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 PrairieCare

1. Crisis Intervention Team Training Advanced Child and Adolescent CIT Michael R. Peterson MA LAMFT Executive Director Steve M. Wickelgren MA MFT President Minnesota CIT Officers Association Jane Marie Sulzle, RN, CNS, MS PrairieCare

2. 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

3. Training Objectives Define the problem Building a Team Understanding the differences between Adult and Child/Adolescent Mental Health Assessing stakeholders needs and resources Building a Partnership Identify the target audience Develop a Training model Market training

5. Define the Problem Officers struggled to understand Increase in kids diagnosed with mental Illness Lack of knowledge about community resources Understanding the difference ODD, ADD, ADHD, Bipolar, or just a kid Parent struggles School/Community

6. 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.

7. Building a Team Who cares Who is impacted Who can help Willingness to commit time and resources Interested in future solutions Understanding of the problem Enthusiasm

8. Understanding the Differences Listen to the experts Research Care about kids Developmental markers What is adolescents When is a person an adult Why

10. Stakeholders Kids Parents Schools Police Courts Mental Health providers Substance abuse treatment Community advocates

11. UnderstandingParents Parents do the best they can with what they have.

12. Building Partnerships PrairieCare NAMI Minnesota School Staff County Social Services Mobile Crisis Teams School Resource Officers Local Police and Sheriff Departments

13. Identify the Audience Police Officers Sheriffs Deputies School Security Officers Juvenile Corrections Mobile crisis workers Mental Health Providers

14. Develop the Training Build off current Minnesota Cit Officers Association CIT Memphis Model curriculum Identify differences Identify the similarities Identify resources available Develop child and adolescent role play scenarios

15. Marketing Post on Website Attend conferences MN SRO association MN Sheriffs association MN Police chiefs association Mental Health conferences Email notices

16. Children's Mental Health and Crisis Intervention

17. Outline of presentation Environment and biology Statistics about mental health Diagnoses and medications to treat them

19. Organic versus Behavioral OCD Brain Anxious Brain Normal brain Bipolar brain Depressed brain

20. 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

21. 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.gov Fast Facts about children and mental health Secondary effects

22. Bipolar Disorder Bipolar Disorder I, II and NOS Little 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

23. 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

24. Medication for Bipolar Disorder Atypical 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

25. 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

26. 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

27. 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

28. Need to Know Info (NKI) Very erratic, unpredictable behavior Defiant Can be difficult to finesse Little ones can be very aggressive, like a toddler response Adolescents more grandiose

29. Psychosis Person (adult or child) is experiencing hallucinations, delusions, distorted thinking. Bipolar Disorder, Mania Schizophrenia Depression Paranoia Drugs Medications

30. 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

31. 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.

32. 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

34. Metabolic disorders

35. High cholesterol

36. Flat affect

37. Sedation

39. 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

40. Psychotic disorder http://www.youtube.com/watch?v=QPXkwYM9G-s&NR=1

41. 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

42. 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.

43. 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!

44. 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.

45. Depression 1 in 33 kids, 1 in 8 adolescents Are more irritable Defiant Big sleep problems Can’t do homework Doesn’t spend time with friends Gives things away

46. Depression Depression Unusual in young children More common in adolescents; more girls than boys. Can be chronic (dysthymia) 20% of children who present with depression actually have Bipolar Disorder Symptoms: Irritable in young children, sad in adolescents Withdrawn Low energy Suicidal ideation Self-harm Difficulty concentrating

47. Suicide in adolescence Every 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”.

48. Acute Suicidal Ideation Chronic Suicidal Ideation What was the trigger? What have been other symptoms Lethality? 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.

49. Medications Side effects Mania, weight gain, weight loss, sedation, activation, impotence, suicidal ideation Mania, weight loss, dry mouth, dizzy, impotence Activation, decreased energy, suicidal ideation SSRI’s: Prozac, Celexa, Lexapro, Luvox, Paxil SNRI’s: Cymbalta, Effexor NDRI: Wellbutrin

50. NKI Slow to process, wait for them to answer Slow to move They will likely not look at you, not about you Be empathetic Medications may be making worse, either more suicidal or manic.

51. 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

52. 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

53. Medications Antidepressants Prozac, Celexa, Zoloft, Luvox, Lexapro, Paxil Stimulants Concerta, Ritalin, Adderall, Metadate, Focalin, Daytrana patch, Vyvanse Strattera Blood pressure medications Clonidine, Tenex Atypical antipsychotics Risperdal and Abilify are both FDA approved, but also use Seroquel, Geodon, and Zyprexa

54. NKI DO NOT TOUCH DO NOT JOKE, remember they take language literally. Quiet the environment Decrease light and sound Decrease number of people Find out their special interest No power struggles You can talk them down Distraction works well.

55. 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

56. 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

57. Oppositional Defiant 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.

58. Conduct 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

59. Antipsychotics Atypical antipsychotics Typical antipsychotics Medications to treat

60. 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.

61. 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 …”

62. 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.

63. Adolescent brains are a work in progress

66. Questions?