Transcript Conflict Resolution and Resiliency Promotion Umesh Jain MD

Children’s Mental Health
Pathology:
Why We Need to Know
Welcome
Umesh Jain
MD, DABPN, FRCP(C), PhD, MEd
Associate Professor of Psychiatry
University of Toronto
Disclosure
• Pharmaceutical Industry Sponsorships for
Research, Ad Boards and Talks
– Eli Lilly Inc.
– GSK
– Janseen-Ortho Inc.
– Purdue Pharma
– Shire Biochem
Objectives
• Review the prevalence literature
associated with childhood mental health
• Disturbing trends
• Three models of mental impairment:
simple but relevant
How big is the problem?
• Lifetime prevalence Adolescents (median
age of onset)
– 31% anxiety disorder
( 6)
– 19.1 % disruptive behavior disorders
(11)
– 14.3% mood disorders
(13)
– 11.1 substance use disorders
(15)
– 40% of affected individuals had more than
one condition (OCHS suggests 68%)
Merikangas, et al. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: results from the
National Co-morbidity Survey Replication. Journal of the American Academy of Child and Adolescent
Psychiatry, 49(10), 980-989.
How big is the problem?
Prevalence rates for Mental Disorders
in 6-16 year olds, BC
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Anxiety Disorder
ADHD
Conduct Disorder
Substance Use Disorder
Any Depressive Disorder
OCD
Autism
Schizophrenia
Eating Disorders
6-8%
2-10%
2-6%
0.1-6%
1-4%
0.2%
0.2%
0.1%
0.1%
Waddell et al., (2002). Child and Youth Mental Health: Population Health and Service Considerations.
University of British Columbia Press, Vancouver, BC
Implication
• Why are children so anxious at such an early
age?
• What role does the school play in identifying
Disruptive Behavior Disorders?
• Are Mood Disorders related to onset of puberty?
• Is Substance Abuse inherently an extension of
adolescence?
• If there are developmental links to these
disorders, why aren’t there pre-emptive strikes
before they happen?
Trends that are alarming
• Increased use of cannabis (the new
gateway drug) in the 13+ population
– Nicotine is still a problem but there has been
some inroad (smoking in public area bans,
better warnings, peer pressures, access)
– Energy drinks have proliferated- high
adrenaline states
– B.C. data
Trends that are alarming
• Proliferation of gaming both in hrs/day and
exposure to content
– On line gambling
– On line gaming
– Increase in aggressive and sexual content
– Social media as an alternative social
connection
Winters, Stinchfield, Wilerson. (2010). Patterns and characteristics of adolescent gambling. J
Gambling Studies. 9(4), 371-386.
Trends that are alarming
• Weight and related disorders
– Obesity in children
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Directly tied to physical health
Evidence of poor nutrition and poverty
Sedentary society
Self esteem
– Eating disorders
• Body image issues
• 2nd highest rate of mortality in psychiatry
Uuay & Albala, Obesity trends: from underweight to overweight: American Society of Nutritional
Science. 131:893S-899S.
Trends that are alarming
• Physical health of children
– 32% increase in allergies in 10 years
– Increased respiratory illnesses (e.g. asthma)
by 75% in just 10 years
– Tubes are the new tonsils
– Unrecognized risks of sleep disorders
– Greater risks with neonatal survival
– Native population
Martinez FD, Wright AL, Taussig LM, et al. Asthma and wheezing in the first six years of life, N
Engl J Med 1995; 332:133-138.
Akinbami, L. Asthma prevalence, health care use and mortality: United States 2003-05, CDC
National Center for Health Statistics, 2006.
Summary Health Statistics for U.S. Children: National Health Interview Survey, 2008.
Trends that are alarming
• Dissolution of the family unit
– Increased rates of divorce
– Decrease in the role of religion
– Increase in single parent families
– Decrease role of community- loss of ethnic
heritage
– Less contact with parents in intact families
• Both parents working
CDC, National Health Survey 2008
Trends that are alarming
• Pseudo-maturity of children due to
competitive pressures
– What do children watch?
• Children save the parents
– The shrinking world and exposure to worry
– Expectations to succeed
– The value of post-secondary education?
Kids are at risk but…
• Stigma of mental health is reducing
– Depression, ADHD, Bipolar
• Doctors are better trained
– Royal College requirements
• There are more vocal and better educated
advocates
– ASD lobby
Corrigan, P. (2004). How stigma affects mental health. American Psychology, 59(7), 614-625.
Entry Point
• Is still very much starts with a medical
diagnosis
• Psychoeducational assessments may be
initial triggers
• Sometimes activated by justice, social
service, or educational systems
The Medical Model
• Diagnostic and Statistical Manual
– DSM-IV-TR
– DSM-V
– ICD-10
– Medical Model of Classification
– Disconnect between child and adult pathology
– Failure to lead to etiology
• Re-evaluation of the diagnostic system
What Are We Really Treating?
• Symptom
– Discrete complaint: self esteem, fever,
cough
• Syndrome
– Collection of symptoms occurring
together- DSM
– Gonorrhea, Measles, Bipolar
• Behavioral dimension
– Behavior with physiological basis
– Impulsivity, Anxiety
Levels of Intervention
Symptom
Syndrome
Behavioral Dimension
Symptom Management
• Addresses the core symptom that requires
management
• Has more relevance for the application of
treatment and promotes prevention
• Easier to use as an educational vehicle
• Patients have a better understanding and
allows them to take a proactive approach
• Does not label the child
• However, without a syndrome diagnosis,
may not be able to get resources
Example: aggression
• Easy to quantify in frequency and intensity
• Prevents us from using a label that gets
fixated
• Multi-disciplinary approach can be taken
• Even though it comes from multiple
sources, the treatments are the same
Aggressive Spectrum
Bipolar
Spectrum
ADHD
Spectrum
Cluster B
Personality Disorders
Tourette’s/
OCD
Developmental
Disorders
Borderline
Personality
Disorders
Impulsivity and
Aggression
Sexual
Compulsions
Substance PTSD
Use
Disorder
Impulse
Control
Disorders
Autism
Spectrum
Disorders
Dimensional Systems
• Impulsive-compulsive spectrum
Impulsivity vs Compulsivity
• Compulsivity
Impulsivity
Impulsivity vs compulsivity
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Impulsive
Reactive
Feeling
Emotional
Short fuse
Externalizing
Heart
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Compulsive
Ruminative
Thinking
Constrained
Can’t let it go
Internalizing
Head
Last time asked you to do some
introspection
• Go back to your childhood
• How many of you feel you are on the
impulsive spectrum- heart people
• How many are on the compulsive
spectrum – head people
Categorical versus Dimensional
• Compulsivity
Impulsivity
– Depression
– Anxiety disorders
– Cluster C personalities
ADHD
Bipolar disorder
Cluster B personalities
NORMAL
Impulsivity vs Compulsivity, Oldham et al, 1996
Developmental Model
• Epigenetic- building on foundations
• We are genetically driven down the same
developmental path regardless of events
• Highly predictable
• Cyclical, much like cell differentiation
– Growth- stable - growth
Normal Childhood Development
• Children cry to communicate
Child Development
• 0-18 months
– Trust versus mistrust
– A child’s sense of security
– Bonding
• 18 months to 2 ½ years
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Autonomy versus doubt
Individuation- Object Permanence
True independence or a feeling of apprehension
“anal retentiveness”- holding on
“What if…” you cut my ears off
or “What if?” the core basis of impulse control
Erikson, Erik H. Identity, Youth and Crisis. New York: Norton, 1968.
Normal Development 2 ½ - 6
• Initiative versus guilt
– Do children feel frightened by the interpretation of
their world
– Do I need to be in control?
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Gender identification
Autonomy
Peer development
Physical Change
Self directedness
Child Development 7-12
• Industry versus inferiority
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Role models
Love to get positive attention
Creative learning
Quiet time of development
– Great to be a parent
Child Development 12-18+
• Adolescence = 2 ½ -6
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Gender awakening and sexuality
Autonomy and independence
Physical change – puberty
Peer development – friends become important
Self - cooperation
Identity versus role confusion
– Unresolved issues from childhood come back
Adult Development 18 - 45
• Stable period just like latency 6-12
• Intimacy versus isolation
• Building families, assets, careers
• Highly predictable likelihood of success
• Work ethic
• Families starting later
– New dynamic but doesn’t change developmental path
Adult Development 45-60
• Just like 2 ½-6, just like adolescence
• Generativity versus stagnation
– Midlife Crisis
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Gender issues- sexuality changes
Autonomy – free from childhood burden
Physical change
Peer stability
Self-transdecence = working for societies good
Prevention and Resiliency model
• If the way children are brought up defines
us as adults and defines us as a societywhy are we not making primary prevention
the priority?
– The medical model glorifies pathology
– The school system poorly handles uniqueness
– The social system is in reactive mode
– Parental models and community lost
Children are our future
• They must be a priority in the mental
health system