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Children and Adolescents’ Depression and Suicide – Survival 101: What We Need to Know September 24, 2003 Nancy Rappaport, MD, Instructor at Harvard Medical School, is the Teen attending psychiatrist with high risk students at SBHC and Director of School Consultation at Cambridge Hospital, Cambridge, MA This is similar to a CPR refresher course where some things are familiar about how to identify at risk suicidal patients and about appropriate interventions. The material that I share with you today is based on what I have found clinically useful when I am working with high risk children, adolescents, and their families. The presentation also is offered with a level of humility, recognizing that we don’t have all the answers, this is a work in progress. But when our students are struggling – in crisis – we need to be decisive in our response. They can’t wait for the longitudinal studies, the randomized control studies to confirm and direct us and we are asked to draw from the research and clinical treatment for best practices. So today I am a tour guide through depression and suicide looking at clinical vignettes, statistical information, developmental characteristics, information from psychological autopsies that help us to appreciate the role of mental illness in suicide, identifying depression and bipolar and treating suicidal patient. I. Faces of Suicidal Ideation – Individual – No typical suicidal adolescent CV- learned to fight before ABC’s, parents’ alcoholic-administrators invested-then disappointed- anger is the mother of depression VM quiet girl, high-risk Internet Acceptable option – aunt anxiety, sweating perseveration Sunday prior to school start Early abuse, hoarded medicine, OD recognition of how devastated mother would be, renewed focus Boy lost father in fight – wants to get gun and even the score Clinical vignettes are interspersed throughout the lecture to illustrate the data. The data is used to create the sense of mosaic and to make the research pertinent to shape good care. It is critical to think of each child individually. 1 II. General Facts about Suicide Fig. 1 12 10 8 6 4 2 0 10-14 years old 15-19 years old 1. Disturbing statistics Fig. 1: Developmental and temporal trends in rates of adolescent suicide. Data from Maguire and Pastore (1999). Fig. 1.2 20 15 10 5 0 Male (15-19 yrs) Female (15-19 yrs) Fig. 1.2: Developmental trends since 1950 in suicide rates for 15- to 19-year old adolescents, by gender. Data from Maguire and Pastore (1999). 322 deaths 5-14 years (.9/100,000) 4956 deaths 15-24 years (13.8/100,000) - Girls 3.4/100,000 Boys 15.1/100,000 For young people 15-24 years old, suicide is the third leading cause of death, behind accidental injury and homicide. 2000 adolescents 15-19 commit suicide each year. Persons under age of 25 accounted for 15% of all suicides in 1997. 2 - - Within schools this statistic translates to in a district of 8,000 students, one suicide every year. How many of us have experienced an adolescent who we know that completed a suicide? How many of us initiated an evaluation of a student or patient that was suicidal this week? Suicide assessment is the most commonly encountered emergency situation for mental health professionals. It probably is one of the most stressful of all clinical endeavors (Cocktail party, terrible at small talk) Within the next 24 hours 1439 teenagers in the US will attempt suicide (to place this in context 3,000 kids will start smoking) As the teenagers get older they are more at risk for suicide Suicide is the third leading cause of death between ages of 15-24 “Age of melancholia” “Age of self-annihilation” Firearms are the most common method for completed suicides, followed by ingestions leading to overdose and then hanging 65% of completed suicides use handguns. The increase in the rates of youth suicide (and the number of deaths by suicide) over the past four decades is largely related to the use of firearms as a method of destruction If a gun is used to attempt suicide, a fatal outcome will result 78-90% of the time. Boys frequently use guns, which is a more lethal method than overdose Suicide attempts are more prevalent among adolescent girls than among adolescent boys. Up to forty percent of teenagers who commit suicide have made a prior attempt. There are four hundred suicide attempts by teenage boys for every completed suicide in males (Shaffer chapter) Four thousand suicide attempts per every death in females (G. C door with girl fainting with OD) Who uses most effective method in completed suicide, boys or girls? This is a trick question highlighting our assumption that men are more lethal in their attempts. But death by overdose is as lethal as death by guns. Don’t be distracted with gender statistics 2. The Center for Disease Control The Center for Disease Control (CDC,2000) has tracked by school survey since 1991 every two years, 12,000 to 16000 students. It is fairly common for teenagers to have suicidal ideation (to think seriously about killing themselves) as demonstrated by students answering yes to the survey question, “ Have you seriously considered suicide within the last year?” Although, fortunately, lethal attempts and completion are relatively rare. Approximately 20 percent of students have had suicidal ideation, about ten percent of students made a suicide attempt in a twelve month period, and 1-3% of teenagers will receive medical attention for an attempt (700,000), while 3 .01% will complete suicide. It is key to remember that ideation is almost always episodic. Hispanic youth report more suicidal thoughts than whites for unclear reasons. It is difficult to assess future behavior but we have some clinical studies and epidemiological studies that help with our decision making process. III. Developmental Characteristics Why do so few youths who are between 10 -14 years old commit suicide as compared with adolescents 15-20 years old? It is key to think of each child developmentally as to what is appropriate for the child’s developmental stage. Rare suicides before twelve years old (prepubertal) More common in males than females (3:1) Causality not developed in children under ten years old. They don’t get degree of lethality. (By age of ten most children understand what suicide means.) 1. Profile of children with completed suicides: - Immature problem solving that translates into more impulsive - Less able to tolerate frustration (with adults data shows decreased seretonin) - Unable to plan future actions - Aggressive or violent outbursts(Aggressive 8-year-olds are more than twice as likely as nonaggressive 8-year-olds to think about or attempt suicide at age 16) (Sourander et al. 2001) - Difficulty making decisions - Less able to assess situations realistically then non suicidal children - Loss of parent before age 12-perception that death is attractive - History of parental abuse- these children can have low self-esteem from poor relationship with parents-developmental needs not adequately met. Difficulties with emotional regulation and poor self-soothing that can lead to impulsivity and aggression Early onset of suicidal behavior prepubertal predicts suicidal behavior in adolescents. Vigilant to signs of emotional stress even though may appear somewhat trivial initially (“I want to be with the angels”). Groholt (1998) looked at suicides between 1990 to 1992 comparing suicides of children below 15 years old (n=14) compared with late-adolescent suicides (15-19 years) n=115. Conflicts with parents were present more often in those children under fifteen years whereas older adolescents’ crisis were precipitated by disappointment in romantic relationships. These researchers found that there were fewer warning signs and precipitating events preceding the suicide of the children and young adolescents compared with older adolescents. They suggested that the lower prevalence of affective disorders among ten to fifteen year olds who completed 4 suicide as well as control group might explain some of the difference in suicide rate. *Be Alert to potential suicide risk in children who have affective disorder. The difficulty in determining prevention is that prepubertal suicides are such an infrequent occurrence and comparatively unpredictable in young children and adolescents. Although suicide attempts in children age 12 and under are relatively rare, suicide attempts are NOT rare in bipolar children (age 12 and under – 20%). Usually these children are difficult to treat and there is considerable controversy about the criteria as they are referred to, as, “rapid cyclers and often have mood lability, mood swings, affective storms irritability and aggressiveness, periodic agitation, explosiveness and severe temper tantrums which can also be in response to trauma and family discord,” (Papolos 1999). “Epidemic of bipolar” rapid shifts (FM) It is key with young children to recognize signs of mania/hypomania 2. Symptoms of bipolar disorder: DIGFAST acronym Distractible Insomnia Grandiosity Flight of Ideas and racing thoughts Agitation Suicidal ideation Talkative, pressured speech Historical context that compelled researchers to try to understand and prevent suicide came from the fact that in the early 1980s there was a sharp increase in the suicide rate particularly with white male teenagers and several teenage clusters.(Papolos) 3. Psychological autopsies This is a technique where researchers examine the circumstances of the suicide victim’s life reconstructed through interviews with friends and families. This retrospective suicide research may create bias because of the devastating outcome and that the survivors may increase their accounting of symptoms and the limitation that the deceased can’t provide insight. Shaffer studied large numbers of completed suicides at an average age sixteen (170 psychological suicide autopsy) in an ethnically diverse population in 198486 interviewing multiple informants with community control subjects. 5 More than 90% of subjects who committed suicide met criteria for at least one major psychiatric diagnosis. Psychiatric disorder is the strongest risk factor for attempted suicide. Fever reflects presence of physical illness; suicidal behavior indicates presence of psychiatric disorder. Half of these subjects had psychiatric disorder for at least two years. This provided compelling evidence that there is a strong link between psychopathology and suicide. Important implications –need for thorough diagnostic interview, never discounting a threat especially in the context of affective or substance abuse disorders, the importance of aggressive intervention in first-episode affective illnesses. The most common diagnostic groups were mood disorders (52% major depression) disruptive disorders and substance abuse. Two thirds of the suicides had a prior suicide attempt, mood disorder and substance abuse. 4. Timing Myth of Dr. Jeckyl and Hyde, teenagers turn into werewolf- reality that with suicide over half of the depressed teenagers suffered more than two years. In Shaffer sample more than a third of the New York suicides had an onset of symptoms more than five years before their death. Often comorbid (two disorders at the same time) diagnoses with suicide victims. *With mood disorder four to five times more likely for a suicide attempt than for a child without a mood disorder. 5. Completer profile Evenly distributed by SES, evenly distributed by educated versus uneducated, Western states highest, 60% fire arms, Both with children and adults 50% of completers die on first attempt 50% of completers were never in therapy 75% of completers communicated thoughts about their suicide aloud to several people several months before dying (This emphasizes the role of natural screeners). *Survivors of attempters are at greater risk of future attempts then are survivors of completion. 6 How does a suicide occur? Active Disorder e.g. Mood disorder Substance Abuse Anxiety Stress Event e.g. in trouble with law/school Loss Humiliation *Crisis hot line Acute Mood Change e.g. Anxiety/dread Hopelessness Anger Agitation *Crisis hot line Inhibition Social: Strong taboo (religiosity?) Available support Presence of others Difficult to access method Mental state: Slowed down SURVIVAL IV. Facilitation Underlying trait: Impulsive Intense (5-HT abnormality?) Social: Weak taboo Available method Being alone Recent example SUICIDE Strategies for suicide prevention A) Suicide awareness programs in schools frequently minimize the role of mental illness and don’t help. The idea of educating students about suicidal behavior was found to be upsetting to high-risk students who could be activated to suicidal ideation and usually were not known to the presenter. These programs were typically designed to encourage self- disclosure by students. Subsequently, 7 Shaffer’s work at Columbia in NYC demonstrated that a Teen Screen is more helpful to teach students to recognize in themselves the clinical characteristics of depression and other mental illnesses and to identify substance abuse. Schools are also excellent setting to identify children and adolescents who are at high risk for suicide. B) Screening. Direct case finding encouraged to assess group at greatest risk for suicide attempt 15-17 years old. Shaffer systematically administered screening programs with high specificity. Shaffer’s team initially screened 2,000 teenagers, 27% of the total number screen scored positively on the initial screen (looking at depression, dysthymia, and complication of substance or alcohol use, coupled with previous suicidal ideation and attempts.) A second stage was implemented with a case manager and a more refined test that included a low cost self administered computerized diagnostic interview that reduced the proportion of students that needed to be interviewed by a clinician by 60 percent. *Most of the adolescents who were at high risk identified by the screening were NOT known to others and very few were in treatment. Clearly this needs to be linked to evaluation and treatment. (The high school where I consult had too much on the agenda despite the fact that we have three adolescents hospitalized per month and ten percent suicidal attempt from THC data, they were reluctant and lacked the strategic will.) C) First step recognition of depression Symptoms – depressed mood as well as five neurovegetative symptoms for more than two weeks to be clinically depressed. D) SIGECAPS poor Sleep (hypersomnia or insomnia) decreased Interest Guilty feelings low Energy poor Concentration change in Appetite Psychomotor agitation or retardation Suicidal Ideation. With adolescents, the mood symptoms can be masked because they can look irritable, impulsive and volatile. With learning disorders, there can be a higher risk for depression (Robert). Symptoms of depression (neurovegetative symptoms) are key to recognize within school setting. Often depression in schools can present as laziness, negativity, and apathy Frequently this can be mistaken in the classroom as normal or part of the student’s temperament. In children depression is less frequently seen 2% demonstrate the more severe formmajor depression with symptoms for more than two weeks, 2% of children demonstrate dysthymia that is low level depression, chronic 7% of teenagers show depression and dysthymia. 8 *Depressed younger children often present with more physical complaints such as recurrent headaches or stomach-aches that can be mistaken for signs of an illness other than a depressed mood. Ratio of boys to girls with depression under twelve years old is one to one but during adolescence, girls with depression outnumber boys by approximately two-to-one. 30-50% of children with depression has a family member with depression (genetic vulnerability) The average length of an episode of MDD in children and adolescents is seven to nine months. Approximately 90% of the MDD episodes remit within two years post onset, whereas the remaining episodes last for a longer time. MDD frequently recurs in children and adolescents (40% chance of recurrence). Most consistently observed risk factors for MDD recurrence are younger age at onset. (Coryell et al, 1991) MDD typically precedes the onset of alcohol or substance abuse by about four years and thereby allows the prevention of substance abuse in depressed adolescents. Rate of shift to bipolar disorder is such that twenty percent of children and adolescents will evolve into bipolar presentation. (Rao,1995) V. Early Detection A. Assessment of suicidal risk in adolescents Research about broad risk factors and assessment of attempters need to be considered. The following is a key to draw several sources child, parent 1. 2. 3. 4. Sex Age recognizing that it is relatively rare incident in under twelve students. Depression –large majority of depressed youth are not suicidal. Availability of firearms or/other potentially lethal methods *Restricting access to available means (SW, AFS) It is important to be explicit. Easy access to guns six to ten times increase for completed suicide. ( This gives a whole new meaning to live free or die). 5. Stress and protection in different family contexts. Level of discord in family or parent psychopathology. Family structure is less important than the relationships in the family . High levels of conflict is associated with risk for more severe forms of suicidal behavior. Family cohesion, families that are emotionally involved, and share common interests are less likely to be suicidal. (CV, make my uncle hair curl and he didn’t have much hair to curl. Sometimes the child can be blamed for the family problems. Sometimes the perception is that the child is expendable because of inordinate shame or guilt. The child can be enraged about perceived abandonment, hostility turned inward (Freud calls suicide murder of the 180th degree)- treatment is to come to terms with parent limitations, ) Often self worth and self-esteem regulation require external support from parents. Sometimes suicide attempt can be interpreted as a noble self sacrifice and deflection away from other conflicts. (SW) Ask the family and the patient about how they communicate and see if the patient can identify who she/he relies on when stressed. 9 McKeown examined community based samples as distinct from samples drawn from clinical facilities. Vulnerabilities and “stress clusters” were denial of parent to acknowledge difficulty of adolescent, shame experienced by the teenager and prior abuse lead to the adolescent’s difficulty asking for help. Assess the family’s capacity to monitor and maintain sufficient watch over the adolescent. There can be constraints with work schedule, anxiety and rage at relentless demands. Transmission of impulsivity and aggression. Relevant quote from Winnicott: “Why not tell him that you know that when he steals he is not wanting the things that he steals but he is looking for something that he has a right to; that he is making a claim on his mother and father because he feels deprived of their love.” 6. Organized plan, intent, preparation. One in four adolescents that completed suicides show evidence of planning. According to Shaffer the timehonored clinical inquiry about planning is a poor measure of serious intent. Simon and Crosby (2000) determined that nonplanner ideators were just as likely to attempt suicide as were planners and that they also had additional risk factors. 7. Lack of social supports/peer conflicts 70% of psychological autopsy subjects exhibited antisocial behavior versus 24% of controls (CV) Isolation, alienation, socially withdrawn Precipitating factors – breakup with boyfriend, intense attachment (AG), trouble with a teacher, failing grades, parental trouble Gould cites recent breakup with girlfriend, excessively dependent relationship more prone to suicide. Earlier suicide ideation/ prior attempts* Males who have made prior attempts are more predictive of completing suicide than females. The prediction is that past behavior predicts future behavior. Only with half of all suicide completers is it verified that they made prior suicide attempts before their death. Estimates of the percentage of attempters across all ages repeating an episode within one year of the first attempt range from 14%-26%. In a Finland study 5% of adolescent repeaters had completed suicide to only 1% of “first timers” Substance abuse/dependence is the probable reason that adolescence attempts are more lethal. When substance abuse is present with mood disorder there is a fifty times increase with risk for suicide. Recommend abstinence for safety reasons. In a study of adolescent substance users, suicide attempts are found to occur at rates of three times those of controls. The “wish to die” increases dramatically 10 after the onset of substance use. Substance use relates to lethality Active substance abuse at the time of death is associated with completed suicide 8. Cognitive distortions/hopelessness about the future –Learned Optimism Seligman (ABC) . The goal is to increase the teenager’s capacity to generate alternative solutions (Brent 12-16 weeks manualized treatment) This entails monitoring and modifying automatic thoughts, assumptions and beliefs. 9. Exposure to other peers’ suicidality. Sometimes completed suicides can act as a deterrent as the adolescent can see how devastated the family is by the death. 10. Temper/aggression- strong relationship between aggressive behavior of first degree relative and suicide attempts in adolescents 11. A much-debated risk factor of suicidality is whether an adolescent is gay or lesbian. Russel and Joyner provide the most thorough analysis. In the twenty prior studies, there were no heterosexual control groups and the studies relied on convenience samples. In Russel study they drew on nationally representative data that included other critical adolescent suicide risk factors (hopelessness, substance abuse, and weighed those risk factors ). The study looked at the two questions: Are youths who report same sex sexual orientation at greater risk for suicidal thoughts and suicide attempts than their peers? Are these youth still at greater risk than their peers after critical adolescent suicide risk factors are taken into account? 6254 adolescent girls 5686 adolescent boys Youth with same sex orientation are two times more likely than their same sex peers to attempt suicide but depression and alcohol use are precursors to suicidality. Also it is key to emphasize the fact that 85% of same sex orientation teenagers have not considered suicide at all. (72% of females 85% of males) (Victimization Teacher –sexual deviant-, project 10 east ETOH and depression suicide attempts acceptable for desperation). 12. Assess Impact of Cultural Factors. Suicide risk of African American rose dramatically after 1986 but since then rates have declined. African American heritage of the blues, religious perspective that it is a sin to be suicidal, depression is often seen as a personal weakness. There is not much history of associating with mental health services and a level of distrust (Pouissant Lay My Burden Down). The difficulty of commanding respect at all costssuffering in silence also can lead to the internalization of racist stereotypes that may have led to the rise in self destructive behavior. Pouissant linked black suicide rates with the high rates of homicide and substance abuse among blacks, which he identified as other manifestations of self destructive behavior. He suggested that feelings of low self worth –expression of rage are turned inward or outward. He raised the concern that blacks seek treatment much later and this is a result of their general skepticism/fearful of the medical establishment. 11 B. Response to a Young Person at Risk for Suicide: Referral and Monitoring Introduce follow up care early in assessment – suicide attempt can mobilize or effect changes, create and strengthen connections- but it also highlights the child’s vulnerability. A suicidal attempt emphasizes the need to increase the safety net. Prevention is resource dependent-there is an urgent need to customize prevention strategies that match adolescents’ experience (basic trust- jump) Assessing need for involuntary hospitalization can be problematic as there are no randomized controlled trials that demonstrate that hospitalization improves outcome. If a patient has an abnormal mental state and is psychotic, clearly the patient needs to be hospitalized for containment. Sometimes brief hospitalization can communicate to parents and children the seriousness of the action and sometimes in the insurance game can access needed home based services that are difficult to get as outpatient . The difficulty is that hospitalizations are often brief and in geographically distinct areas from where the patient lives and different staff provide follow-up. (AL) Usually the patient is discharged from inpatient 24 hour supervision to outpatient treatment once a week therapy rather than to an intermediate level of care (e.g.step-down unit or partial treatment). The high reattempt rate among hospitalized suicide attempters suggests need for a greater intensity of treatment than once-a –week Menu of school-based support, after-school partial programs,flexible funding C. Follow-up Action Plan/Continuum of care 1. Arm patients and families with prevention knowledge such as suicidal ideation as an indicator of mental illness, alcohol use increases risk of depression, the value of reaching out to others to evaluate their problems, the importance of not isolating and building coping strategies. 2. It is useful to give reassurance that depressed people do benefit from treatment (AR-depression timeless quality) Elkind describes the imaginary audience, personal fable. 3. Maintain regular communications with family. 4. Even when knowing the referral network in your area there is the difficulty of accessing services, building infrastructure within the school and getting around budgetary allocation, SBHC, Sped and work with inpatient hospitals). 5. Maintain regular collaboration with mental health provider (obtain releases at discharge if possible. It is difficult when family doesn’t allow access to 12 hospitalization information, and it is then helpful to create policy for school based evaluation to determine safety to return to school ). Only a relatively low proportion of suicide victims were identified as ever having had mental health treatment (33%-50%) and a much smaller proportion (15%) were actually in treatment at the time of death (Brent). ) One study (Spirito) drop out ranged from 35-40% for adolescents in treatment after suicide attempt with three visits, 58% to 78% dropped out within nine visits. 6. Check on status of referral/s. 7. Identify someone in school who periodically reevaluates suicidality/suicidal risk. Be careful of pathologizing kids that they are “resistant” –timing key and often therapy is used as a form of castigation or shaming by family (MS, Haitian family). 8. There are structural barriers against family treatment but family treatment helps to shift the focus from the “identified patient” to potentially toxic environment. There can be family barriers to treatment such as transportation difficulties, language problems, parent or adolescent ambivalence about treatment, cost of treatment and scheduling difficulties. There can also be service barriers-delays in getting an appointment, being placed on a waiting list, inability to switch therapists due to agency policy and problems with insurance coverage. Offer looked at help seeking behavior of teenagers and teenagers usually identified friends or parents. Few studies exist that have assessed adolescents’ perceptions of the helpfulness of the helping agents. Out of 497 adolescents, two thirds of disturbed adolescents had not sought help. Usually it is the parents’ initiative to get their child or adolescent help. Further barriers to seeking help (Girl Val with gun and insurance) Also critical to find support within environment (MSPY program). Advocacy work is critical and leveraging (MM VI. Treatment 1. In the absence of “best” therapy clinicians may chose to a. Treat any associated psychiatric disorder b. Teach the family to recognize and then avoid or diffuse conflict c. Therapy that helps build self acceptance, train the patient to avoid situations that trigger negative moods, increase tolerance of distress d. Classical approach with therapy is to try to determine maladaptive patterns that stem from unconscious conflicts e. Group approaches 13 2. Medications We all know that there is no “anti-suicide pill”. It is generally recognized that it is critical to treat underlying pathology with medication. In Shaffer group only 10% adolescents had been treated with antidepressants and even fewer adolescents were in substance abuse programs Symptom reduction may occur with medication, for example it can alleviate psychomotor retardation and increase capacity to verbalize. I often refer to “safety nets” and “jumpstarts”. Although bipolar is difficult to diagnose in this population, with bipolar 44% attempted suicide. Lithium or depakote are first line with bipolar patients. Treatment is protective with antisuicidal, antiaggressive properties in adults (Baldessarini) Lithium greatly reduces the rate of both suicide and suicide attempts in adults with bipolar disorder. If an adult patient is bipolar, discontinuing Lithium is associated with increases in suicidal morbidity. There are no studies on bipolar children and adolescents on the impact of Lithium on suicidality. With children and adolescents, there are many other anticonvulsants that are being used (Lamictal, Trileptyl, Topamax, Neurontin). In epidemiologic studies (not controlled studies) reduction in suicide among patients treated with antidepressants was demonstrated. The decrease in the suicide rate between 1988 to 2000 coincides with a substantial increase in the prescribing of antidepressants for the general population. Isacson et al (1996,1997) showed in Sweden that there were more SSRI-treated adults in Sweden and that this was much higher than the rate of SSRI-positive autopsies among persons who committed suicide, suggesting that SSRIs were protective of suicide from depression. SSRI –selective serotonin re-uptake inhibitors (Although usually highest risk patients are excluded from rigorous trials). 30-40% of adults and adolescents with major depression are treatment refractory and don’t respond. A poor response to SSRI can be predicted if there is a history of chronic depression, comorbidity (substance abuse), family discord, history of sexual abuse and parental mental illness For patients that are treatment resistant there are several options: Increase dose of current antidepressant Change to another SSRI Change to another class or agent particularly if patient failed two trials of SSRI (Can use venflaxine or buproprion) Augment, boost treatment with Lithium Key to recognize side effects from SSRIs (Walkup research) SSRIs usually take one month to reach consistent blood level – two months to leave system. Also other antidepressants are Effexor, Wellbutrin, Remiron, Trazadone and Serzone **** There are potentially subtle side effects with SSRIs . Usually doctors review physical side effects of SSRIs although it is important to be aware of possible 14 complications of treatment as well as behavioral changes that can emerge from taking medication. Activation – increase in activity level that does not include any real change in mood, impulse control. Patient may not note this and activation is most often seen early in the course of treatment or soon after a dose increase. Young patients more than adolescents (response dose reduction or medication discontinuation) Bipolar switching predisposition – not only a change in activity level but also includes a prominent change in mood, behavior, and impulse control. Activation – too much of the same child, versus bipolar switching “ he has never been like this before. More likely to appear after the child has been on the medication for awhile Celebration – anxiety and avoidance move to more capability, elation and parents are confused with think manic reaction. Dimensional Issues or Comorbid disorders. More energy for oppositional and conduct, cautious with those kids with risks for conduct disorder. Parents and teachers need to be prepared to set boundaries and redirect energy. Evolving psychopathology – anticipate problems (recent patient hospitalized) Frontal Lobe-type symptoms such as apathy. More common at higher than lower dose and does not necessarily go away with time. Emotional numbness or blunting, not caring about anything, inertia, passivity, and feeling flat. Decreasing dose can sometimes make a significant difference. (Give example of junior who was treated with depression, difficulty applying herself, sleep, dropping AP classes, stopped medications) Gastrointestinal symptoms Hey what happened to my sex life? -problematic trying to figure out Advising presence of consistent adult, “Creating Caring Institutions”, “Empty Rhetoric or Meaningful Relationships?” In Passion for the Possible ,William Sloane Coffin recognizing that each of us plays a critical role in keeping our children safe, exhausting and exhilarating. Importance of self-care, written to a friend that was suicidal (Galway Kinell Wait) “Hope makes us persistent when we can’t be optimistic, faithful when results elude us. For like nothing else in the world, hope arouses a passion for the possible, a determination that our children not be asked to shoulder burdens we let fall..” Wait, by Galway Kinnell Wait, for now Distrust everything, if you have to But trust the hours. Haven’t they Carried you everywhere, up to now? Personal events will become interesting again Hair will become interesting Second hand gloves will become lovely again; Their memories are what give them 15 The need for other hands. And the desolation Of lovers is the same;that enormous emptiness Carved out of such tiny beings as we are Asks to be filled; The need for new love is faithfulness to the old Wait Don’t go too early You’re tired. But everyone’s tired But no one is tired enough Only wait a little, and listen Music of hair Music of pain, Music of looms weaving all our loves again. Be there to hear it, it will be the only time Most of all to hear The flute of your whole existence Rehearsed by the sorrows, play itself into total exhaustion. 16