advanced child and adolescent cit
DESCRIPTION
Presented by: Michael R. Peterson MA LAMFT Executive Director Steve M. Wickelgren MA MFT President Minnesota CIT Officers Association Jane Marie Sulzle, RN, CNS, MS PrairieCareTRANSCRIPT
Crisis Intervention Team Training
Advanced Child and Adolescent CIT
Michael R. Peterson MA LAMFTExecutive Director
Steve M. Wickelgren MA MFT President
Minnesota CIT Officers AssociationJane Marie Sulzle, RN, CNS, MS
PrairieCare
Our youth now love luxury. They have bad manners, contempt for authority; they show disrespect for their elders and love chatter in the place of exercise; they no longer rise when elders enter the room; they contradict their parents, chatter before company, gobble up their food and tyrannize teachers.
--Socrates, Fifth Century BC
Training ObjectivesDefine the problemBuilding a TeamUnderstanding the differences between
Adult and Child/Adolescent Mental HealthAssessing stakeholders needs and
resourcesBuilding a PartnershipIdentify the target audience Develop a Training modelMarket training
Define the ProblemOfficers struggled to understandIncrease in kids diagnosed with mental
IllnessLack of knowledge about community
resourcesUnderstanding the difference ODD, ADD,
ADHD, Bipolar, or just a kidParent strugglesSchool/Community
What emotion do you see?
DIFFERENCES IN PERCEPTION
Adults see Surprise: In the adult brain,
reading emotions involves the prefrontal cortex.
Adolescents see Anger: In the adolescent brain, it involves the amygdala.
Building a TeamWho caresWho is impactedWho can helpWillingness to commit time and resourcesInterested in future solutionsUnderstanding of the problemEnthusiasm
Understanding the Differences Listen to the expertsResearch Care about kidsDevelopmental markersWhat is adolescentsWhen is a person an adultWhy
StakeholdersKidsParentsSchoolsPolice CourtsMental Health providersSubstance abuse treatmentCommunity advocates
UnderstandingParents
Parents do the best they can with what they have.
Building Partnerships
PrairieCareNAMI MinnesotaSchool StaffCounty Social ServicesMobile Crisis TeamsSchool Resource OfficersLocal Police and Sheriff Departments
Identify the Audience
Police OfficersSheriffs DeputiesSchool Security OfficersJuvenile CorrectionsMobile crisis workersMental Health Providers
Develop the Training
Build off current Minnesota Cit Officers Association CIT Memphis Model curriculum
Identify differencesIdentify the similaritiesIdentify resources availableDevelop child and adolescent role play
scenarios
Marketing
Post on WebsiteAttend conferences
MN SRO association MN Sheriffs association MN Police chiefs association Mental Health conferences
Email notices
Children's Mental Health and Crisis Intervention
Outline of presentation
Environment and biologyStatistics about mental healthDiagnoses and medications to treat them
Influences on Children
Biology
Static
Congenital
Environment
PositiveInfluences
FamilyChanges
School TraumaReversible
Medicine PsychiatryAcquired•Abuse
•Neglect
•Domestic Violence
•Natural Disaster
•Divorce
•Separation
•Death
•Frequent moves
•Good fit
•Not good fit
•Positive parenting
•Positive community support
•Faith community
•Diabetes
•High blood pressure
•Aids
•ADHD
•Bipolar
•Schizophrenia
•Depression
•Anxiety
•Head injury
•Stroke
•Down Syndrome
•Autism
•Learning Disabilities
•Fetal Alcohol Syndrome
Intellectual property of Josh Newman, MD, Wilder Foundation
Normal brain
OCD Brain Anxious Brain
Bipolar brain Depressed brain
Organic versus Behavioral
Prevalence of Mental Illness in Children and Adolescents
5% of children
10-15% of adolescents
1 of 5 have a mental illness, 2 of 5 get the care they need.
15-20% incidence of MI in adults
Secondary effects
Untreated School failure Family conflicts
Substance abuse
Violence Suicide May increase
risk of juvenile justice Have at least one
mental disorder 66 % boys 75% girls
www.mentalhealth.samhsa.govFast Facts about children and
mental health
Bipolar DisorderBipolar Disorder I,
II and NOSLittle agreement
about diagnostic criteria Does Bipolar Disorder
really exist in children?
What does it look like
Co-morbid with ADHD
Most challenging to treat
High co-morbid with drug use/abuse
What does bipolar disorder look like?
Between 20-25% of children who first present with MDD will eventually prove to have bipolar.
“ADHD on speed” Doesn’t need much sleep, goes from very
sad (irritable) to wild and crazy in a flash, grandiosity is seen as “I don’t have to, you’re not the boss of me.” “I don’t need directions”, scary risk takers, can rage for hours.
Very difficult to diagnosis/treat
Medication for Bipolar DisorderAtypical antipsychotics
Abilify, Seroquel, Risperdal, Zyprexa, Geodon Should follow lab work as starting, 3 months out and
annually Weight showed be followed closely May cause “dulling” EPS (Extrapyramidal side effects) movement
disorders that require immediate interventions
Atypical Antipsychotics
Abilify Middle range for
weight gain Helps with frontal
lobe functioning Akathisia
Seroquel Sedation, calming Weight gain Great to help with
sleep Zyprexa
Most significant for weight gain, but works well
Really helps with aggression
Atypical Antipsychotics (cont)Risperdal
Weight gain Breast enlargement,
lactation Dulling FDA approved for kids
in autism spectrum
Geodon Difficult to use Fewest side effects Not very effective
Medications for Bipolar Disorder (cont.)
Mood stabilizer Anti-seizure medications
Depakote, Trileptal, Lamictal Can cause dulling, weight gain, life-threatening rash,
pancreatitis, Depakote needs frequent lab draws
Lithium Frequent lab draws Very narrow window between helpful level and toxic Can cause thyroid to stop functioning
Need to Know Info (NKI)
Very erratic, unpredictable behavior
DefiantCan be difficult to
finesse Little ones can be
very aggressive, like a toddler response
Adolescents more grandiose
Psychosis Person (adult or child)
is experiencing hallucinations, delusions, distorted thinking. • Bipolar Disorder,
Mania• Schizophrenia• Depression• Paranoia • Drugs• Medications
Schizophrenia Rare in children
• Children under 12:1 in 40,000• Adolescents: 3 out of every 1,000
Hallmarks• Disheveled appearance• Odd expressions and behaviors• Little to no emotional expression• Hearing voices, seeing things, bizarre beliefs, odd
speech
What you might see Behavior seen
• Irrational• Paranoid
Someone is out to get them
Conspiracy • Delusional
Has special powers “God” Can see, hear, know
things others do not Physically strong
What to do• Be calm• Go slow• Do not use humor,
they don’t understand
• Avoid confrontation, they don’t understand
• Play with them to get them to cooperate.
What you might see (cont.) Behaviors (cont)
• Hyperactive/reactive• Agitated• Rapid, disorganized
speech• Poor self control• Very poor judgment• No insight
Arguing is useless Calm the
environment
Medications for Schizophrenia Atypical
antipsychotics• Risperdal, Zyprexa,
Geodon, Seroquel, Abilify, and Clozaril Weight gain, more in
kids Metabolic disorders High cholesterol Flat affect Sedation Extra pyramidal
symptoms, (EPS)
Other medications Typical
antipychotics• Haldol, Prolixin,
Thorazine, Trilafon, Melleril
• Dulling (slow thinking
• Flat affect• EPS/ temporary• Tardive Dyskinesia
Involunary movements that are permanent
NKI Very rare in children/adolescents More likely chemically induced or
secondary to other disorder (depression, bipolar disorder)
Very unpredictable Join in their delusions/hallucinations,
don’t challenge them. Very unpredictable
Psychotic disorder
http://www.youtube.com/watch?v=QPXkwYM9G-s&NR=1
Attention Deficit/Hyperactivity
Disorder
Impulsive
Does without thinking; stealing, blurting, buying
Inattentive; disorganized, can’t follow directions
Hyperactive; can’t sit or stand still, constant motion, will walk/run from parents
Combination of all three
ADHD
Often co-morbid with learning disabilities (trouble reading, writing)
Often co-morbid chemical dependency.
Very often with kids with Bipolar disorder
Impairs executive functioning; organization, movement, time understanding.
Medications
Stimulants: Concerta, Adderall, Vyvanse, Daytrana Patch, Metadate, Focalin, Dexedrine, Ritalin
Daytrana patch and Vyvanse with hx of chemical abuse.
Decrease appetite
Cause mania and depression.
Can cause trouble getting to sleep.
Only work the day they take them and not into the evening!
NKI Will run without thinking, little ones get
lost, older kids when they are in trouble
Will “mouth off” without thinking, often will have remorse later. Don’t react!
Can’t remember 2-3 step directions
Can’t stand still, move with them. Don’t make them be still, often they think better when moving.
If you are working with them in the evening MEDICATIONS HAVE WORN OFF
Seldom see just a child with ADHD, likely co-morbid with something else.
Depression1 in 33 kids, 1 in 8
adolescents Are more irritableDefiantBig sleep problemsCan’t do homeworkDoesn’t spend time with
friendsGives things away
DepressionDepression
Unusual in young childrenMore common in adolescents; more girls than
boys.Can be chronic (dysthymia)20% of children who present with depression
actually have Bipolar DisorderSymptoms:
Irritable in young children, sad in adolescents Withdrawn Low energy Suicidal ideation Self-harm Difficulty concentrating
Suicide in adolescenceEvery year, nearly 5,000 people between age
15 and 24 commit suicide.
Suicide is the 2nd leading cause of death in adolescents.
Suicide threats/attempts within schools can occur in “clusters”.
Acute Suicidal Ideation
Chronic Suicidal Ideation
What was the trigger?What have been other
symptomsLethality? Are they on medication
that could cause this?
Is how they cope with stress
Common in Borderline Personality Disorder
May have history of self-injuring behavior
Don’t belittle, they will escalate their lethality.
Frequent non-lethal attempts.
Medications Side effects
SSRI’s: Prozac, Celexa, Lexapro, Luvox, Paxil
SNRI’s: Cymbalta, Effexor
NDRI: Wellbutrin
Mania, weight gain, weight loss, sedation, activation, impotence, suicidal ideation
Mania, weight loss, dry mouth, dizzy, impotence
Activation, decreased energy, suicidal ideation
NKISlow to process, wait for them to answerSlow to moveThey will likely not look at you, not about
youBe empatheticMedications may be making worse, either
more suicidal or manic.
AUTISM SPECTRUM DISORDERS/PDD
1 in 150 kids Autism, Asberger’s Syndrome Symptoms:
Impairment in social interaction Nonverbals: eye contact, gestures, facial expressions Peer difficulties
Stereotypic interests Communication problems: use of speech and type of play
Nonverbals: eye contact, gestures, facial expressions Peer difficulties Talks language literally!!!!
Will power struggle with you
BEHAVIORS YOU MIGHT SEE Significant trouble with sensory issues:
light, sound, textures Easily overwhelmed and confused Has a special interest, find out what it is Can be manipulated with special
interest Transitions are very difficult Very persistent
MEDICATIONS Antidepressants
Prozac, Celexa, Zoloft, Luvox, Lexapro, Paxil Stimulants
Concerta, Ritalin, Adderall, Metadate, Focalin, Daytrana patch, Vyvanse
StratteraBlood pressure medications
Clonidine, Tenex Atypical antipsychotics
Risperdal and Abilify are both FDA approved, but also use Seroquel, Geodon, and Zyprexa
NKI DO NOT TOUCH DO NOT JOKE, remember they take language
literally. Quiet the environment
Decrease light and soundDecrease number of people
Find out their special interest No power struggles You can talk them down Distraction works well.
Has been exposed to a trauma that felt life threatening
Triggers are often unknown Reactive, fear based Fight or flight response Use “soothing” responses Move slowly, deliberately, NO
SURPRISES!!!!!
Post traumatic Stress Disorder
Did not have a healthy attachment as infant◦ Most often children who are adopted◦ Children separated from mother◦ Mother’s with significant depression
Behavior is very defiant Reacts in aggression Little social thought “Stuff” is very important to them, can be
bribed.
Reactive Attachment Disorder
ODD:5-15% of school aged children A 6 month pattern of negative, hostile and
defiant behavior, including:◦ Blames others◦ Argumentative◦ Defies adults◦ Annoys others and is easily annoyed
I seldom diagnosis, usually a reason for behavior.
Oppositional Defiant Disorder
6% of the population (4:1 M/F) Violates basic rights of others/ societal rules Aggression toward people and/or animals Destruction of property Theft or deceitfulness Likely has source, PTSD, RAD, et al
Conduct Disorder
Antipsychotics◦ Atypical antipsychotics◦ Typical antipsychotics
Medications to treat
Myths and Misperceptions
“All teenagers are moody/hormonal”
“She’s just trying to get attention”
”She’s just trying to get out of school”
“He’s just a bad kid.” “It’s all the parent’s fault.” “She just needs to get up and get outside.” It only happens to weak people/poor people. It will never happen to me or my family.
When negotiating choices…..
Negotiate = both sides get their needs met Find a way to honor some of the subject’s
needs. Allow choices when possible. (increases sense of control and safety)
Only offer two choices: be prepared s/he will make the “wrong” choice.
Be open to a modified version of the two choices.
“I can’t do that, but there in another option …”
Engaging the Family Understand that your presence may alter the child’s
behavior. Use parent interview to determine:
History/severity of problem History of mental health care/parent intervention
What has helped in the past Medical problems/medications Available supports/resources Parent’s ability to keep child safe
Assess parents’ contribution to the problem. Expect parent to follow child to ED and participate in
assessment. Treating parents as part of the solution; working
together will increase compliance.
Adolescent brains are a work in progress
Time Day #1 Day #2 Day #3
Date Date Date
0800 - 0830 Opening Introductions Mental Health/Behavioral Sites/Community Res discussion
0830 - 0900 Mental Health/Illness MN CIT and PrairieCare Mental Health/substance Abuse
0900 - 0930 Child/Adolescent Mental Illness Medications MN CIT and PrairieCare
0930 - 1000 MN CIT and Prairie Care PrairieCare___________ Bio, Psycho, Social Affect
1000 - 1030 continued Role Play Exercises MN CIT and PrairieCare
1030 - 1100 continued continued Legal Update
1100 - 1130 Consumer/Family Panel continued NAMI Sue Abderholden
1130 - 1200 continued continued Lunch
1200 - 1230 Lunch continued Cultural Awareness
1230 - 1300 De-escalation Skills Lunch Panel
1300 - 1330 MN CIT Site Visits and continued
1330 - 1400 Role Play Exercises Community Resources Role Play Exercises
1400 - 1430 continued One group PrairieCare continued
1430 - 1500 continued One group Fairview Riverside continued
1500 - 1530 continued continued continued
1530 - 1600 continued continued continued
1600 - 1630 Day 1 Debrief Travel home from Site Debrief and Wrap up
Day #1 Day #2 Day #3 Day #4 Day #5
Monday Tuesday Wednesday Thursday Friday
Introduction Introduction Introduction Introduction Introduction
Why CIT? Adult Mental Illness Suicide Prevention Mental Health Review Suicide by Cop
Introduction to Child and
Role Play #3
Military/Family Reintegration
Adolescent Mental Illnesses Adult Mental Illness Excited DeliriumHotel Room / Disturbance
Connie Bengston VA
MN CIT (Cont.)
Consumer Panel Psychotropic Medications Community Resources(Cont.)
Juvenile Detention
(Cont.)
(Cont.) NAMI Debrief Role PlayCommitment Process
Lunch Lunch Lunch Lunch
Introduction to Child and De-escalation Skills II Drug/Alcohol Awareness Travel to Site VisitsLunch
Adolescent Mental Illnesses (Cont.) (Cont.) Role Play #4
Experiential Exercise Role Play #1 Role Play #2 School Disturbance/ Break Up
"Hearing Voices" Storefront / Domestic Pedestrian / Overpass (Cont.)
Introduction to Child and (Cont.) (Cont.) (Cont.)
Adolescent Mental Illnesses (Cont.) (Cont.) (Cont.)
De-escalation Practice (Cont.) (Cont.) Debrief Workshop
Debrief Day 1 Debrief Day 2 Debrief Day 3 Travel home from Site Visits Meet the Actors/Graduation
Questions?