This is a 17 year old male who is brought to the emergency room by his family. Earlier, he got into an argument with his girlfriend and began to ingest several ibuprofen tablets in front of her. He says he didn't really premeditate the act, and he denies having written a note. He has been feeling very depressed and upset for the past several months. Family members also note that he has been moody and explosive. In fact, one week ago, he was referred to the school based police officer because he threatened to go on a shooting rampage using his family's hunting rifle. He has been doing worse in school for the past semester and is at risk of not graduating. Reportedly, his teachers have complained that he is disruptive with his non-stop talking and "giggliness". His family suspects that he may be using marijuana. Apparently, he had been referred for a mental health evaluation at the school, but his family decided not to keep the appointment.
His past history is otherwise negative. Family history is significant for alcohol abuse in the biological father, who tended to use corporal punishment on the children.
Exam: His vital signs, including blood pressure, are normal. He is superficially cooperative, though restless and fidgety. His eye contact is poor, and he frequently looks to the side during the conversation. Speech is mumbled and rapid. Affect is angry. He thinks that what he did (with the ibuprofen) was "stupid" but does not elaborate very much. Even though he recognizes his difficulties in school, some of his plans seem a bit unrealistic (e.g., becoming a decorated fighter pilot in the military). Physical examination is otherwise unremarkable.
Laboratory studies: Urine toxicology screen positive for cannabis only. Other screening labs, including tests of thyroid function, are normal.
Psychiatric consult obtained. Provisional diagnoses: Bipolar disorder (not otherwise specified), marijuana abuse. A decision is made to admit the patient for psychiatric care. After discharge, it is discovered that his school is very nervous about accepting him back, for fear that he might become violent again.
In the United States, homicide and suicide are the second and third leading causes of death among teenagers (1). Consequently, all health professionals caring for children and adolescents must give high priority to the prevention, early identification, and early referral for these significant causes of morbidity and mortality. For the purposes of this chapter, suicide and violence will be considered together, as violence to others is often a risk factor for violence to self.
Major risk factors for completed suicide in adolescents include previous suicide attempts, mood disorders, and substance abuse (2). Hence, primary care physicians should be attentive to signs of substance abuse (discussed in another chapter) and possible symptoms of depression, which include a persistently sad mood, lack of enjoyment, sleep/appetite/energy level disturbances, and/or difficulties concentrating and performing adequately in school. Youth who present with a major depressive episode have about a 30% risk (3) of going on to develop a bipolar disorder, which often has a "mixed" (e.g., depressive and hypomanic/manic symptoms coexisting) and/or "rapid cycling" presentation in this age group. Hence, other symptoms which should lead the physician to suspect a mood disorder include irritability, "mood swings," angry outbursts, grandiosity, rapid speech, increased motor activity, and impulsive behavior (which the patient described above seems to have). Often, these youth present in juvenile correctional and other legal settings and would otherwise be diagnosed as having a "conduct disorder". Biederman et al's findings (4) of significant co-morbidity (i.e., correlation) between "conduct disorder" and treatable mood disorders should prompt the primary care physician to carefully consider mood disorders in any "delinquent" adolescent, and to appropriately refer for psychiatric care.
All physicians should be familiar with screening for suicidality and assessment of the suicidal patient. Suicidality is often assessed in the context of routine health maintenance examinations for teenagers. One may enhance the sensitivity of inquiry about suicidality by "leading into" the topic and then definitively asking the questions: e.g., "How do you feel most of the time? Are there ever any times when you would say you feel depressed? How intense does it get? Does it ever get to the point when you think that life isn't worth living anymore? Did you ever make a plan to end your life? Do you have thoughts about ending your life right now?" In the patient who is acutely suicidal, the following items are important to assess: previous attempts, command auditory hallucinations (voices encouraging suicide leading to the attempt), intoxication during the attempt, stressors, and symptoms of mood disorders.
In the patient who has attempted suicide (such as the patient described above), additional items of value are: premeditation, note writing, giving away of objects, setting/context of suicide attempt, how discovered (e.g., in front of others versus all alone, with no expected chance of discovery), appreciation of lethality (e.g., might have thought that ibuprofen could kill instantly; or might have thought that iron pills were harmless), how one feels now, and what has changed since the suicide attempt.
The history and physical should include a thorough psychosocial history (including exposure to violence and abuse) and should be complete enough to rule out any medical conditions which could manifest as a mood disorder (e.g., thyroid disorders, EBV infections, etc.)
The risk factors for, and the assessment of violence, are similar to what is described above (e.g., past violence, intoxication during violence, etc.). There is also a significant emphasis, nationally, on the prevention of violence. The Commission for the Prevention of Youth Violence (5) identifies prevention of youth violence as a high priority, and lists several objectives: 1) to support the development of healthy families; 2) to promote healthy communities; 3) to enhance services for early identification and intervention for children, youth, and families at risk for or involved in violence; 4) to increase access to health and mental health care services (which the family described above had difficulty with); 5) to reduce access to and risk from firearms for children and youth (a priority for the patient described above); 6) to reduce exposure to media violence; and 7) to ensure national support and advocacy for solutions to violence through research, public policy, legislation, and funding. The American Academy of Pediatrics (1) also emphasizes avoidance of corporal punishment (which could have been important for this case).
Management of a case such as the one described above, mandates a comprehensive bio-psycho-social approach. From a biological perspective, the patient may have a genetic predisposition to a mood disorder amenable to a mood stabilizer medication. However, the patient also uses substances which could affect mood; therefore, maintenance of a drug free state is also important for treatment. Other medical conditions should be ruled out. From a psychological perspective, recent stressors may include academic difficulties and difficulties in his relationship. Furthermore, poor coping skills and exposure to family violence may increase his risk of committing a violent act. He may therefore benefit from: an educational evaluation to identify and address any possible learning difficulties; supportive psychotherapy; and training in anger management. From a social/cultural perspective, dysfunction in the home may have led him to seek support from substance abusing peers. Culturally sensitive services for the family would also be key to effective treatment, keeping in mind the possible language and cultural barriers to timely mental health intervention. The family and school should be educated on community resources for violence (e.g., suicide and crisis hotline). Finally, firearms and other potential agents of violence should be removed from the home.
Understandably, even with optimal, comprehensive management, this will be a significant challenge for families, schools, and communities. Prevention is therefore an important task for all healthcare professionals.
Questions
1. True/False: Mood disorders should be seriously considered in all teenagers with disruptive behaviors and decline in academic performance.
2. True/False: Otitis media, meningitis, and pneumonia are the top leading causes of death in children and adolescents.
3. True/False: The comprehensive bio-psycho-social approach to suicide/violence prevention is a potentially life saving skill that all physicians should practice.
4. True/False: Physicians should liberally use antidepressants to treat any child or adolescent who appears depressed.
5. True/False: A teenager who intentionally ingests a large yet non-toxic dose of a non-toxic medication may still be at significant risk for suicide.
6. True/False: Physicians caring for teenagers with disruptive behaviors should attempt to minimize contact with the teenagers' families.
7. True/False: In the future, pediatricians will likely have little role in violence prevention, because there are projected to be enough child and adolescent psychiatrists to fulfill this role.
References
1. American Academy of Pediatrics Task Force on Violence. The Role of the Pediatrician in Youth Violence Prevention in Clinical Practice and at the Community Level. Pediatrics 1999; 103: 173-181.
2. Pfeffer CR. Suicidal Behavior in Children and Adolescents: Causes and Management. In: Lewis M (ed). Child and Adolescent Psychiatry: A Comprehensive Textbook, 2nd edition. 1996. Baltimore: Williams and Wilkins, pp. 666-673.
3. American Academy of Child and Adolescent Psychiatry. Practice Parameters for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder. J Am Acad Child Adolesc Psychiatry 1997; 36: 138-157.
4. Biederman J, Faraone SV, Chu MP, Wozniak J. Further evidence of a bidirectional overlap between juvenile mania and conduct disorder in children. J Am Acad Child Adolesc Psychiatry 1999; 38:468-76.
5. http://www.ama-assn.org/violence
6. http://www.aacap.org/training/workforce.htm
Answers to questions
1. T
2. F
3. T
4. F. Compared with adults, children and adolescents presenting with a major depressive episode are at relatively higher risk of actually having a bipolar disorder. Significant caution must therefore be exercised in prescribing an antidepressant, which may precipitate mania or hypomania. The author advises that child and adolescent psychiatric consultation be sought.
5. T.
6. F. Often, working with the family is a key component of treatment.
7. F. Currently, there are only 6300 child and adolescent psychiatrists in the United States, where the estimated need is for up to 30,000. The population of children is expected to grow 40% in the next 50 years (6). Pediatricians will likely play a very significant role in insuring the psychosocial health of children.