2 0 1 3 A n n u a l C h i l d A b u s e C o u n c i l S p r i n g C o n f e r e n c e “Strengthening the Social and Emotional Health of Children?” Depression.

2 0 1 3 A n n u a l C h i l d A b u s e C o u n c i l S p r i n g C o n f e r e n c e

“Strengthening the Social and Emotional Health of Children?”

Depression is Adolescents’ Greatest Risk

2 0 1 3 A n n u a l C h i l d A b u s e C o u n c i l S p r i n g C o n f e r e n c e

“Strengthening the Social and Emotional Health of Children?”

Depression is Adolescents’ Greatest Risk

Greg Billiard, LMSWMarilyn Cleary, RNRandy Koch, LPCMichael Lucido, PHD

Suicide Prevention Workgroup

Suicide Prevention WorkgroupHuman Services Coordinating Body of

Charlevoix & Emmet Counties

In order to lighten then mood…

Mental Health Defined:

Mental Health Defined:

Mental health is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work

productively and is able to make a contribution to his or her community. In this positive sense, mental health is the foundation for individual well-being and the effective functioning of a

community.World Health Organization

If you have good mental wellness you:

• are in control of your thoughts & behaviors;• feel positive about yourself;

• have good relationships;• keep problems in perspective;

• have both self-awareness and self-control

If you have good mental wellness you:

• are in control of your thoughts & behaviors;• feel positive about yourself;

• have good relationships;• keep problems in perspective;

• have both self-awareness and self-control

Adolescents are exposed to increased rates of stressful life experiences and there is some

evidence that increases in stressors account, at least in part, for the increased rates of

psychological problems associated with this developmental period.

Stress and Mental Health ProblemsGrant, K.E. at el. 2005

Youth TodayYouth TodayMay feel overwhelmed by the emotional & physical changes they

are going through.

PRESSURES:• Fitting in

o Relationshipso Body changes

• Bullying especially Cyber-bullying (e.g., facebook)!!!o Teens/young adults are committing suicide with a

significant history of being victimized in bullying.o Playground/bus incident-re-victimized

• Performing well o Academics/jobo Familyo Sports

A Tragedy: Alex Harrison

• Cadillac, MI- Alex was a bright and truly gifted who was taking college level courses

• He never told anyone about being bulliedo Tennis team called him names- “Creeper”o Student said, “Don’t you know everyone hates you”

• At the age of 16, he shot himself at 2 am.• Parents advocate for anti-bullying programs to

prevent more casualties.http://www.eyesonbullying.org/

When transitioning from childhood into adulthood, youth may struggle with being dependent while

wanting to be independent. They “try-on” styles, ideas & friends as they define themselves.

Symptoms of StressSymptoms of Stress• Feeling tired for no good reason• Headaches; body pains• Eating more or less than usual• Trouble sleeping• More colds than usual• Flashes of anger / tears• Irritability• Sad, moody, lonely• Forgetful, trouble concentrating, cloudy

thinking

Mental disorder is a term for psychophysiological disorders affecting mood, thought, or behavior.

•1 in 5 will have a mental health disorder.•1 in 10 will be a severe impairment.•About 3 children in a class of 30 will have a mental health condition that needs treatment.

Common in children include:

• Depression • Bipolar Disorder• OCD• Conduct Disorder• Oppositional Defiant• Eating Disorders

• Anxiety/Phobias/PTSD/OCD• Autism Spectrum

Conditions• ADHD • Tourette’s

What is the deadliest mental disorder for teens?

DEPRESSIONDEPRESSION

• Major Depressive Disorder is the leading disease related cause of death in the U.S. for ages 11-24

• More than 90 percent of people who take their lives have a diagnosable mental disorder, most commonly a depressive disorder and/or a substance abuse disorder.

National Institute of Mental Health

Terminal Depression: Suicide

• According to the CDC, 1,386 children and adolescents between the ages 13 to 18 committed suicide.

• According to the Journal of Adolescent Health, 1 in 8 teenagers had persistent suicidal thoughts at some point and a third of those made an attempt.

• 40% of adolescents who have attempted to take their own life admitted they first tried to kill themselves prior to high school.

• A Harvard study found that 55% of adolescents who plan or attempt suicide have had at least some mental health treatment prior to the attempt which contradict the notion that they lacked treatment services.

Bipolar Disorder• A third of children with depression have

misdiagnosed bipolar• Often presents as ADHD• Manic episode must last 1 week

o Typically not up and down throughout the day

• Impulsive, lack judgment

• Rage, defiant, disrespect property

• Rapid mood swings- many times a day

• Elevated, expansive, irritable mood

• Grandiosity• “I hate myself!”

• Distractible• Decreased need for

sleep• Increased talking• Racing thoughts• Increased activity,

agitation• Engage in Risky

behaviors• Possible psychosis

Be aware of the factors that put youth at risk.

Be aware of the factors that put youth at risk.

• Family history of depression

• Substance abuse, chronic illness, death/loss, disabilities, absent parent/family conflict

• Personality traits that change dramatically can signal trouble

• Impulsive, obsessiveness, fears, aggression, antisocial, poor social skills, poor self worth, overachieving, pressure to perform

• Personal competence (learning disability, ADHD)

• Medical conditions such as hypothyroid may increase risk

• Social events that contribute to problems and stress

• Loss experienced, problems with friends, rejection, pregnancy, financial issues , or relocations/moves to another location

Biological Basis• Significant genetic

loading with higher rates when a first degree relative has depression of 34%

• Serotonin hypothesis with dysregulated levels

• This is the reason for selective serotonin reuptake inhibitors (SSRI) treatment in depression.

Depression Leads to Impaired Immunity and

Neurotransmission

PET Scan Imaging Comparison• Comparing brain

activity during depression with normal brain activity. o An increase of blue and

green colors, along with decreased white and yellow areas, shows decreased brain activity due to depression.

o PET scans measures blood flow and volume, oxygen usage, tissue acidity (pH), and glucose metabolism.

Development of Depression

• ADHD diagnosis 4-6 y/o increases risk for depression. • Children –

o Do not verbalize depressive thoughtso More physical complaints or exaggerated when sick or achingo More irritability, o Uncooperativeness, apathy, disinterestedo Lower rate of hypersomnia and more psychomotor agitation

• Adolescents-o Hopelessness, verbalize symptoms, hypersomnia, weight losso Decrease with age- appear depressed, somatic complaints, low self-

esteemo Increase with age-anhedonia, psychomotor retardation, diurnal

variationo Major depressive disorder onset at 14.

• Milder depression seen at around 11• Girls have longer depressive episodes than boys.

Signs and Symptoms of Depression• Sadness and hopelessness • Most children/adolescents deny depression• Poor performance or failing performance in school • Withdrawal from friends and activities • Lack of enthusiasm, energy or motivation • Anger, overreaction to criticism, problems with

authority• Feelings of being unable to satisfy ideals • Poor self-esteem or guilt• Indecision, lack of concentration or forgetfulness • Restlessness and agitation • Changes in eating or sleeping patterns • Substance abuse• Severe symptoms cause paranoia and hallucinations

Depression may co-occur with any of the mental illnesses mentioned.

Depression impacts:o Behavioral o Cognitive o Emotional

Emotional Signs

• Irritable• Anxious• Sadness• Bored or apathetic• Guilt/shame• Mood swings

Behavioral Signs

• Disruptive • Social withdrawal/loss of interests• Fearful• Crying• Falling asleep in class• Cutting/self-injury• Low energy/exhaustion• Restlessness• Insomnia/hypersomnia• Increase/decrease in appetite• Complains about illnesses & pain• Cuts/burns/bruises (wear sweaters to hide)

Things you may see in school

• Unexplained drop in performance • Overly invested in achieving good grades• Loss of interest in activities like sports or

games• Turning in poor quality work• Low tolerance for frustration/gives up easily• Complains of being tired and fatigued • Unmotivated/can’t finish work• Changes in attendance• Apathetic• Disrespect• Aggression

Cognitive Signs• Cognitive errors

o catastrophizing, personalization, overgeneralization

o Negative triad- self, world, and future.

• Negative self-talk • Problems concentrating• Forgetful• Indecisiveness & Confusion• Negative memory bias• Hopelessness• Helplessness• Worthlessness• Severe depression leads to

psychotic symptoms such as hallucinations/delusions (less common)

Increased Risk for Depression Mixed with

Substance Abuse

• What came first, the chicken or the Egg?

• Self-medication?• Associated Risks• Impact of Alcohol

and Marihuana Use

The Survey Says:• 33 percent of 8th graders & 70 percent of 12th

graders in the United States said they tried alcohol at some time in their lives (SAMSHA 2012)

• 6.5 percent of 8th graders, 17.0 percent of 10th graders, and 22.9 percent of 12th graders had used marijuana in the past month (NIDA 2012)

• Perception of risk: Alcohol ~ 39.3% in 2007 to 40.7% in 2011& Marihuana ~ 11.1% in 2004 to 7.4% in 2011(NSDUH 2012)

• Significant differences by sex in the perceived danger of using marihuana and alcohol

Perception of Great Risk from Using Selected Substances Once or Twice a

Week Adolescents Aged 12 to 17, by Gender: 2011

Alcohol• 56.8% of males aged 12 or older were current

drinkers; 47.1% of females (NSDUH 2011)• Impulsivity and aggression are strongly

implicated in suicidal behavior - Alcohol use impairs reasoning & increases impulsive behavior

• Evidence suggests association between: aggression ~ serotonin deficiency AND between aggression ~ alcohol consumption (Columbia University)

• 35% of students who reported alcohol use prior to age 13 had increased risk for violent behaviors and significant increase in suicide attempts (SAMHSA 2012)

Marihuana• THC affects the nerve cells in the part of the brain

where memories are formed• Marihuana affects self-control & decision making

abilities• Chronic/heavy use (3 or more times per week)

increases likelihood of depression, anxiety and panic attack

• Cannabis dependence = 2.9 times as likely to think about suicide without attempting it & 2.5 times as likely to make a suicide attempt (Michael Lynskey, PhD,

Washington University School of Medicine 2012)

• The Double Whammy ~ Cannabis withdrawal increases anxiety, depression, insomnia, irritability

Other Considerations…

• Alcohol & Marijuana ~ gateways to other substance use

• Additional risk taking behaviors• Impaired social and academic functioning• Increased injury or death from accidents • Para-suicidal behaviors• Family History• Don’t forget the synthetics: Spice/K2 & Bath

Salts

Early intervention does begin in early elementary school.

What is professional help?

• Evaluation and diagnosis (Beck’s checklists, CBCL, Conner’s, MMPI-A, observation reports)

• Psychotherapyo Individual therapy like cognitive behavioral

therapyo Family therapy (PMTO)o Group therapy (youth groups)

• Psychopharmacological interventions• Special academic support

o 504o IEP

Who are licensed professionals?

• Physician• Psychiatrist• Psychologist• Clinical counselor*• Social worker*• School psychologist**(may have limitations for service)

Depression is Treatable

• Early intervention does begin in early elementary school

• Depression can be effectively treated with a combination of psychotherapy and antidepressants. • Mild depression may be treated with psychotherapy alone, but serious

episodes may require medication.

• For the treatment to be fully effective, it is critical that the treatment continue for several months or longer.

• One half of the children diagnosed with depression are likely to have a relapse over a five-year follow-up

• Young people who suffer from depression are also likely to suffer from depression in their adult lives.

• Early interventions are critical!University of Michigan Depression Center (2010)

Psychotropic Intervention

• Antidepressant medications have been historically helpful

• Includes MAOIs, tricyclics, SSRI, SNRI, and other medications that have similar effects on serotonin.

• May have side effects such as increased irritability and have “black box” warnings for risk of suicide.

• Only medication proven to be helpful in preventing suicidal ideations and behaviors was lithium.

• Always monitor and/or administer the medication. o Often teens are unreliable even with their self care habits.

• Always be sure to right down questions, comments or other notes prior to talking with the doctor.

Psychotherapy Interventions

• Dialectal behavioral therapy provides reduction in self harm behaviors.o Cognitive behavioral therapy approach- acceptance based strategies, skills training,

motivational enhancement, generalization outside of clinical setting, structure of environment, and group facilitation.

o Very problem-solving focused and on emotional regulation with validation, mindfulness and acceptance.

• Cognitive Behavioral Therapy (CBT) for Adolescent Depressiono The use of concrete examples to illustrate points, education about the nature of

psychotherapy and socialization to the treatment model, active exploration autonomy and trust issues, focus on cognitive distortions and affective shifts that occur during sessions, and acquisition of problem-solving, affect-regulation, and social skills.

o The treatment program is delivered in 12 to 16 weekly sessions.

• Interpersonal Psychotherapy for Depressed Adolescentso Short term manual driven treatment for ages 12-18 for mild to moderate depression. o Improves adolescents' communication and social problem-solving skills to increase

their personal effectiveness and satisfaction with current relationships. o Identifies risk factors like separation from parents, development of dyadic

relationships, death of a relative or friend, peer pressure, single-parent families. o Parental involvement is strongly encouraged (but not mandatory).

School-Based Interventions

• Red Flags Programo Mental health awareness program for middle/Jr high schoolso Teaches signs of depression & other mental health issueso Encourages peers to react and get help for others

• Zippy's Friends o School-based mental health program for children ages 5-7. o Teacher 24 weekly sessions, each 45-60 minuteso Identifying and describing feelings; communication; friendship;

bullying/conflict resolution; change/loss; and coping. • TeenScreen

o Middle to high school age youth with undetected mental illness.o 10-minute screen for teens at risk for suicide or mental illness.o A clinical interview and onsite mental health professional. o If need is beyond school based support then referral to more in

depth mental health evaluation.

When you suspect a problem...

When you suspect a problem...

• Ask questions• Listen• Don’t ignore the signs • If you have a “hunch”, ask others to gain

perspective. Trust your instincts!• Educate yourself• Discuss concern with parent • Encourage them to get it “checked out”

Teach Young People To…

Teach Young People To…

• Learn to identify problems or stress agents

• Practice coping strategieso emphasize self-responsibility and offer

positive, nondestructive ways of finding relief• Find good listeners• Express feelings• Communicate problems• Develop problem solving skills• Set goals and make plans to achieve

them• Act positively to assist their friends/peers• Recognize their own warning signs

1. ASK• Take it seriously. 70% of who commit suicide give warnings. • Be willing to listen.2. Care• Voice your concern. Take the initiative to ask what is troubling, and

attempt to overcome any reluctance to talk. • Let the person know you care and understand.• Asking about suicide does not cause suicide.3. TELL • get professional help immediately. • If the person is unwilling to accept treatment get them to a local

emergency room or community mental health center. • They will be more likely to seek help if you accompany.

Stop a Suicide-Screening for Mental Health (2010)

ACT:Ask, Care, & Tell

Survivors of Suicide Support Group

• Attending monthly at the Vital Care Hospice of Little Traverse Bay in the Hiland Cottage Petoskey, MI

• 6-7:30 pm and every second Tuesday of the month (next meeting May 14)

• Provides support for after the loss of suicide• Facilitated by a therapists and survivor

Final ThoughtFinal Thought

It is through awareness and recognition of adolescent stress, depression and mental health

that parents and caring adults engage youth positively and constructively to stimulate their

emotional development.

Resources• Local Healthcare Practitioners

• First line support/referral service• Third Level Crisis Center

• (800) 442-7315• North Country CMH Access Center

• (800) 834-3393• National Suicide Prevention Lifeline

• (800) 273-TALK• Hospice of Little Traverse Bay-Survivors of Suicide

Group• (231) 487-4825

• Michigan Department of Community Health• National Institute of Mental Health• SAMHSA for national resources