Crisis Intervention Team Training

Advanced Child and Adolescent CIT

Michael R. Peterson MA LAMFTExecutive Director

Steve M. Wickelgren MA MFT President

Minnesota CIT Officers AssociationJane Marie Sulzle, RN, CNS, MS

PrairieCare

Our youth now love luxury. They have bad manners, contempt for authority; they show disrespect for their elders and love chatter in the place of exercise; they no longer rise when elders enter the room; they contradict their parents, chatter before company, gobble up their food and tyrannize teachers.

--Socrates, Fifth Century BC

Training ObjectivesDefine the problemBuilding a TeamUnderstanding the differences between

Adult and Child/Adolescent Mental HealthAssessing stakeholders needs and

resourcesBuilding a PartnershipIdentify the target audience Develop a Training modelMarket training

Define the ProblemOfficers struggled to understandIncrease in kids diagnosed with mental

IllnessLack of knowledge about community

resourcesUnderstanding the difference ODD, ADD,

ADHD, Bipolar, or just a kidParent strugglesSchool/Community

What emotion do you see?

DIFFERENCES IN PERCEPTION

Adults see Surprise: In the adult brain,

reading emotions involves the prefrontal cortex.

Adolescents see Anger: In the adolescent brain, it involves the amygdala.

Building a TeamWho caresWho is impactedWho can helpWillingness to commit time and resourcesInterested in future solutionsUnderstanding of the problemEnthusiasm

Understanding the Differences Listen to the expertsResearch Care about kidsDevelopmental markersWhat is adolescentsWhen is a person an adultWhy

StakeholdersKidsParentsSchoolsPolice CourtsMental Health providersSubstance abuse treatmentCommunity advocates

UnderstandingParents

Parents do the best they can with what they have.

Building Partnerships

PrairieCareNAMI MinnesotaSchool StaffCounty Social ServicesMobile Crisis TeamsSchool Resource OfficersLocal Police and Sheriff Departments

Identify the Audience

Police OfficersSheriffs DeputiesSchool Security OfficersJuvenile CorrectionsMobile crisis workersMental Health Providers

Develop the Training

Build off current Minnesota Cit Officers Association CIT Memphis Model curriculum

Identify differencesIdentify the similaritiesIdentify resources availableDevelop child and adolescent role play

scenarios

Marketing

Post on WebsiteAttend conferences

MN SRO association MN Sheriffs association MN Police chiefs association Mental Health conferences

Email notices

Children's Mental Health and Crisis Intervention

Outline of presentation

Environment and biologyStatistics about mental healthDiagnoses and medications to treat them

Influences on Children

Biology

Static

Congenital

Environment

PositiveInfluences

FamilyChanges

School TraumaReversible

Medicine PsychiatryAcquired•Abuse

•Neglect

•Domestic Violence

•Natural Disaster

•Divorce

•Separation

•Death

•Frequent moves

•Good fit

•Not good fit

•Positive parenting

•Positive community support

•Faith community

•Diabetes

•High blood pressure

•Aids

•ADHD

•Bipolar

•Schizophrenia

•Depression

•Anxiety

•Head injury

•Stroke

•Down Syndrome

•Autism

•Learning Disabilities

•Fetal Alcohol Syndrome

Intellectual property of Josh Newman, MD, Wilder Foundation

Normal brain

OCD Brain Anxious Brain

Bipolar brain Depressed brain

Organic versus Behavioral

Prevalence of Mental Illness in Children and Adolescents

5% of children

10-15% of adolescents

1 of 5 have a mental illness, 2 of 5 get the care they need.

15-20% incidence of MI in adults

Secondary effects

Untreated School failure Family conflicts

Substance abuse

Violence Suicide May increase

risk of juvenile justice Have at least one

mental disorder 66 % boys 75% girls

www.mentalhealth.samhsa.govFast Facts about children and

mental health

Bipolar DisorderBipolar Disorder I,

II and NOSLittle agreement

about diagnostic criteria Does Bipolar Disorder

really exist in children?

What does it look like

Co-morbid with ADHD

Most challenging to treat

High co-morbid with drug use/abuse

What does bipolar disorder look like?

Between 20-25% of children who first present with MDD will eventually prove to have bipolar.

“ADHD on speed” Doesn’t need much sleep, goes from very

sad (irritable) to wild and crazy in a flash, grandiosity is seen as “I don’t have to, you’re not the boss of me.” “I don’t need directions”, scary risk takers, can rage for hours.

Very difficult to diagnosis/treat

Medication for Bipolar DisorderAtypical antipsychotics

Abilify, Seroquel, Risperdal, Zyprexa, Geodon Should follow lab work as starting, 3 months out and

annually Weight showed be followed closely May cause “dulling” EPS (Extrapyramidal side effects) movement

disorders that require immediate interventions

Atypical Antipsychotics

Abilify Middle range for

weight gain Helps with frontal

lobe functioning Akathisia

Seroquel Sedation, calming Weight gain Great to help with

sleep Zyprexa

Most significant for weight gain, but works well

Really helps with aggression

Atypical Antipsychotics (cont)Risperdal

Weight gain Breast enlargement,

lactation Dulling FDA approved for kids

in autism spectrum

Geodon Difficult to use Fewest side effects Not very effective

Medications for Bipolar Disorder (cont.)

Mood stabilizer Anti-seizure medications

Depakote, Trileptal, Lamictal Can cause dulling, weight gain, life-threatening rash,

pancreatitis, Depakote needs frequent lab draws

Lithium Frequent lab draws Very narrow window between helpful level and toxic Can cause thyroid to stop functioning

Need to Know Info (NKI)

Very erratic, unpredictable behavior

DefiantCan be difficult to

finesse Little ones can be

very aggressive, like a toddler response

Adolescents more grandiose

Psychosis Person (adult or child)

is experiencing hallucinations, delusions, distorted thinking. • Bipolar Disorder,

Mania• Schizophrenia• Depression• Paranoia • Drugs• Medications

Schizophrenia Rare in children

• Children under 12:1 in 40,000• Adolescents: 3 out of every 1,000

Hallmarks• Disheveled appearance• Odd expressions and behaviors• Little to no emotional expression• Hearing voices, seeing things, bizarre beliefs, odd

speech

What you might see Behavior seen

• Irrational• Paranoid

Someone is out to get them

Conspiracy • Delusional

Has special powers “God” Can see, hear, know

things others do not Physically strong

What to do• Be calm• Go slow• Do not use humor,

they don’t understand

• Avoid confrontation, they don’t understand

• Play with them to get them to cooperate.

What you might see (cont.) Behaviors (cont)

• Hyperactive/reactive• Agitated• Rapid, disorganized

speech• Poor self control• Very poor judgment• No insight

Arguing is useless Calm the

environment

Medications for Schizophrenia Atypical

antipsychotics• Risperdal, Zyprexa,

Geodon, Seroquel, Abilify, and Clozaril Weight gain, more in

kids Metabolic disorders High cholesterol Flat affect Sedation Extra pyramidal

symptoms, (EPS)

Other medications Typical

antipychotics• Haldol, Prolixin,

Thorazine, Trilafon, Melleril

• Dulling (slow thinking

• Flat affect• EPS/ temporary• Tardive Dyskinesia

Involunary movements that are permanent

NKI Very rare in children/adolescents More likely chemically induced or

secondary to other disorder (depression, bipolar disorder)

Very unpredictable Join in their delusions/hallucinations,

don’t challenge them. Very unpredictable

Psychotic disorder

http://www.youtube.com/watch?v=QPXkwYM9G-s&NR=1

Attention Deficit/Hyperactivity

Disorder

Impulsive

Does without thinking; stealing, blurting, buying

Inattentive; disorganized, can’t follow directions

Hyperactive; can’t sit or stand still, constant motion, will walk/run from parents

Combination of all three

ADHD

Often co-morbid with learning disabilities (trouble reading, writing)

Often co-morbid chemical dependency.

Very often with kids with Bipolar disorder

Impairs executive functioning; organization, movement, time understanding.

Medications

Stimulants: Concerta, Adderall, Vyvanse, Daytrana Patch, Metadate, Focalin, Dexedrine, Ritalin

Daytrana patch and Vyvanse with hx of chemical abuse.

Decrease appetite

Cause mania and depression.

Can cause trouble getting to sleep.

Only work the day they take them and not into the evening!

NKI Will run without thinking, little ones get

lost, older kids when they are in trouble

Will “mouth off” without thinking, often will have remorse later. Don’t react!

Can’t remember 2-3 step directions

Can’t stand still, move with them. Don’t make them be still, often they think better when moving.

If you are working with them in the evening MEDICATIONS HAVE WORN OFF

Seldom see just a child with ADHD, likely co-morbid with something else.

Depression1 in 33 kids, 1 in 8

adolescents Are more irritableDefiantBig sleep problemsCan’t do homeworkDoesn’t spend time with

friendsGives things away

DepressionDepression

Unusual in young childrenMore common in adolescents; more girls than

boys.Can be chronic (dysthymia)20% of children who present with depression

actually have Bipolar DisorderSymptoms:

Irritable in young children, sad in adolescents Withdrawn Low energy Suicidal ideation Self-harm Difficulty concentrating

Suicide in adolescenceEvery year, nearly 5,000 people between age

15 and 24 commit suicide.

Suicide is the 2nd leading cause of death in adolescents.

Suicide threats/attempts within schools can occur in “clusters”.

Acute Suicidal Ideation

Chronic Suicidal Ideation

What was the trigger?What have been other

symptomsLethality? Are they on medication

that could cause this?

Is how they cope with stress

Common in Borderline Personality Disorder

May have history of self-injuring behavior

Don’t belittle, they will escalate their lethality.

Frequent non-lethal attempts.

Medications Side effects

SSRI’s: Prozac, Celexa, Lexapro, Luvox, Paxil

SNRI’s: Cymbalta, Effexor

NDRI: Wellbutrin

Mania, weight gain, weight loss, sedation, activation, impotence, suicidal ideation

Mania, weight loss, dry mouth, dizzy, impotence

Activation, decreased energy, suicidal ideation

NKISlow to process, wait for them to answerSlow to moveThey will likely not look at you, not about

youBe empatheticMedications may be making worse, either

more suicidal or manic.

AUTISM SPECTRUM DISORDERS/PDD

1 in 150 kids Autism, Asberger’s Syndrome Symptoms:

Impairment in social interaction Nonverbals: eye contact, gestures, facial expressions Peer difficulties

Stereotypic interests Communication problems: use of speech and type of play

Nonverbals: eye contact, gestures, facial expressions Peer difficulties Talks language literally!!!!

Will power struggle with you

BEHAVIORS YOU MIGHT SEE Significant trouble with sensory issues:

light, sound, textures Easily overwhelmed and confused Has a special interest, find out what it is Can be manipulated with special

interest Transitions are very difficult Very persistent

MEDICATIONS Antidepressants

Prozac, Celexa, Zoloft, Luvox, Lexapro, Paxil Stimulants

Concerta, Ritalin, Adderall, Metadate, Focalin, Daytrana patch, Vyvanse

StratteraBlood pressure medications

Clonidine, Tenex Atypical antipsychotics

Risperdal and Abilify are both FDA approved, but also use Seroquel, Geodon, and Zyprexa

NKI DO NOT TOUCH DO NOT JOKE, remember they take language

literally. Quiet the environment

Decrease light and soundDecrease number of people

Find out their special interest No power struggles You can talk them down Distraction works well.

Has been exposed to a trauma that felt life threatening

Triggers are often unknown Reactive, fear based Fight or flight response Use “soothing” responses Move slowly, deliberately, NO

SURPRISES!!!!!

Post traumatic Stress Disorder

Did not have a healthy attachment as infant◦ Most often children who are adopted◦ Children separated from mother◦ Mother’s with significant depression

Behavior is very defiant Reacts in aggression Little social thought “Stuff” is very important to them, can be

bribed.

Reactive Attachment Disorder

ODD:5-15% of school aged children A 6 month pattern of negative, hostile and

defiant behavior, including:◦ Blames others◦ Argumentative◦ Defies adults◦ Annoys others and is easily annoyed

I seldom diagnosis, usually a reason for behavior.

Oppositional Defiant Disorder

6% of the population (4:1 M/F) Violates basic rights of others/ societal rules Aggression toward people and/or animals Destruction of property Theft or deceitfulness Likely has source, PTSD, RAD, et al

Conduct Disorder

Antipsychotics◦ Atypical antipsychotics◦ Typical antipsychotics

Medications to treat

Myths and Misperceptions

“All teenagers are moody/hormonal”

“She’s just trying to get attention”

”She’s just trying to get out of school”

“He’s just a bad kid.” “It’s all the parent’s fault.” “She just needs to get up and get outside.” It only happens to weak people/poor people. It will never happen to me or my family.

When negotiating choices…..

Negotiate = both sides get their needs met Find a way to honor some of the subject’s

needs. Allow choices when possible. (increases sense of control and safety)

Only offer two choices: be prepared s/he will make the “wrong” choice.

Be open to a modified version of the two choices.

“I can’t do that, but there in another option …”

Engaging the Family Understand that your presence may alter the child’s

behavior. Use parent interview to determine:

History/severity of problem History of mental health care/parent intervention

What has helped in the past Medical problems/medications Available supports/resources Parent’s ability to keep child safe

Assess parents’ contribution to the problem. Expect parent to follow child to ED and participate in

assessment. Treating parents as part of the solution; working

together will increase compliance.

Adolescent brains are a work in progress

Time   Day #1 Day #2 Day #3

    Date Date Date

0800 - 0830   Opening Introductions Mental Health/Behavioral Sites/Community Res discussion

0830 - 0900   Mental Health/Illness MN CIT and PrairieCare Mental Health/substance Abuse

0900 - 0930   Child/Adolescent Mental Illness Medications MN CIT and PrairieCare

0930 - 1000   MN CIT and Prairie Care PrairieCare___________ Bio, Psycho, Social Affect

1000 - 1030   continued Role Play Exercises MN CIT and PrairieCare

1030 - 1100   continued continued Legal Update

1100 - 1130   Consumer/Family Panel continued NAMI Sue Abderholden

1130 - 1200   continued continued Lunch

1200 - 1230   Lunch continued Cultural Awareness

1230 - 1300   De-escalation Skills Lunch Panel

1300 - 1330   MN CIT Site Visits and continued

1330 - 1400   Role Play Exercises Community Resources Role Play Exercises

1400 - 1430   continued One group PrairieCare continued

1430 - 1500   continued One group Fairview Riverside continued

1500 - 1530   continued continued continued

1530 - 1600   continued continued continued

1600 - 1630   Day 1 Debrief Travel home from Site Debrief and Wrap up

Day #1 Day #2 Day #3 Day #4 Day #5

Monday Tuesday Wednesday Thursday Friday

Introduction Introduction Introduction Introduction Introduction

Why CIT? Adult Mental Illness Suicide Prevention Mental Health Review Suicide by Cop

Introduction to Child and    

Role Play #3

Military/Family Reintegration

Adolescent Mental Illnesses Adult Mental Illness Excited DeliriumHotel Room / Disturbance

Connie Bengston VA

MN CIT   (Cont.)  

Consumer Panel Psychotropic Medications Community Resources(Cont.)

Juvenile Detention

     

(Cont.)

 

(Cont.)   NAMI Debrief Role PlayCommitment Process

Lunch Lunch Lunch Lunch  

Introduction to Child and De-escalation Skills II Drug/Alcohol Awareness Travel to Site VisitsLunch

Adolescent Mental Illnesses (Cont.) (Cont.)   Role Play #4

Experiential Exercise Role Play #1 Role Play #2   School Disturbance/ Break Up

"Hearing Voices" Storefront / Domestic Pedestrian / Overpass   (Cont.)

Introduction to Child and (Cont.) (Cont.)   (Cont.)

Adolescent Mental Illnesses (Cont.) (Cont.)   (Cont.)

De-escalation Practice (Cont.) (Cont.)   Debrief Workshop

Debrief Day 1 Debrief Day 2 Debrief Day 3 Travel home from Site Visits Meet the Actors/Graduation

Questions?