 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on children and mental health. One of the reasons we're doing a lot on children and mental health and parenting and that kind of stuff over the last week and this week and a little bit into next week, May is mental health month, if you remember. And one of the things that we found is a lot of times mental health issues start in childhood and adolescence. And, you know, you can say there are problems in childhood and adolescence that can trigger them. But for a lot of people, they have their first episode in childhood and adolescence. So if we are educating people to be more aware, then we can provide earlier intervention services and hopefully prevent people from becoming adults who are struggling with chronic, recurrent, major depressive disorder, generalized anxiety or something. So that's really kind of what we're going to look at or why we're focusing on these things right now. During this course, we're going to recognize normal developmental stages in children and signs of problems in development. Remember, our mental health is tied to our physical health. So when children are evidencing delays in physical development, they may also have some cognitive delays and vice versa. There's also been connections between children who start to fail in school. Maybe they were doing well and then all of a sudden they start doing poorly in school. There's a connection between that and them starting to develop anxiety and depressive disorders. So we want to make sure that children are developing roughly in line with their peers. Everybody develops at slightly different rates but roughly in line. We're going to list risk factors that negatively affect children's mental health and we can't list all of them, but we're going to hit some of the highlights. Describe and identify symptoms of childhood mental health disorders, the big ones. We're not going to cover everything, not time for that with the DSM. We'll name community-based prevention and treatment resources and identify major services offered by these organizations. So we know where to refer to and I will tell you I am a huge fan of early intervention services, but we'll talk about that later. And I want you to gain knowledge of how to treat mental health problems in children. This is one of those things that I find is really kind of quirky. We have specialties and requirements to do hypnosis. We have specialties and requirements to do sex therapy, but we don't have any specialty requirement to treat children and children are not little adults. They require a whole different approach to treatment. So I've always found that as a little bit odd because, you know, I was, when I went through graduate school, I think as most of us did, we were prepared to work with adults. We were not trained in play therapy. We were not trained to work with children. So those are things that we want to consider when we're looking at clients and going, is this a client that I can take on or is this somebody I need to refer? So remember that children are not little adults. They have their unique developmental needs. When we talk about problems and mental disorders in children, a lot of times they express or are symptomatic in different ways than adults are. So it's important to make sure we understand what depression in a child looks like, what bipolar in a child looks like as opposed to in adults because it's probably going to look different. The estimates for the prevalence of mental disorders in children ranges from 5% and that's those children that have severe mental health issues to 21% children with minimal mental health issues enough to be diagnosed maybe just with adjustment disorder but enough to be diagnosed. Let's think about that for a second. 21% that is one in five children right now are meeting the criteria for having a diagnosable mental disorder. That's staggering and that's heartbreaking. Research indicates that half of all lifetime cases of mental illness begin by the age of 14. So we're looking for generalized anxiety if we're looking for those things. We can start intervening early. We can educate teachers and parents about what to look for. We can ensure that pediatricians are on the lookout for some of these developmental things when children go in for their checkups. We can make sure that school counselors are well-versed in what mental health issues look like so we can provide early intervention. Additional training ensures increased availability for early intervention in preschools, schools, juvenile justice, and medical offices. So there's a couple that I didn't mention yet. Juvenile justice. A lot of times kids end up in DJJ because they're acting out for some reason. Maybe because they're lacking coping skills, could be conduct disorder, could be a lot of things. But if the DJJ officer is able to identify and make referrals effectively, it's likely going to help reduce recidivism and keep that child from continuing to offend and become an adult offender. And preschools. A lot of times we just kind of skim over preschools. But preschools are awesome places for us to provide education and early intervention to children. They don't have the restrictions of having to meet the state testing standards. In elementary, middle, and high school now, even getting outreach programs into those locations is really difficult because the school administration sees that as detracting from the time that they can focus on preparing the children for their state test, the FCAT, the TCAP, whatever it is in your state. So we really want to look at number one, convincing administration that your kids are going to do a lot better on these tests if they can learn and they're going to learn a lot better if they're not depressed or anxious. But that's a whole different ball game. But we also want to look at preschools because a lot of preschool teachers have a lot of contact with these youth and they have the ability to intervene and teach these skills early and serve as role models for good coping skills early on when children are just absolute sponges. So normal development. And we're going to hit the big four that I really like to cover. There are other developmental theories out there, but Eriks and psychosocial stages. So trust versus mistrust is the first one. And this is really the infancy stage where the child is learning that they can trust other people to meet their needs. They cry because they're hungry, they get fed, they cry because they're cold, they get bundled up. Autonomy versus shame is kind of your toilet training area. The child is learning to become independent and they want to take responsibility and ownership of their own body. They're starting to learn how to bathe themselves. Toilet training and they're going to start trying to dress themselves at this point. And, you know, that can be challenging, but it's really important for parents to be somewhat lenient. I mean, you know, my kids sometimes picked out outfits that I'm looking at going, oh, wow, you know, that's not something I would put together. But that's what they wanted to wear. And it was weather appropriate. So I chose not to correct them. Some parents will correct them, but I wanted to allow them to express themselves as much as possible and feel like, okay, I can do this. Feel a sense of self-efficacy. Initiative versus guilt. This is when we start moving into kindergarten and elementary years where the children are trying to move out from that home base. They're trying to take initiative and make plans and do things and ask people to engage with them. And if they keep getting shut down, then they may feel guilty about taking initiative and they may kind of withdraw. And then industry versus inferiority. That is your middle school and into high school sort of age range where children are trying new things. They're going to different types of classes. They're going to art class and gym class and home mech and shop class and, you know, whatever lessons and teams they're on. And they're figuring out what they're good at. And it's up to us during this period to help them remember or recognize that you're not going to be good at everything. You know, you are going to fail and that's okay. It means you're not perfect and nobody is. But we want to help them focus on the things that they're good at. You know, you are able to do this. So awesome. Let's focus on this over here. Okay. So you're not going to be the star quarterback. Not everybody can be the quarterback. So what can you focus on? What can you do well? Piaget's cognitive development, if you remember, really focuses on what children, how children can think. And in the beginning, it's sensory motor. They think with their hands. Then it comes to pre-operational and then concrete operational. And concrete operational is elementary school years when they have to see things. Up until the time children are in middle school really, they have difficulty with abstract concepts. So when we're trying to talk to them about things, we need to make it as concrete as possible because they have difficulty thinking about things that aren't right there in front of them. Bandura social learning theory tells us that children are going to learn what they live, basically. They are going to learn by observing others in their school, others in their community, others in their household, and others in the media. So it's important that as parents, we try to monitor and make sure that children are exposed to appropriate social modeling. Now, they're going to have inappropriate exposure at certain times. They may see a show on TV when they're at their friend's house that you wouldn't have let them see. Okay, no harm, no foul. You can usually just process that with the child. You don't want to keep them in a cocoon, but it's important to talk about things. Why it's the right thing to do, why that may have been the wrong thing to do, whatever it is. And then Colberg's moral development. The first stage when people are generally are really young, it's obedience. You're going to do it to avoid getting punished. Then instrumental is you're going to do it because it benefits you. Conformity is you're going to do it because those are the rules and you're just going to, you're going to follow. And that kind of goes with obedience, but in conformity it's less about punishment and more about assimilation. And then the final stage is kind of in individual rights when it gets into more ethical moral development. So those are the ones we'll talk about. There's one other stage past that that most people don't even get to. But when you're reasoning with a child, you have to take this into consideration. If they are motivated by obedience, then you want to tell them what you want done and be very clear so they can follow because they want to follow. They want to please you. They want to be obedient. When they get a little older, you want to rationalize with them, reason with them in terms of how is this beneficial for you and for me. You know, if you do this or when you do this, then I will read you another story. Or when you do this, you will avoid losing your privilege or whatever the case may be. But you want to make sure they understand the purpose of what they're doing and how it benefits them. Conformity and it doesn't have to be a bribe. It can be you're going to avoid punishment. It benefits you because you want to be able to go out and ride your bike tomorrow. Well, if you want to be able to do that, then you can't be on restriction. So these are things we've got to consider when we're working with children. We want to look at, you know, are they getting their needs met? And are we communicating in a way that makes sense to them cognitively and morally? And what kind of environment are they in and what are they learning from their environment? And sometimes helping children feel better is a matter of changing their environment. Sometimes that's not possible. You know, if you've got a child who's in middle school and is being bullied, it may not be possible to yank that child out of one school and put them in another school. So we want to look at social learning theory and help them find positive role models. So developmental psychopathology comes from multiple sources. And this can, you know, kids can develop depression for a variety of reasons. And we need to look at the overlap of these reasons. You can take two kids and expose them to the same situation. And they, one may have a very dramatic reaction and the other may not care. So we want to look at what affects them and how can we sort of predict sometimes who may be more troubled by certain things or who may struggle more with depression or anxiety. So specific characteristics of the child, including biological characteristics, how old they are and any cognitive issues they may have, psychological and genetic factors. Some children are going to be more responsive and more emotional than others. And that's just the way they're wired. And the environment is going to impact how the child deals with things, including their parents, siblings and family relations. Are they supportive? Are they nurturing or not? They're peer and neighborhood factors. Do they have friends they can rely on? Do they feel a connection to their neighborhood? School and community factors. If they are doing well in school and feeling an attachment there, that's going to be supportive and buffer against mental health issues. If they are feeling like they're failing and like they don't fit in, then they're going to experience more stress, which sets them up to be more vulnerable to mental health issues. And then the larger social cultural context. Things that are going on, such as racism and discrimination and how the person experiences those. And a lot of this, if you understand Bronf and Brenner's ecological systems theory, that's kind of what we're talking about here. And you can Google that, go online and learn more about that if you want to understand sort of the multiple factors that influence. And if you try to do a regression analysis to predict which factors would make somebody more likely to become depressed, you'd find that you had, you know, hundreds when you started looking at all the different things that can impact somebody. We want to understand adaptability. Children are typically and humans are typically self-writing and self-organizing. Within a given context, we tend to adapt as much as possible in order to get our needs met. So if you're in a particular environment and it is better to just to keep your mouth shut and fly under the radar, then that's what you're probably going to do. If you're in an environment where it is better to speak up and try to be the leader of the class or something, then that's what you're going to do. So we want to look at their environment in terms of if this child is presenting as depressed and withdrawn. In what environments are they experiencing this as a self-writing behavior? In what environments, you know, what about their environments might be existing that are teaching them that this is really what you want to do. You want to fly low so nobody really notices. Psychopathology may be the result of survival adaptations to a pathological environment. It may not be the kid at all. The kid may want to survive and this is the creative way that they have found to survive in their particular situation. In addicted households, there is the phrase, if you will, don't talk, don't trust, don't feel. And that is a self-writing set of behaviors in an addicted household. You're more likely to not trigger the person with the addiction and not get in trouble and have all kinds of chaos if you just don't talk, don't trust, don't feel. Just numb it out and go through it. Not saying this is how we want children to go through life, but I'm trying to highlight the fact that the environment itself could be the identified patient basically and the child really could be pretty resilient because they're surviving through that. Understand timing. Is this an appropriate behavior at this age? If a three-year-old is wetting the bed, that's different than if a 13-year-old is wetting the bed. If a three-year-old or a two-year-old bites somebody, that's different than if a 12 or 13-year-old does it. So we want to look at appropriate behavior. I use the term appropriate, not that hitting or biting or wetting the bed is necessarily appropriate, but is it expected at this age? And if so, then we can deal with it. If it is something that is grossly age inappropriate, then we need to look at what might be causing that. We also need to understand the context. The same behavior in one setting or culture might be acceptable and even normative where it can be seen as pathological in another. There are some cultures where making direct eye contact with your elders and talking back and being assertive is not okay. And in other cultures, it's almost encouraged, not to be insubordinate, but to stand up for yourself to be independent, to have your own thoughts and opinions. And that can be culturally sanctioned. So we want to understand the context that this is happening. The way you behave at home, for example, and that's a context, is going to be different likely than the way you behave at school or the way you behave somewhere else in public. And it's considered more appropriate. We have to look at the context of what's going on and whether that's appropriate. And we have to understand the degree. You know, if somebody gets upset, if a child gets upset or does something that is, let's take depression. That's one we see a lot with teenagers. We want to look at the degree of depression. Teenagers can be kind of moody. And not to say that we want to ignore that. We want to make sure that we're checking in with them and they've got the coping skills. But when those hormones are going all over the place, it is not uncommon for teenagers to be moody. So we want to look at, for this person, you know, is this a normal level of moodiness? And in comparison with others, you know, other teenagers, does this seem like it's kind of in the ballpark or is this person experiencing an extreme level of distress? So let me go over those again real quick. Multiple sources. We want to look at all the different factors that could be contributing to either the resilience or the psychopathology. We want to understand how this behavior is serving a function because all behaviors that we do tend to serve a function. If a child is acting out, they may be just craving structure and boundaries because they feel out of control or they may not have coping skills or they may be in a pathological environment that's teaching them inappropriate ways to respond. But we want to understand that, you know, generally what they're doing is adaptable. We want to look at the timing and the degree. You know, for this child at this age, is this degree of whatever this behavior is appropriate or not? And does the behavior occur across contexts or is it only in one context? I had one child that I worked with that, when she was at school, she would pull out her eyebrow hairs and she didn't do that when she was at home but she only did it when she was at school and it got much worse during state testing time. So obviously the context there was the stress of performance at school which was enhanced during state testing time. So we wanted to understand what was going on. So risk factors for psychopathology, genetics, if it runs in the family then there's a chance the person is predisposed. It doesn't mean they're going to have it. It just means they have a greater likelihood. Substance exposure can alter brain chemicals. Low birth weight. When children have a low birth weight, you know, they're not exactly sure why but when children are born with low birth weight, they tend to have more cognitive and emotional difficulties. And prematurity. If a child is premature, they are almost always low birth weight. My son was two pounds and 14 ounces and my daughter was three pounds and seven ounces. So, you know, they were both premature when they were born and obviously small. Psychosocial, domestic violence, if they're exposed to that, that can, that will have an effect. If they're abused themselves, that will have an effect. If they're exposed to others who are misusing substances, a parent who is, comes home every night and gets just completely drunk because they cannot deal with life on life's terms, so they're emotionally unavailable to the child. Well, the child is not learning effective coping skills. The child is actually learning ineffective coping skills and the child lacks the emotional support from the caregiving unit. So, there are a lot of things that happen when there is substance misuse in the household. Household mental illness can be the same way. If you've got a parent who is struggling with mental illness, they may become emotionally unavailable and for extended periods of time and it can have an impact. It doesn't mean it has to, but we want to look, you know, if a caregiver or a person in the household is regularly struggling with mental illness, how do we help the children understand and cope with that? That's the big thing. It's not to make this other person go away. It's to help the children understand and cope with it. And bullying is a huge factor for depression, anxiety, social phobia. Stressful life events including parent separation, parent incarceration, and parent abandonment all have their own independent issues and impact on children. Sometimes, you know, parents can separate and children deal with it okay if it's handled well and they understand. Other times it can get really ugly and the children can feel stuck in the middle or feel responsible for it. So, again, none of these is saying that a person is doomed to have psychopathology if they have any of these risk factors. But risk factors say they're at a greater chance so we need to provide them extra buffering resources. Childhood maltreatment, not getting enough food, not being in a safe environment. That can, and child neglect. And peer and sibling influences can also be a risk factor for psychopathology if peers and siblings, and this kind of goes with bullying, are unsupportive or downright mean to one another. And siblings will occasionally be mean to one another. Don't get me wrong. You know, when my son was four and a half his daughter had just, or his sister, had just started crawling. And I remember one day going in the kitchen to make supper and I heard him in the living room and he was going, stop resisting, stop resisting. And I walked in there and he had his sister prone out on the floor and he was trying to put his little baby handcuffs on her. And I'm like, no son, we don't arrest our sister. And he would regularly, you know, do sort of weird things like that to her. Not because he was trying to be mean but he was actually trying to play. So those are just different things. We want to make sure that we process with the children. So almost two thirds of surveyed adults report at least one adverse childhood experience and more than 20% of adults more than one in five report three or more adverse childhood experiences when they were growing up. The adverse childhood experience score and the ACE score is additive. If you have one, then, you know, okay, it may be a risk factor. The more risk factors you get, the greater the likelihood is that you're going to experience some sort of mental psychopathology at some point in your life. As the number of ACEs or adverse childhood experiences increases, so does the risk of heart attack and heart disease. Well, let's think about that. Heart attack and heart disease are directly related to lifestyle factors and stress. So, you know, we've got somebody who has been stressed out their whole life. Mental distress, depression, smoking, which is often, you know, some people take it up in order to fit into a crowd, but a lot of people use smoking as a coping tool, if you will, when they start to get stressed out. Disability, unemployment, lowered educational attainment, stroke and diabetes are all linked to adverse childhood experiences. And you can go online to the Adverse Childhood Experiences website and look at the survey, and there's all kinds of information there. Assessment and treatment. Assessment of children is more difficult because children often can't verbalize some things. They don't know what's normal. You know, in their household, if the parents have always yelled at one another, that may seem normal to them. They may not understand that that doesn't happen in all households. So, a lot of what we have to go on has to be observed from the children, watching them play. You know, if they start playing house and the, you know, adult figures in the household are constantly arguing and bickering at each other's throats, we have an idea that they may be being exposed to that a lot. Information on the assessment is also gained from adults, whether or not it's appropriate for a child's diagnosis. So, we're going to get information, but you've got to remember, adults often are going to put the best foot forward. They're not going to say, oh, yeah, we're fighting all the time and there's at least domestic violence, you know, twice a month in our household. They're not going to say that. We can only go on the information that we have. And that's true with adults too, but for children, there's just so much more that they just don't know what to report or how to report it. Treatment for children focuses on psychotherapy, play therapy, and in some instances, psychopharmacology. Now remember, I think it was 2007, the FDA put out that black box warning on SSRIs that said that in children and adolescents, antidepressants can increase the risk for suicide. So a lot of physicians have gotten away from psychopharmacology as much except for for ADHD. Amber asked the question, if there are studies regarding which more affects a child, maternal depression or paternal depression? And honestly, I don't know. I did do a presentation on postpartum depression. And we learned that in postpartum depression, it can happen to both mothers and fathers. It's not just a mom thing. And it does affect the child. My guess would be, and I'll just have to look up the studies after this class, my guess would be part of it depends on who the primary caregiver is. So if dad is the one staying home with the child before the child goes to school, then it may be more impactful if dad has postpartum or has depression. But, you know, I'm not sure. I want to take a look at that. Overview of childhood and mental health disorders. They have anxiety disorders, attention and disruptive disorders, eating disorders, yep. A lot of kids go on their first diet at the age of eight. That's just painful. And mood disorders. So ADHD. And we're going to go through these really quickly because I'm sure you're familiar with a lot of these diagnoses. But two major components are hyperactivity and impulsivity and inattention. A lot of times boys get diagnosed more with hyperactive ADHD and girls get diagnosed more or missed diagnosed as inattentive. They may have attention deficit disorder, but they're not jumping all over the place. They tend to be more daydreaming and wander off and, you know, suddenly they're not paying attention. A lot of times the symptoms will present before the age of seven. And again, we want to look at age appropriateness here. A five-year-old boy, you expect, and girl, but you expect to be kind of a little bit wild. Kind of wanting to go out, wanting to play, having a lot of energy. Any child you want to expect to expect that a little bit. Any child you're going to expect to occasionally daydream. So we want to look at, you know, how normative is it for this age group. They're not going to have the attention span of a 12 or a 13-year-old. So, you know, can they pay attention for enough time that's appropriate for them? Causes of ADHD, they're really not sure. They've related it to genetics, brain injury, exposure to environmental toxins during pregnancy or at a young age, alcohol and tobacco use during pregnancy, premature delivery and low birth weight. So during that fetal development period, a lot can go wrong. It doesn't mean that the child is doomed. I worked in a postpartum unit. We had 10 beds and the women we brought in as early as we could in their pregnancy and kept them through delivery and the first six months that the child was out. And a lot of those children had been exposed in utero to a variety of substances, including alcohol, marijuana and cocaine. And a lot of those children had no developmental delays. You know, they really, they came out and it was just, it was kind of a miracle. We're looking at treatment for ADHD often involves medication. Unlike some of the other disorders, ADHD does tend to respond pretty well to medication. Now some medications will, as my son's pediatrician referred to it, zombify them. And some of your older ADHD medications, when kids take them, they tend to not be nearly as responsive. Some of the newer medications they've taken out part of the drug that made them zombified and it still helps with their attention but they're not quite as flat and unresponsive. So encourage parents to work with the physician to find a medication that works and find a medication that the child can still be a happy go lucky child on. You know, we don't want them just completely blank faced all the time. We just want them to be able to slow down enough to focus. Parent training and parent child interaction therapy are super helpful for ADHD. Parent child interaction therapy often involves videotaping the family at home and the therapist observing it in order to identify how the parents interact and find places that can be fine tuned to help the parent better help the child deal with their ADHD symptoms and straight up behavior therapy behavior modification can be really helpful. PTSD and yeah, children do get PTSD unfortunately. They may relive the event over and over in thought or play. So we want to look at what's going on and remember for children what's traumatic can be very different than what's traumatic for adults. Children have a very limited scope of reference. So what's traumatic to them can adults can not think twice about it. Television can be traumatic for children if they're seeing something like the World Trade Center or Hurricane Katrina or Hurricane Harvey for hours and hours day after day after day to a child especially a young child think cognitively they're in concrete operational so what they see is what's happening it seems like that what they're seeing on television is happening over and over again and it's not going away so it's retraumatizing them so we want to make sure we process that with children if we're going to watch that in front of them make sure they understand that this is over it's a replay just like when we put on you know Elmo for the 14th time they recorded it once and we're just putting the tape in again and help them understand these things but pay attention to the child and what seems like it might be traumatic for them nightmares and sleep problems becoming very upset when something causes memories of the event lack of positive emotions intense ongoing fear or sadness irritability or angry outbursts hyper vigilance constantly looking for possible threats or being easily startled acting helpless hopeless or withdrawn where the child just wants mom or dad to take care of them or they don't want anything to do with anybody denying that the event happened or feeling numb or avoiding places or people associated with the event now a lot of these are pretty standard PTSD symptoms but they may be displayed a little bit differently in children such as reliving the event through play most 40 year olds aren't going to relive the event through play but a 4 year old will there is an overlap between ADHD and PTSD that is important to be aware of difficulty concentrating or learning being easily distracted not seeming to listen disorganization hyperactivity restlessness and difficulty sleeping are symptoms of both ADHD and PTSD so if you've got a child who's coming in for one of those you want to make sure to rule out the other one could they have them both sure but we want to make sure that we're treating the right thing if they're if they've really got PTSD and the parent doesn't understand maybe they don't know about the trauma that happened so they're bringing Johnny in for ADHD we want to make sure we figure out what we're dealing with depression and suicide are the most frequently diagnosed mood disorders in teens especially major depressive disorder bipolar disorder and what we now call persistent depressive disorder used to be dysthymia approximately two-thirds of children with major depressive disorder also have another mental health disorder a lot of times it's one of the anxiety group sometimes it's PTSD but a lot of times it's either generalized anxiety or social phobia in the 15 to 19 year old age group boys are four times more likely to commit suicide than girls when we say commit that means actually be successful in following through but girls are twice as likely to attempt so we want to be aware of self injurious behaviors and anything like that factors that can trigger depression in youth bullying or other peer issues again remembering that for a child their high school or their middle school is likely their whole world you know they haven't had the experiences they haven't had the breadth of contacts that we have by the time we get to be 20 30 40 so if their peer group if they're one you know their social system seems like it's against them or hateful it can be really devastating academic pressure or problems can also trigger depression if the child is struggling and it could just be in one subject or it could be in multiple subjects going from kindergarten to first grade is a huge transition for a lot of kids because kindergarten yeah you're learning things but it's much less structured when they go to first grade it becomes much more structured and much more about the state testing chronic disease can trigger depression if the child has Crohn's disease or anything like that alcohol or drug use in the child can trigger depression family discord sleep deprivation confusion about sexual orientation other mental health disorders learning disabilities we want to make sure we're screening for visual problems not just cognitive problems visual problems dyslexia and any other learning disabilities remember children can have learning disabilities with reading text can have learning disabilities with math and or across the board so make sure that your your school counselor is knowledgeable which most of them are on learning disabilities because that's one of those things that just one more thing we have to learn about if we're going to take it on and it's just a whole big thing to learn about so it's better to have somebody you can refer to who can do the assessment for learning disabilities low self-esteem and a history of witnessing or being the victim of violence can trigger depression examples of behaviors that are often seen when children are depressed feeling sad hopeless or irritable most of the time now sad and hopeless not uncommon in adult depression irritability is the unique thing with children if children are contrary and irritable and cranky a lot we may want to look at depression not wanting to do or enjoy fun things they just they want to sit down they want to watch tv they don't want to do anything changes in eating patterns changes in sleeping patterns changes in energy you know those are pretty standard symptoms having a hard time paying attention now for adults we talk about difficulty with concentration but for children a lot of times they're not able to articulate that but parents and teachers will start complaining that he just doesn't pay attention I'll be talking to him when he walks off so those are things that we want to look for to kind of translate into difficulty concentrating that hard time paying attention feeling worthless useless or guilty about things yes children are going to make mistakes we all make mistakes but there's very little that a child is probably going to should feel guilty for because there's very little that they're going to do that's that bad self injury and self destructive behavior can also be symptoms of depression when the pain gets too much self injury injurious behaviors remember that self writing reflects self injurious behaviors can be either to get attention and that's if they're putting it out there going look what I did but in most cases children hide self injurious behaviors that self injury is a way of controlling when they are in physical pain they are not in psychological pain they're focusing on controlling this physical pain and it gives them the relief from what's going on inside their head so we want to look at those behaviors as potentially expressions of depression and a feeling of helplessness relapse rate is high for depression among young people they're going through transitions they're trying to figure out their identity they're trying to develop social skills and they've got hormones and growth spurts and voice changes and everything else going on yeah it's a really tough time so I can see why relapse rate would be high depression tends to run in families so we want to screen early and if mom and dad or mom or dad had a history of depression be a little bit more alert to junior it is higher in families in which a parent mom or dad it doesn't matter had postpartum depression higher among girls cognitive behavioral therapy has been deemed effective for pre adolescent children so there's a lot of things we can do with cognitive distortions that can help children buffer and learn to use more positive self-talk quiet that internal critic deal with anxiety there's a lot of cognitive behavioral stuff that children even in the concrete operational phase can handle for adolescents behavioral problem solving and self-control therapies have also been found to be useful and yes hormone changes can cause can be highly correlated I don't want to say can cause can be highly correlated with depression just like hormone changes can be highly correlated with premenstrual dysphoric disorder we're kind of looking at the same thing here but we're also looking at it for adults for adults and children for boys and girls changes in testosterone levels when testosterone gets really high you can see a lot more aggression and anxiety when testosterone is low you can see more depression flatness lack of energy so we do want to pay attention to those it may be you know doctors can measure that really easily so it may be worth referring the kid in for an evaluation because it may be something that's going to pass in a couple of weeks it may be one of those growth spurt things but we do want to bring it to the attention of the primary care suicide risk factors hopelessness low self-esteem and the attribution virus bias and negative views about their own competency risk factors for suicidality now attribution bias is that feeling that we attribute everything to us you know and we attribute everything to either powers out of our control or it's our fault over 90% of teens who commit suicide have a history of mental illness a low level of communication between parents and teens or a stressful event can also be linked to suicide well you know we can impact the communication between parents and teens we can encourage parents to communicate and teens are sometimes just going to roll their eyes that's okay you know at least we're trying even if they think we're obnoxious and annoying at least they know we care we can't buffer them from every stressful event so what we want to do is try to make sure that we minimize any other factors out there exposure to suicide in the media can trigger copy cat suicides so we do want to be aware of that and again bullying is a huge risk factor for suicidal ideation because sometimes kids feel like they can't escape it because it's on their Instagram it's on their Facebook it's at school it's 24-7 just nastiness and flaming so treatment for suicidal ideation is cognitive behavioral therapy focused on problem solving you know this is where you are right now this is very unpleasant what can we do to help you address it dialectical behavior therapy focused on vulnerability prevention if children are you know children need a lot more sleep than adults do and a lot of children don't get enough sleep don't eat a good enough diet which means their body is going to have higher levels of cortisol and not have the building blocks to make the neurotransmitters to help them be happy so we need to make sure that they've got a good diet good sleep and they're regulating their circadian rhythms you don't want a child going home and sitting in a dark room playing video games until it's time to go to bed because then their pineal gland just doesn't even know when it's time to make melatonin for sleep so those are some of the big vulnerabilities that we put out there distressed tolerance teaching them skills for tolerating anger and anxiety and depression what can they do and dbt has two great acronyms their accepts and improves and if you look up dbt acronyms online you'll find all kinds of images and handouts on them problem-solving skills can help you solve problems and start feeling better and figure out how to improve the next moment we can't change right now but we can improve the next moment and interpersonal effectiveness skills most of us need those tuned up occasionally so helping youths who are still developing their interpersonal skills become more effective and be able to communicate their wants needs wishes and boundaries we need to provide intervention after the suicidal death of a peer or a person make sure there's community outreach for youth who are thinking about suicide a suicide hotline especially a youth oriented suicide hotline and method restriction it's ideal not to have lots and lots of opiates or benzodiazepines available or unlocked firearms now if a youth wants to do it they can hang themselves with a belt cut themselves with a knife there are things that they can do and just because I'm saying it doesn't mean it's prompting anybody because they've thought about it you want to be able to bring it up and talk about it and put it out there not make it a secret so just recognize that if someone is determined to do it they most likely will but we can generally before that that they're ambivalent where we can intervene anxiety in children can be evidenced by being very afraid when away from their parents which is your separation anxiety having extreme fears or phobias being afraid of school or other places where there are people you know your social anxiety being worried about the future and about bad things happening generalized anxiety and having repeated episodes of sudden unexpected intense fear that come with symptoms like heart pounding having trouble breathing and feeling dizzy which is panic disorder so all of those anxiety disorders that we see in adults kids can have them too and we usually use cognitive behavioral therapy for those autism risk factors for autism include having a sibling with an autism spectrum disorder now remember there's a spectrum 5 they kind of did away with the individual diagnoses and now it's just autism spectrum disorders having older parents having certain genetic conditions and a very low birth weight can contribute to the risk of developing autism people with autism spectrum disorders have difficulty with communication and interaction with other people a lot of times difficulty with making eye contact difficulty with understanding what other people are interested in restricted interests and repetitive behaviors symptoms that hurt the person's ability to function properly in school work and other areas of life which problems with communication and interaction are going to impair them in multiple domains repeating certain behaviors or having unusual behaviors such as repeating words or phrases can be common having a lasting intense interest in certain topics such as numbers details or facts some children get fascinated by things my son went through periods there was dinosaurs for a while then there was trains for a while then it became Star Wars and I'm still waiting for him to get out of that phase but you know they develop these intense interest and that can be very very normal it's when that's all the child is interested in and they can't seem to focus on anything else it can become a problem getting upset by slight changes in routine and being more or less sensitive than other people to sensory input such as light, noise, clothing or temperature so again these last two things think about life on life's terms routines are going to change and you're going to go into different places where the temperature the light and the noise are different and for people with autism those are really traumatic experiences those can be really intense sensory or experiential things strengths of people with autism though include being able to learn things in detail and remember information for long periods of time especially about that one thing that they're interested in they're often strong visual and auditory learners and many excel in math, science music or art treatment for autism focuses on special education helping them have an environment where they can learn behavior modification and some limited psychopharmacological interventions in order to address especially anxiety issues associated with changes in routine or lighting or anything like that disruptive disorders are your oppositional defiant disorder and conduct disorder ODD usually starts before eight years of age but no later than 12 children with ODD are more likely to act oppositional or defiant around people they know well and more frequently than their peers so we expect children to be oppositional and defiant occasionally that's not pathological that's them asserting their independence and trying to push boundaries that do it more frequently than their peers and tend to do it to the people that they know really well this is when we want to start looking at this diagnosis examples include being angry or losing one's temper arguing with adults or refusing to comply with rules or requests being resentful and spiteful deliberately annoying others or becoming annoyed by others and blaming other people for one's own mistakes or misbehavior now every single one of those characteristics is perfectly normal for an adolescent to express or a child to express once in a while it's when it's pretty much the stereotypical way for that child to behave that it starts crossing over into a problem conduct disorder is diagnosed when children show an ongoing pattern of aggression toward others there are rules and social norms in multiple different settings and these rule violations may involve breaking the law and result in arrest children with conduct disorder are more likely to get injured and may have difficulties getting along with peers so we want to look at children who are bullies we want to look at children who get injured a lot to see if what's causing other kids to beat you up all the time examples of conduct disorder including breaking serious rules such as running away staying out all night or skipping school being aggressive in a way that causes harm such as bullying or being cruel to animals lying, stealing or damaging other people's property on purpose there has to be a purposeful intent substance abuse has a high correlation with mental disorders in the 15 to 24 age group the likely reason for most youth is self-medication sometimes they abuse substances or they start using substances to fit in but then once they start using substances since the adolescent brain is so much it's still developing and their impulse control areas really don't finish developing until they're 25 they are more likely to become dependent on the substances eating disorders mainly affect females although there's a high percentage higher percentage than we used to think of males with eating disorders and consist of anorexia, bulimia and binge eating disorder the age of onset for eating disorders they think is approximately 17 years old but I can tell you I have worked with children as young as 11 who are exhibiting pathological eating behaviors treatment options for adolescents and children outpatient day treatment and partial hospitalization residential treatment inpatient community based treatment now a lot of times you can get case management and home based services for children you can't get that for adults but you can get that for children so look into that because you're going to gain much more information from doing home visits than you are from the office visits foster care and therapeutic group homes are also options for some children crisis intervention has three basic components evaluation and assessment intervention and stabilization and follow up planning when a youth is in crisis we want to try to make sure that there are options available not just a hotline crisis group homes can be helpful which is kind of a step down from an inpatient crisis stabilization unit but inpatient crisis stabilization units are helpful runaway shelters, telephone hotlines and even mobile crisis teams that can come out and help de-escalate a situation hopefully to help the child stay in the home overnight and be safe service delivery can run the gamut of what a child needs from case management to inpatient hospitalization the emphasis is on being culturally competent community based and family inclusive so we need to obviously be culturally competent community based means making sure that we're taking advantage and building on the resources in the community and making sure that people can access it they're not having to go to the next town over and they need to include the family children live with their family so if they are in a dysfunctional environment they're going to have difficulty coming out of it likewise if the child is having these problems the family probably needs additional tools to help the child take care of him or herself a major problem in children getting help is the complexity of the system which causes it to be underutilized only one in five children with serious emotional disturbances get the help they need and a lot of times that starts out because of a school referral financing of services private insurance often covers it public sector care style thinking if we're talking about Medicaid can cover it and Medicaid actually I've worked at facilities that were approved by Medicaid we actually were able to build for a whole lot of services if the parents were willing to bring the child in so effectiveness studies just real quick Fort Bragg study provided a wide range of services without any limitations no capitation on visits no none of that stuff that we have to struggle with to get compensation access was increased children stayed in treatment longer and there was higher satisfaction with services because they were actually getting to the point where they were ready to discharge and the recovery had been integrated into their behavior and their lifestyle some of those old habits had been broken instead of eight or ten weeks and you're out you know they were able to stay as long as they needed the Stark County study served the public sector with a multi-agency system more case management and home care was provided than in other groups there was no difference in clinical or functional status 12 months after intake so you know providing case management and home care alone is not going to necessarily do it what we need to look at is really reaching in into the community and providing services without limitations if we want to look at these two studies and try to draw something from it deviations from developmental standards within cultural and familial context is the best standard by which to define childhood mental illness is this appropriate I mean if if mom tends to act one way when she gets upset and that's how junior acts you know social learning would tell us you know Bandura's theory tells us junior learned it through social learning so does that mean it's a mental illness or does that mean it's an unhelpful behavior that junior learned you know we want to look at look at that children deserve their own category when it comes to defining mental health problems because they do display them differently they have far fewer tools that they can use and they have far fewer experiences on which to draw in order to normalize what's going on so it can be traumatic and it can be it can seem like the end of the world to them family history genetic stressful events child abuse and more can be risk factors for child psychopathology the key is prevention we want to look at any of these risk factors and if families have them we want to make sure they can access additional resources as needed we want to make sure that parents have access to you know quick little chunks of information about how to effectively manage child outbursts and effective parenting skills and that can be done online that can be done in public service messages there are a bunch of different ways that they can do that a pastor can give a tip at the end of a sermon you know there are a lot of different ways you can get that information out there research is still underway to validate the effectiveness of mental health treatment forms in children just like adults we don't know for certain what's going to work with every child often the best approach is a multi systemic approach not surprising make sure the medical teams involved make sure the parents are involved try to get the school involved with permission and then we provide the mental health component okay are there any other questions and I will look up that question about whether the impact of depression in mothers or fathers is more impactful and let me show you on our homepage we have a tab called resources and this is where I will post any information that I find that way you know if you want to come back to it you can find answers to those questions so I will post something there a little bit later today and let you know whether I find anything or not alrighty everybody thank you so much for being here on Thursday have an amazing weekend and I'll see you on Tuesday if you enjoy this podcast please like and subscribe either in your podcast player or on YouTube you can attend and participate in our live webinars with Dr. Snipes by subscribing at allCEUs.com this episode has been brought to you in part by allCEUs.com providing 24-7 multimedia continuing education and pre-certification training to counselors therapists and nurses since 2006 use coupon code to get a 20% discount off your order this month