The Brown University Child and Adolescent Behavior Letter

Childhood Suicide

CABL
grandfather in heaven. A week ago Carlos twisted his ankle when trying to jump from the roof of his house to a tree. This week he had an abrasion on his wrist, from swinging from the tree with his sisters jump-rope. Yesterday his teacher found a disturbing drawing: in one corner was a depiction of heaven with an old man wearing an angry expression, and at the bottom was a boy alone looking up at the old man. There was a noose in another corner that was broken in two with blood dripping out of the crack.

Toward a developmental understanding and judicious clinical intervention

By Steven J. Barreto, Ph.D., and G. Oana Costea, M.D.
Published in cooperation with Bradley Hospital

Carloss story
Carlos is a 9-year-old Puerto Rican boy beginning third grade whose grandfather died about two years ago. At age 5 Carlos was diagnosed with ADHD due to impulsivity and problems with attention and concentration. This year, Carlos began to have peer conflicts during recess and to be more withdrawn in the classroom. He has been more hyperactive and easily frustrated and expresses concerns about his mothers safety. When confronted with expectations he says he wishes he was never born and that his family would be better off without him. About two weeks ago Carlos began asking his mother questions about heaven and hell, and wondered what its like for his

July 2008
Vol. 24, No. 7 ISSN 1058-1073 Online ISSN 1556-7575

Highlights
Drs Barreto and Costea discuss childhood suicide, focusing on prevalence, risk factors and clinical interventions. Also, Dr. Horacio Hojman examines the dangers of taking shortcuts when diagnosing children and adolescents, particularly in relation to ADHD. Keep Your Eye On See page 2 AHA recommends cardiac screening for children with ADHD Prescription drug prevention program for school nurses High rate of past year depression among adolescents Whats New in Research See pages 35 Pediatricians role in helping traumatized children Treating maternal depression linked to outcome in pediatric MDD

Prevalence
Carloss story is not uncommon among children seen in inpatient or intensive
See Childhood Suicide, page 5

Is it really ADHD?

The danger of shortcuts in diagnosing children and adolescents

By Horacio Hojman, M.D.
Despite significant gains in the identification of psychiatric disorders in children and adolescents, diagnosis in young patients remains complicated. Primary care pediatricians and mental health professionals are subject to many conscious and unconscious pressures: from managed care; in school settings, where prompt responses are needed to manage kids with behavioral and academic problems; and from parents, who want a tailored and rapid diagnosisa solution for their childs troubling behaviors. However, a solution cannot always be immediate. In many instances, there is a fine line between making a diagnosis quickly and giving the child sufficient time and patience to open up so that the diagnosis is accurate. Nowhere is the danger of misdiagnosis more real than with possible attention-deficit/hyperactivity disorder (ADHD) in a child. A typical scenario involves a teenager inaccurately diagnosed with ADHD at a busy pediatricians office, where there is often inadequate time for a comprehensive evaluation and referrals for consultation are hard to come by due to a lack of available mental health professionals.
See ADHD, page 7

Editor's Commentary
Academic medical centers and the pharmaceutical industry By Gregory K. Fritz, M.D. See page 8 Free Parent Handout

Is your child depressed?

A guide to recognizing and responding to despressive symptoms

Monthly reports on the problems of children and adolescents growing up

Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/cbl.20071

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family structure, abrupt transitions out of foster or adoptive care) may also contribute to a sense of hopelessness, rage and intolerable anxiety.

Clinical intervention
Childrens motivation to attempt suicide is less complex than that of adolescents and their method of choice is more immediate and convenient. For example, in a moment of rejection or anger, a child may be more likely to threaten to jump down a flight of stairs, jump off a moving vehicle or attempt to choke themselves with an electrical cord. Thus many attempts occur in the presence of supervising adults. Firearms in the home or access to other lethal means (e.g. fire experimentation, cleaning items, batteries) may contribute to risk for impulsive children who are not closely supervised. Alleviating immediate psychological distress and addressing social skills and emotional coping deficits will reduce the risk of suicidal behavior. Cognitive-behavioral interventions that teach emotional coping strategies and social skills training are well validated approaches for reducing psychological distress in children. Family therapy and parent training may also play a critical role. The focus should be on identifying supports for parental emotional distress, eliminating abuse or parental maltreatment, improving communication, and strengthening capacity for adult supervision and monitoring. Psychopharmacological intervention may be beneficial in addressing underlying depressive or anxiety disorders as well as improving concentration or impulse control. Attention should be paid to the childs access to prescription medicine in the home and time spent with peers who could be modeling substance use, which may contribute to the risk of suicidal behavior. Clinicians must be alert to risk, yet careful to not over-react to suicidal ideation in children. The danger in under-reaction

is obvious; the risk in over-reaction is to burden already overwhelmed emergency response systems (e.g. emergency rooms or urgent mental health care centers). In general, contact with the parent and consultation with the current mental health provider is a good place to start. Any comprehensive assessment should include an understanding of childrens emerging concepts of death and preoccupations regarding their own death or injury. In cases where a high level of risk for injury is apparent, emergency evaluation is required. Assessing the risk for injury extends beyond access to lethal means and should include psychological distress and impulsivity, problem solving and judgment, as well as physical abuse or disrupted attachments. If urgent and comprehensive care is available and attention is paid to insuring the presence of supervision and monitoring, acute inpatient treatment may not be necessary.

Carloss story, continued

Carloss school social worker, contacted by his teacher, phoned his mother and explained that sometimes seemingly accidental injuries happen when children become preoccupied with thoughts of self-harm. Carlos outpatient psychologist agreed to see Carlos for an appointment that same day. Upon assessment, Carlos presented with signs of depression (irritability, hopelessness, withdrawal from peers and activities). He often had thoughts about what it might be like to be dead and in heaven, but not about how he might die. He understood the physical realities of death but became more confused and anxious when talking about dreams of his grandfather. The psychologist explained that dreams of someone who has died can be very confusing for children because they can seem so real like the person is actually alive. But when kids wake up, they see that the person is not alive and may feel

very sad, hopeless and even worried that they might have the dream again. Carlos revealed that he had avoided telling his mother about his worries because he felt he needed to be strong for the family. Carlos practiced strategies to control his anxiety and took home a drawing as a reminder of the difference between dreams and reality. He appeared less anxious and confused, as indicated in mood and anxiety self-ratings. With his parents present, Carlos agreed to let them know if he was having thoughts about death or hopelessness. The parents were educated about child development and depression as well as the conflict between the boys need for communication and his adherence to cultural role expectations. When Carlos was not in the room, Carloss mother revealed an ambivalent relationship with her own father, who had been abusive. She sought comfort in prayer but feared that she had already violated many of her familys religious and cultural expectations through exposing his abuse. She was encouraged to identify social supports and to practice self-care. Carlos was referred for more intensive services at the local mental health center, including a psychiatric evaluation. The psychologist collaborated with the school to decrease academic pressures and boost his support network. The psychologist increased meetings to twice per week and included a short-term family therapy intervention. Carloss parents were advised to seek emergency evaluation at a hospital should his status change.
Steven J. Barreto, Ph.D., is the Psychology Coordinator of the Bradley Hospital Child Inpatient Program and Clinical Asst. Professor in the Warren Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior. G. Oana Costea, M.D., is Clinical Assistant Professor of Psychiatry and Human Behavior at Brown Medical School and Director of the Combined Child and Adolescent Inpatient Program at Bradley Hospital.

ADHD
From page 1

Sometimes diagnoses of ADHD are made purely on parental or school personnel accounts of signs and symptoms, while a comprehensive diagnosis also must

include the childs family dynamics and the psychosocial stressors that are impacting the symptoms that we see. Responsible clinicians make their own diagnosis before treating because they understand that once made, it is difficult to change a diagnosis or look for differentials. Many psychiatric

disorders or other issues can masquerade as ADHD or present with some of the same symptoms and several can be present comorbid with ADHD. The most common of these are adjustment disorder, anxiety disorder, bipolar disorder, post-traumatic stress disorder, and learning disorders.

The Brown University Child and Adolescent Behavior Letter July 2008

Adjustment disorder with anxious mood

There is often diagnostic confusion between ADHD and adjustment disorders with anxiety. Teachers and school counselors report that the child cannot concentrate, seems to be daydreaming or does not listen. In many instances, these children are struggling with intense psychosocial stressors (e.g., loss, constant relocations, parents separating, witnessing abuse, etc.) that impede them from concentrating properly in class and keeping up with their work. In this case, the development of emotional or behavioral symptoms in response to an identifiable stressor (occurring within 3 months of the stressor) must be distinguished from the cardinal symptoms of inattention, hyperactivity and impulsivity with ADHD. Also, the child that suffers from adjustment disorder with anxious mood will show marked distress that is in excess of what would be expected from exposure to a stressor, with predominant symptoms of nervousness, worry or fear or separation from attachment figures.

Child begins to have episodes of exaggerated elation, grandiosity, depression, reduced need for sleep or inappropriate sexual behaviors linked with signs of sexual abuse. Child has recurrent severe mood swings, temper outbursts or rages. Child has hallucinations or delusions. Child has strong family history of bipolar disorder, particularly in the absence of response to ADHD treatments.

PTSD
The presence of PTSD and a potential comorbid diagnosis with ADHD requires careful assessment of the developmental timing of the onset of symptoms, the pattern of problem

a lack of resources to do proper testing for these disorders. According to DSM-IV criteria, a learning disorder can be diagnosed when the individuals achievement standardized tests is substantially below that expected for age, schooling or level of intelligence. A child with a learning disorder demonstrates typical levels of cognitive functioning. Typical learning disorders include a dysfunction in one or more psychological processes, such as phonological processing, sustained attention, different types of memory and executive functioning, which can inhibit the mastery of a particular academic domain.

Other factors
There are other factors complicating an accurate diagnosis that are often overlooked in their seeming simplicity, including ethnic differences, sleep disorders and poor nutrition. Increasingly, pediatricians and clinicians must assess bilingual children in the school setting, where they are having difficulties integrating into a new culture, with an impact on their academic success and ability to make friends and generally thrive. Also, sleep disorders or improper nutrition can lead to symptoms that mimic ADHD. Children who are sleep deprived are unable to concentrate, as particularly evidenced in the school setting. Also, a child who is not eating enough or the right foods can suffer from fatigue, lack of focus, mood swings and listlessness. In conclusion, despite multiple pressures for swift answers, an immediate treatment plan and prompt results, it is vitally important to consider that shortcuts in diagnosis can lead to misdiagnosis and ineffectual treatment. Over-diagnosis of ADHD due to a simplistic diagnostic process is likely one factor responsible for the burgeoning rates of stimulant use in children and adolescents.
Horacio Hojman, M.D., is Child & Adolescent Psychiatry Attending, Child and Family Psychiatry Outpatient Department, Rhode Island Hospital and Clinical Assistant Professor in the Department of Psychiatry and Human Behavior at the Warren Alpert Medical School of Brown University.

Anxiety disorder
In the case of confusion between ADHD and anxiety disorder, the difficulty in reaching an accurate diagnosis is biological in nature. Symptoms such as poor concentration, nervousness, not following instructions secondary to fears and worries, and somatic explanations for not keeping up with homework are also frequently seen in kids that are already being treated for ADHD. Teachers and parents report these symptoms as typical of ADHD without knowing that a comorbid disorder can arise. With these kinds of subtle symptoms, anxiety disorder can pass at times unnoticed. Thus, the child remains partially untreated.

Despite multiple pressures for swift answers, an immediate treatment plan and prompt results, it is vitally important to consider that shortcuts in diagnosis can lead to misdiagnosis and ineffectual treatment.
behaviors and their association with trauma triggers. For example, for concentration problems and distractability to be attributed to ADHD, they should have existed before the age of 7, been evident before the trauma occurred, be relatively chronic and generally be worse in the school setting. If concentration issues and distractability emerge after the trauma and are worse in the home setting or when the child is exposed to trauma triggers, they are likely not related to ADHD.

Bipolar disorder
Symptoms of bipolar disorder and ADHD are commonly confused. It is relevant to suspect the presence of bipolar disorder in a child with ADHD if: ADHD symptoms appear later in childhood (10 years or older) or appear abruptly in an otherwise healthy child. ADHD symptoms were responding to stimulants and suddenly are not. ADHD symptoms tend to occur with mood changes.

Learning disorders
Many times when considering a diagnosis of ADHD, one tends to navigate through the most relevant psychiatric comorbidities (such as anxiety and mood disorders) without paying enough attention to learning disorders. Schools commonly ask a clinician to treat a child with attention difficulties. Yet even while treating ADHD, we might find that there is a continued problem in the learning process. This can go undiagnosed due to

The Brown University Child and Adolescent Behavior Letter July 2008