Best-Practice Assessment and Treatment of SMI in AdolescentsMichael G. McDonell, Ph.D.Acting Assistant ProfessorDepartment of Psychiatry University of Washington School of Medicine

Foster Care Center for Health Harborview Medical Centermikemcd@u.washington.edu

SED-SMI (Alphabet Soup)

SEDChildren

Any Disorder +

HighLevel of Impairment

SMIAdults

SchizophreniaBipolarMDD

Axis II?

Why talk about SMI in Adolescents? • Disorders often present in adolescence/early

adulthood• They present unique challenges to the child mental

health system and child/adolescent clinicians– Focus on psychotherapy rather than case

management in the youth system– Little expertise in treating these disorders in

child/adolescent clinicians• Current controversies make treatment challenging

– Diagnostic uncertainty • Disagreement about diagnostic criteria for children• Little data on diagnostic stability (e.g. bipolar

disorder) across time

– Little awareness of available treatments

SMI Assessment and Diagnosis

Occam’s Razor: its horses not zebras

• Rare cases are usually explained by– Simplicity: simplest

explanation – Most reasonable:

most common/obvious explanation.

• SMI disorders (bipolar & schizophrenia) are zebras

• Other childhood disorders are horses

• Assessment is a process of Ruling Out other disorders 1st

Prevalence of Adolescent Onset Schizophrenia

• Adult onset Schizophrenia – Lifetime prevalence of 1% – Onset mid 20-30s– Females 5 year later onset (Loranger,

1984)

• Adolescent Onset: Onset <18 yoa – Rare: < 15 yoa (14/100,000)

• Very EOS (VEOS) < 12 years of age – Extremely rare: (1.6/100,000) – Mostly males

Adolescent Onset Schizophrenia Symptoms (McDonell & McClellan, 2007)

• Symptoms– Positive symptoms (more common in older

adolescents)• Hallucinations• Delusion: organized delusions less common

– Thought disorder• Loose associations• Illogical thinking• Impaired discourse skills • Less common: incoherence and poverty of

speech/thought– Negative symptoms

• Impaired social functioning, typically a change from previous functioning

• Decreased self-care, motivation

Onset/course

• Onset:– Prodromal phase– Acute onset vs. Insidious onset

• Course is typically episodic and chronic

Best practice assessment (McDonell & McClellan, 2007)• Multi-method/multi-informant

assessment• Comprehensive medical exam• Record review

– Medical, psychiatric, educational• Clinician administered structured

interview– With youth and parent

• Mental status exam/observation• Data from collaterals (including

school)• TIME, TIME, TIME

Epidemiology of Early Onset Bipolar Disorder (EOBD)• Adult Prevalence

– Lifetime prevalence of – Bipolar I = 0.4% to 1.6%– 0.5% Bipolar II (APA, 2000) – ~ 6 % when including sub-threshold or

“spectrum” cases (Judd and Akiskal, 2003)• EOBD Estimates vary widely

– .6-22% (Yongstrom, 2007)– Its appears to be a US phenomenon

• Onset???– 50% of adults report first symptoms <18 yoa

(Kessler et al, 1997)– Depressive symptoms typically precede

mania

Symptoms that may differentiate based on research (Yongstrom, 2007)

• Elated mood: extreme, impairing, situation inappropriate, episodic

• Grandiosity: episodic and associated with mood• High energy: MUST be episodic, not hyperactivity• Decreased need for sleep, not insomnia • Mood swings: intense, with longer periods, beyond

what is developmentally appropriate• Hypersexuality: R/O abuse• LOW ability to differentiate: Irritable and

distractibility• Assessment: very similar to assessment of EOS

– Mood diaries also helpful– Monitoring over time is important

Temper Dysregulation Disorder with Dysphoria (NEW DSM-V Dx)A. Severe recurrent temper outbursts in response to common

stressors. 1.  The temper outbursts are manifest verbally and/or behaviorally,

such verbal rages, or physical aggression towards people or property. 

2.  The reaction is grossly out of proportion to the situation. 3.  The responses are inconsistent with developmental level.B. Frequency: The temper outbursts occur, on average, three or more

times per week.C. Mood between temper outbursts: 1.  Nearly every day, the mood between temper outbursts is

persistently negative.2.  The negative mood is observable by others (e.g., parents, teachers,

peers). D. Duration: Criteria A-C have been present for at least 12 months. E. The behaviors are present in at least 2 settings and severe in at

least in one setting.  F.  Chronological age is at least 6 years (or equivalent developmental

level).G. The onset is before age 10 years.H. In the past year, there has never been a distinct period lasting more

than one day during which abnormally elevated or expansive mood was present most of the day for most days

I.  The behaviors are not due to other disorders.

Just thinking about evidence based treatments gives me a headache…

Treatment of SMI in adolescents

• There are few empirically supported treatments for this population

• Most treatment options are based on evidence based adult approaches

Evidence based/informed txs for SMI in adolescents1. Psychiatric medications: 1st line treatment, but have

serious side effects with less (or more recent) evidence of efficacy, relative to adult populations.

2. Multi-informant monitoring and case management

3. Specific psychosocial interventions

• Family psychoeducation (Miklowitz, Fristad, others)• Other promising approaches

– Dialectical behavior therapy (DBT) • Self-harm• Emotional dysregulation

– Interpersonal and social rhythm therapy for bipolar disorder (Stephanie Hlastala, Ph.D, Seattle Children’s/UW)

Family psychoeducaton and support interventions• Best-practice for adult schizophrenia and bipolar

disorders– Have been adapted and demonstrated efficacy for

adolescents with mood disorders • Focus is on:

– Education about the causes, triggers of relapse, and treatments

– Patients and families bring their expertise to treatment and become “experts” in the treatment of SMI.

– Modification of family response to the illness to improve communication (expressed emotion) and improve problem solving

• Goal: to prevent relapse and achieve and maintain recovery

• Duration: from 16 weeks to 2 years• Individual family (Miklowitz bipolar disorder) (Falloon

schizophrenia)• Multiple family groups (Fristad bipolar disorder) (McFarlane

schizophrenia)

Family focused therapy for adolescents with bipolar disorder (Miklowitz et al., 2008)

• Adaptation of his adult model• 21 single family sessions over 9 months • Family psychoeducation (7-10 sessions)

– Develop family understanding of bipolar disorder

– Formulate a family relapse prevention plan

• Remaining sessions focus on – Communication training– Problem solving skills training

Multiple family group treatment (MFGT) for schizophrenia (McFarlane, 2002)

• Designed for adults, but applicable to adolescents with EOS

• Delivered by 2 clinicians to 5-8 families over 2 years • 4 phases

– Joining (3-4 sessions)– Psycho-educational workshop (1 day)– Relapse prevention (24 sessions)– Social and vocational recovery (12 sessions)

• Relapse prevention is promoted through– Family guidelines (set of science based principles for

relapse prevention)– Problem solving skills for preventing relapse

MFGT Family Guidelines• Go Slow • Keep It cool • Give each other Space• Keep It Simple• Lower Expectations Temporarily• Pick Up on early Warning Signs• Set Limits• Ignore What You Can’t Change• Follow Doctor’s Orders• No Street Drugs and Alcohol• Solve Problems Step by Step• Carry on Business as Usual

Typical MFGT problem solving session

Structure• Initial Socializing 15 minutes• Go Around 30 minutes• Select a problem to work on 5 minutes• Solving a problem 35 minutes• Final Socializing 5 minutes

Why might DBT work for SMI adolescents?• In SMI populations

– Suicide and attempted suicide risk is high– Emotional dysregulation is a primary symptom of

bipolar disorder and also an issue in schizophrenia

– Interpersonal skills are impacted by SMI• Developmentally adolescents are more likely than

others to have– Higher rates of suicidality– More difficulties with emotion regulation &

interpersonal difficulties– Engage in other problematic risk taking behaviors

(e.g., drinking/drug use, unprotected sex)

Adolescent DBT goals and tx targets • Goals:

– Reduce Suicidal and non-suicidal self-injurious behaviors– Improve emotional regulation and interpersonal skills– Improve quality of life

• Targets:– Decreasing life-threatening behaviors

• Suicidal behaviors• Non-suicidal life threatening behaviors

– Decreasing therapy-interfering behaviors• Not completing homework/attending appointments on

time– Decreasing quality of life-interfering behaviors

• High risk impulsive behaviors– Increasing behavioral skills

• Interpersonal skills• Distress tolerance skills

Child DBT model (Miller et al, 2007)• Orientation and assessment (2 sessions)• Pretreatment/orientation and commitment stage

(varies in length)• 1st Phase (16 weeks)

– Individual therapy (reducing self-harm, treatment interfering behaviors, supporting skills learned in group)

– Multiple family skills group (adolescent & family)– Phone consultation (adolescent = ind. therapist,

family = group therapist)– Family sessions (as needed)– Team meetings (weekly)

• Graduate group (16 week modules)– Graduate group (adolescents)– As needed: Phone consultation, individual therapy,

family sessions, other non-DBT treatments

Evidence for DBT in adolescents• No randomized trials have been

completed investigating DBT efficacy in adolescents.

• Inpatient/residential treatment studies– Reductions in self harm, re-hospitalization,

behavior problems (Katz et al. 2004; McDonell et al., in press; Rathus & Miller, 2002; Trupin et al. 2004 )

• Outpatients– Bipolar youth (Goldstien et al. 2007)– 1 year of treatment – Improved suicidality, emotional regulation

and depression in 10 pilot patients.

Now what should I do?• Perform an accurate assessment and monitor

individuals over time• Treatment

– Medication management– Effective case management/coordination of care– Multidisciplinary team

• Adolescent and family are an active part of the team

• Consult with experts in our area– Integrate evidence based psychosocial

treatments into your practice• Some tx are easier to learn/adhere to than others

– Get ready for transition to adulthood• Many young do not engage in the adult mental

health system

Resources• Assessment

– Mash, E.J. & Barkley, R.A. (2007) Assessment of childhood disorders, 4th Edition. Guilford Press: New York.

– AACAP (2007). Practice parameters for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder. Journal of the American Academy of Child & Adolescent Psychiatry. 46(1):107-125.

• Treatment– McFarlane, W. R. (Ed.). (2002). Multiple family

groups in the treatment of severe psychiatric disorders. New York: Guilford Press.

– Miklowitz, D. (2007). The Bipolar Teen: What You Can Do to Help Your Child and Your Family. Guilford Press: New York.

– Miller A.L., Rathus J.H., & Linehan M.M. (2007). Dialectical behavior therapy with suicidal adolescents. Guilford Press: New York.