Mental Illness and Suicidal Behaviour in Children and Youth

1. Mental Illness and Suicidal Behaviour in Children and Youth Dr Phil Ritchie, Psychologist Children’s Hospital of Eastern Ontario

2. Mental Illness in Children and Youth • Statistics suggest that by the time students graduate from high school, 1 in 5 will have met criteria for a diagnosable mental illness. • Unfortunately, only 1 in 6 of these will have received appropriate treatment for this.

3. Adolescence The period of life when your child kicks you off the pedestal they’d put you on only to step up onto it themselves. That period that immediately follows your child’s first sleeping through the night in which they decide to stay up all night and sleep through the day.

4. Adolescence – A Series of Crises (with thanks to Dr. Tracy Vaillancourt) Identity – increasingly self-conscious, who do they want to affiliate with, sexuality Autonomy – move away from parental influence to that of peers Intimacy – relationships no longer based on common activities, now focuses on meeting emotional needs

5. A Series of Crises cont’d Sexuality – biologically driven Risk-taking – stimulation-seeking Egocentrism – concerned with how others perceive them

6. The Adolescent Brain Brain develops to mid-20s At puberty, pruning process Motor and sensory areas are quite sophisticated while decision-making (important for impulse-control and emotional regulation) centres remain underdeveloped

7. The Adolescent Brain cont’d In short, adolescents are physically capable of complex feats, but psychologically ill-prepared to make good decisions One giant, tingly nerve looking to get stimulated but little judgment about the dangers such stimulation might entail

8. The Adolescent Brain, cont’d

9. Anxiety Disorders in Youth – A Pattern of False Alarms Anxiety is a good thing – anticipating future danger or misfortune is helpful Keeps us from diving into unknown waters or walking in a dangerous neighbourhood late at night When anxiety becomes extreme or irrational, it goes from adaptive to maladaptive Most common Mental Illness affecting 12% of population, half of which will develop as children or youth

10. Anxiety Disorders in Youth cont’d Panic Disorder Specific Phobia Social Phobia (Social Anxiety Disorder) Obsessive Compulsive Disorder) PTSD (the only 1 that requires a “trigger” event) Generalized Anxiety Disorder Separation Anxiety Disorder Anxiety Disorder NOS

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

12. Treating Anxiety Disorders Cognitive Behaviour Therapy (CBT) is evidenced-based non-medication treatment of choice Mood, thoughts, and actions inextricably linked You are their teacher, not therapist, but helpful to understand principles (e.g., exposure/response prevention)

13. Classroom Accommodations for the Anxious Student • Check in with student on arrival • Don’t penalize for being late (sx at home often interfere with getting out the door) • Assist with peer interactions • Anticipate difficulty with transitions • Give notice re. changes in routine

14. Classroom Accommodations cont’d Extra time for tests and assignments Safe place Use of nonverbal cues so as not to centre out the student Model appropriate coping behaviours

15. Interventions for the Anxious Student Worry Answer the “what ifs” and take away anxiety associated with the unknown Track improvements with feedback to the student Have the student rate their fear and then track it

16. Interventions for the Anxious Student cont’d • Emotional Outbursts • Identify triggers with the student • Encourage them to problem-solve (e.g., CPS) • Develop a hierarchy of safe places in which to de-escalate from a meltdown

17. Mood Disorders in Youth • Major Depressive Disorder • Dysthymic Disorder • Bipolar I and II Disorders • Cyclothymic Disorder

18. Mood Disorders cont’d • Important to understand that mood disorders affect not just how the student feels, but also sleep, appetite, concentration, motivation, interests, and energy. • This is a recipe for a decline in functioning at school (as well as home and social), likely to compound an already fragile self-esteem. • Treat depression and other factors tend to improve.

19. Suicidal Behaviour in Children and Youth • With thanks to Dr. Allison Kennedy

20. A Complicated World for Teens • Amanda Todd’s video has almost 6 million views, almost 45 thousand likes, and almost 100 thousand comments • There are a number of RIP Amanda Todd Facebook sites with 100 of thousands of likes • Adolescents have unprecedented access to unfiltered information about suicide through social media and the Internet

21. Social Media – A Pox on All Our Houses? • Preliminary studies suggest that internet use in a country was associate with an increase in suicides. • Cyberbullying has been tied to increased suicide risks particularly in adolescents. • Social media may help people form suicide pacts and unlike more traditional pacts, may involve complete strangers and bogus participants/eggers on. • Internet provides a “how-to” guide for suicide. • Internet provides access to pro-suicide sites.

22. Social Media – A Pox on All Our Houses? • But social media are also being used to prevent suicide. • National Suicide Prevention Lifeline (US) developed a Facebook chat add-on for users to report at-risk individuals. • Similar links being developed for Twitter, Tumblr, and Google (e.g., “I want to kill myself” results in top sponsored link being to prevention resources)

23. Canadian trends In Canada, suicide is 3rd leading cause of death for 10 to 14-year-olds and the 2nd leading cause for 15 to 19 year olds In Canada, suicide is the cause of death for 24% of 16 to 24-year-olds A large percentage of youth experience suicidal thoughts At CHEO, youth are increasingly presenting to the ED with suicidal risk

24. Reasons for suicidal behaviour in adolescence Changes in cognitive development capacity for abstract and complex thinking more capable of contemplating life circumstances, envisioning a hopeless future, suicide as a possible solution and planning and executing a suicide attempt Onset of substance use/abuse Increased rates of mental health problems Increased access to potentially lethal suicidal means

25. Risk: Clinical factors • Psychiatric history • Depression and conduct disorder • Drug/alcohol use • Previous suicide attempt • Hopelessness

26. Risk: Personal and family history • History of abuse • Family history of suicide/exposure to suicide • Exposure reduces the suicidal taboo • Issues with family communication and problem solving • Attachment issues, inability to approach parents for support

27. Risk: Life stressors • Suicidal adolescents present with significantly increased levels of life stress • Increased interpersonal conflict and social isolation • Other stressors may serve as a trigger to vulnerable youth who are already at risk (e.g., loss, transition)

28. Risk: Emotional and cognitive factors Problem solving deficits Difficulty generating alternative solutions to interpersonal conflict Poor emotional regulation Impulsivity

29. Sex differences Adolescent girls also are more likely than boys to attempt suicide --- although boys are more likely to complete it (3 males:1 female) Most studies relate the differences in completion rates to the method chosen Girls --- overdose or cutting Boys --- hanging or firearms

30. Other demographic risk factors • Age • Increased risk with increased age within the teen years • Race • Aboriginal youth at particularly high risk • Sexual orientation • Gay/transgendered youth at higher risk

31. Some Statistics … 15 to 20% seriously consider suicide 10 to 15% make a suicidal plan 6 to 9% attempt suicide 2 to 3% present for necessary medical treatment after a suicide attempt

32. … in a classroom • 4 or 5 students will seriously consider suicide • 3 students will have a suicidal plan • 2 students will attempt suicide • Students in an alternative setting are at higher risk for suicidal behaviour

33. How school staff can help • Learn • … the signs of risk in students • Identify • … at risk students • Refer • … to appropriate resources

34. Warning signs in school Suicidal threats Talking or writing about death, dying, suicide Changes in appearance, mood, attendance, academic functioning Social isolation Bullying

35. Talking to at-risk students • Know your limits • Listen • Acknowledge feelings, clarify, summarize, validate • Know your resources • Act and ask: “have you thought about killing yourself; have you already tried to hurt yourself?” • Follow up

36. School based prevention Be aware of signs and know how to respond Foster a healthy school environment Educate students on coping skills De-stigmatize mental health issues by talking about it Educate students regarding mental health resources in the community

37. Non Suicidal Self Injury (NSSI) Intentional self-harm without conscious suicidal intent (e.g., cutting, scratching, burning, hitting) Relatively common, particularly for girls An attempt to cope that is often learned from other youth Primary goal of behaviour is affect regulation Youth who engage in NSSI are at elevated risk for suicidal behaviour

38. Assessment of nonsuicidal self-harm Examine onset, frequency, intensity, and duration Assess risk of injury Identify triggers

39. The role of parents/caregivers • Engage parents whenever possible • Parents need to be aware of safety issues • Parents need guidance regarding how to respond if their teen approaches them • Stay calm, listen, don’t judge, provide comfort and reassurance (e.g., “I know that you are in a lot of pain right now but I am with you and we will get you the help you need to feel better”) • Parents can call crisis lines directly • Even if the teen does not feel comfortable directly confiding in them, they can check in, monitor, and assist with distraction during an episode of acute distress • In general, parents and professionals provide better support than peers

40. Follow-up – the elephant in the room? Having asked “the question” and referred to a school, community, or hospital-based resource, as appropriate, it is important to re-establish your relationship with the student. Make time to see the student the next available opportunity, let the student know how glad you are that s/he spoke with you, that you care about how they’re doing, but that you will leave it to the mental health professionals to deal with that part of things. And that if s/he wants to talk again, you’re always happy to listen, and that this doesn’t otherwise change anything about the relationship.

41. The Adult (i.e., Teacher) Brain (with thanks to Dr. Matthew Sharps) When communicating with anyone in crisis, important to understand how it affects not only their thinking, but also ours. Big stress response (HPA Axis) results in blood being diverted from neocortex to lower areas (limbic and reptilian brains)

42. The Adult Brain cont’d Go into survival mode and the reptilian brain kicks in Alligators are brilliant survivors, “living fossils” that have existed 200M years Alligators are not so good at conversation, investment advice, or problem-solving in the midst of crisis

43. The Adult Brain cont’d In survival mode, we get “alligator stupid” Reptilian brain is reliable but rigid and compulsive “Four Fs” – feeding, fleeing, freezing, and mating

44. The Adult Brain cont’d Survival mode is a vestige of our hunter/gatherer brain Tunnel vision can be helpful if pursuing a wild boar looking to turn it into dinner Not so helpful if staring at the hickey on our teenage daughter’s neck or the crack in the new HDTV after our son invited a “few friends” over c/o Facebook while we were out of town

45. The Adult Brain cont’d Need our neo-cortex for more advanced problem-solving (don’t try to fit head in peanut butter jar – get a spoon) Also need the neo-cortex to manage sub-cortical parts of brain, and to separate affect from problem-solving

46. Alligator Stupid - There is No “Us and Them” While negotiating with those in crisis, important to get out/stay out of “alligator stupid” mode, and have the higher centres of the brain remain active Those with a past of early trauma, chronic stress, bad night’s sleep, or 12 skinny pumpkin spice lattés (they were on sale) compound matters

47. Alligator Wrestling When appropriate, taking a few slow, big breaths can help Your paraverbals – calm, not too loud, not too fast, but reassuring Become their surrogate neo-cortex – get them to slow down, help them see that there are other solutions

48. Web-Based Resources • www.cheo.on.ca • www.ementalhealth.ca • http://www.kidsmentalhealth.ca/children_youth/learn_more.php • http://www2.massgeneral.org/schoolpsychiatry/for_educators.asp