

• In general, in order to meet criteria as an anxiety In general, in order to meet criteria as an anxiety disorder, the associated fear may be recognized as disorder, the associated fear may be recognized as excessive or unreasonable (though sometimes, excessive or unreasonable (though sometimes, particularly in children this may not be the case), is particularly in children this may not be the case), is not just a brief and passing phenomenon, and is not just a brief and passing phenomenon, and is interfering with regular development/normal interfering with regular development/normal functioning.functioning.

Treating Anxiety DisordersTreating Anxiety Disorders

• Cognitive Behaviour Therapy (CBT) is evidenced-Cognitive Behaviour Therapy (CBT) is evidenced-based non-medication treatment of choicebased non-medication treatment of choice

• Mood, thoughts, and actions inextricably linkedMood, thoughts, and actions inextricably linked• You are their teacher, not therapist, but helpful to You are their teacher, not therapist, but helpful to

understand principles (e.g., exposure/response understand principles (e.g., exposure/response prevention)prevention)

Classroom Accommodations for Classroom Accommodations for the Anxious Studentthe Anxious Student

• Check in with student on arrivalCheck in with student on arrival• Don’t penalize for being late (sx at home often Don’t penalize for being late (sx at home often

interfere with getting out the door)interfere with getting out the door)• Assist with peer interactionsAssist with peer interactions• Anticipate difficulty with transitionsAnticipate difficulty with transitions• Give notice re. changes in routineGive notice re. changes in routine

Classroom Accommodations cont’dClassroom Accommodations cont’d

• Extra time for tests and assignmentsExtra time for tests and assignments• Safe place Safe place • Use of nonverbal cues so as not to centre out the Use of nonverbal cues so as not to centre out the

studentstudent• Model appropriate coping behavioursModel appropriate coping behaviours

Interventions for the Interventions for the Anxious StudentAnxious Student

• WorryWorry– Answer the “what ifs” and take away anxiety Answer the “what ifs” and take away anxiety

associated with the unknownassociated with the unknown– Track improvements with feedback to the studentTrack improvements with feedback to the student– Have the student rate their fear and then track itHave the student rate their fear and then track it

Interventions for the Interventions for the Anxious Student cont’dAnxious Student cont’d

• Emotional OutburstsEmotional Outbursts– Identify triggers with the studentIdentify triggers with the student– Encourage them to problem-solve (e.g., CPS)Encourage them to problem-solve (e.g., CPS)– Develop a hierarchy of safe places in which to de-Develop a hierarchy of safe places in which to de-

escalate from a meltdownescalate from a meltdown

Mood Disorders in Youth

• Major Depressive Disorder• Dysthymic Disorder• Bipolar I and II Disorders• Cyclothymic Disorder

Mood Disorders cont’d

• Important to understand that mood disorders affect not just how the student feels, but also sleep, appetite, concentration, motivation, interests, and energy.

• This is a recipe for a decline in functioning at school (as well as home and social), likely to compound an already fragile self-esteem.

• Treat depression and other factors tend to improve.

Suicidal Behaviour in Children and Youth

• With thanks to Dr. Allison Kennedy

A Complicated World for Teens

• Amanda Todd’s video has almost 6 million views, almost 45 thousand likes, and almost 100 thousand comments

• There are a number of RIP Amanda Todd Facebook sites with 100 of thousands of likes

• Adolescents have unprecedented access to unfiltered information about suicide through social media and the Internet

Social Media – A Pox on All Our Houses?

• Preliminary studies suggest that internet use in a country was associate with an increase in suicides.

• Cyberbullying has been tied to increased suicide risks particularly in adolescents.

• Social media may help people form suicide pacts and unlike more traditional pacts, may involve complete strangers and bogus participants/eggers on.

• Internet provides a “how-to” guide for suicide.• Internet provides access to pro-suicide sites.

Social Media – A Pox on All Our Houses?

• But social media are also being used to prevent suicide.

• National Suicide Prevention Lifeline (US) developed a Facebook chat add-on for users to report at-risk individuals.

• Similar links being developed for Twitter, Tumblr, and Google (e.g., “I want to kill myself” results in top sponsored link being to prevention resources)

Canadian trends

• In Canada, suicide is 3rd leading cause of death for 10 to 14-year-olds and the 2nd leading cause for 15 to 19 year olds

• In Canada, suicide is the cause of death for 24% of 16 to 24-year-olds

• A large percentage of youth experience suicidal thoughts

• At CHEO, youth are increasingly presenting to the ED with suicidal risk

Reasons for suicidal behaviour in adolescence

• Changes in cognitive development– capacity for abstract and complex thinking– more capable of contemplating life circumstances, envisioning a hopeless future, suicide as a possible solution and planning and executing a suicide attempt

• Onset of substance use/abuse

• Increased rates of mental health problems

• Increased access to potentially lethal suicidal means

Risk: Clinical factors

• Psychiatric history

– Depression and conduct disorder

• Drug/alcohol use

• Previous suicide attempt

• Hopelessness

Risk: Personal and family history

• History of abuse

• Family history of suicide/exposure to suicide– Exposure reduces the suicidal taboo

• Issues with family communication and problem solving– Attachment issues, inability to approach parents for support

Risk: Life stressors

• Suicidal adolescents present with significantly increased levels of life stress

• Increased interpersonal conflict and social isolation

• Other stressors may serve as a trigger to vulnerable youth who are already at risk (e.g., loss, transition)

Risk: Emotional and cognitive factors

• Problem solving deficits– Difficulty generating alternative solutions to interpersonal conflict

• Poor emotional regulation

• Impulsivity

Sex differences

• Adolescent girls also are more likely than boys to attempt suicide --- although boys are more likely to complete it (3 males:1 female)

• Most studies relate the differences in completion rates to the method chosen– Girls --- overdose or cutting– Boys --- hanging or firearms

Other demographic risk factors

• Age

– Increased risk with increased age within the teen years

• Race

– Aboriginal youth at particularly high risk

• Sexual orientation

– Gay/transgendered youth at higher risk

Some Statistics …

• 15 to 20% seriously consider suicide

• 10 to 15% make a suicidal plan

• 6 to 9% attempt suicide

• 2 to 3% present for necessary medical treatment after a suicide attempt

… in a classroom

• 4 or 5 students will seriously consider suicide

• 3 students will have a suicidal plan

• 2 students will attempt suicide

• Students in an alternative setting are at higher risk for suicidal behaviour

How school staff can help

• Learn– … the signs of risk in students

• Identify– … at risk students

• Refer– … to appropriate resources

Warning signs in school

• Suicidal threats• Talking or writing about death, dying, suicide• Changes in appearance, mood, attendance,

academic functioning• Social isolation• Bullying

Talking to at-risk students

• Know your limits • Listen

– Acknowledge feelings, clarify, summarize, validate

• Know your resources• Act and ask: “have you thought about killing yourself;

have you already tried to hurt yourself?”• Follow up

School based prevention

• Be aware of signs and know how to respond• Foster a healthy school environment• Educate students on coping skills• De-stigmatize mental health issues by talking about it• Educate students regarding mental health resources

in the community

Non Suicidal Self Injury (NSSI)

• Intentional self-harm without conscious suicidal intent (e.g., cutting, scratching, burning, hitting)

• Relatively common, particularly for girls

• An attempt to cope that is often learned from other youth

• Primary goal of behaviour is affect regulation

• Youth who engage in NSSI are at elevated risk for suicidal behaviour

Assessment of nonsuicidal self-harm

• Examine onset, frequency, intensity, and duration

• Assess risk of injury

• Identify triggers

The role of parents/caregivers• Engage parents whenever possible

• Parents need to be aware of safety issues

• Parents need guidance regarding how to respond if their teen approaches them– Stay calm, listen, don’t judge, provide comfort and reassurance (e.g., “I know that you are in a lot of pain right now but I am with you and we will get you the help you need to feel better”)

– Parents can call crisis lines directly

• Even if the teen does not feel comfortable directly confiding in them, they can check in, monitor, and assist with distraction during an episode of acute distress

• In general, parents and professionals provide better support than peers

Follow-up – the elephant in the room?

• Having asked “the question” and referred to a school, community, or hospital-based resource, as appropriate, it is important to re-establish your relationship with the student.

• Make time to see the student the next available opportunity, let the student know how glad you are that s/he spoke with you, that you care about how they’re doing, but that you will leave it to the mental health professionals to deal with that part of things.

• And that if s/he wants to talk again, you’re always happy to listen, and that this doesn’t otherwise change anything about the relationship.

The Adult (i.e., Teacher) Brain (with thanks to Dr. The Adult (i.e., Teacher) Brain (with thanks to Dr. Matthew Sharps)Matthew Sharps)

• When communicating with anyone in crisis, important When communicating with anyone in crisis, important to understand how it affects not only their thinking, to understand how it affects not only their thinking, but also ours.but also ours.

• Big stress response (HPA Axis) results in blood being Big stress response (HPA Axis) results in blood being diverted from neocortex to lower areas (limbic and diverted from neocortex to lower areas (limbic and reptilian brains)reptilian brains)

The Adult Brain cont’d The Adult Brain cont’d

• Go into survival mode and the reptilian brain kicks in Go into survival mode and the reptilian brain kicks in • Alligators are brilliant survivors, “living fossils” that Alligators are brilliant survivors, “living fossils” that

have existed 200M yearshave existed 200M years• Alligators are not so good at conversation, Alligators are not so good at conversation,

investment advice, or problem-solving in the midst of investment advice, or problem-solving in the midst of crisiscrisis

The Adult Brain cont’d The Adult Brain cont’d

• In survival mode, we get “alligator stupid”In survival mode, we get “alligator stupid”• Reptilian brain is reliable but rigid and compulsiveReptilian brain is reliable but rigid and compulsive• ““Four Fs” – feeding, fleeing, freezing, and matingFour Fs” – feeding, fleeing, freezing, and mating

The Adult Brain cont’dThe Adult Brain cont’d

• Survival mode is a vestige of our hunter/gatherer Survival mode is a vestige of our hunter/gatherer brainbrain

• Tunnel vision can be helpful if pursuing a wild boar Tunnel vision can be helpful if pursuing a wild boar looking to turn it into dinnerlooking to turn it into dinner

• Not so helpful if staring at the hickey on our teenage Not so helpful if staring at the hickey on our teenage daughter’s neck or the crack in the new HDTV after daughter’s neck or the crack in the new HDTV after our son invited a “few friends” over c/o Facebook our son invited a “few friends” over c/o Facebook while we were out of townwhile we were out of town

The Adult Brain cont’d The Adult Brain cont’d

• Need our neo-cortex for more advanced problem-Need our neo-cortex for more advanced problem-solving (don’t try to fit head in peanut butter jar – get solving (don’t try to fit head in peanut butter jar – get a spoon)a spoon)

• Also need the neo-cortex to manage sub-cortical Also need the neo-cortex to manage sub-cortical parts of brain, and to separate affect from problem-parts of brain, and to separate affect from problem-solvingsolving

Alligator Stupid - There is No “Us and Them”Alligator Stupid - There is No “Us and Them”

• While negotiating with those in crisis, important to get While negotiating with those in crisis, important to get out/stay out of “alligator stupid” mode, and have the out/stay out of “alligator stupid” mode, and have the higher centres of the brain remain activehigher centres of the brain remain active

• Those with a past of early trauma, chronic stress, bad Those with a past of early trauma, chronic stress, bad night’s sleep, or 12 skinny pumpkin spice lattnight’s sleep, or 12 skinny pumpkin spice lattéés (they s (they were on sale) compound matterswere on sale) compound matters

Alligator Wrestling Alligator Wrestling

• When appropriate, taking a few slow, big breaths can When appropriate, taking a few slow, big breaths can helphelp

• Your paraverbals – calm, not too loud, not too fast, Your paraverbals – calm, not too loud, not too fast, but reassuringbut reassuring

• Become their surrogate neo-cortex – get them to Become their surrogate neo-cortex – get them to slow down, help them see that there are other slow down, help them see that there are other solutions solutions

Web-Based ResourcesWeb-Based Resources

• www.cheo.on.ca• www.ementalhealth.ca• http://www.kidsmentalhealth.ca/children_youth/learn_

more.php• http://www2.massgeneral.org/schoolpsychiatry/for_ed

ucators.asp