Kristie Ladegard, MD, Monica Morris, LCSW and Elizabeth Milhaupt, LCSW

Presented by:
Kristie Ladegard, MD,
Monica Morris, LCSW and Elizabeth Milhaupt, LCSW
Denver Health School Based Health Centers
Kristie Ladegard, MD, Denver Health Child Psychiatrist
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At 9 School Based Health Centers (SBHC) in Denver, CO
Family Crisis Center (FCC)
Substance Abuse Treatment Education & Prevention program (STEP)
Outpatient Behavioral Health
Monica Morris, LCSW, Denver Health Mental Health Therapist
Abraham Lincoln High School SBHC, Denver, CO
Elizabeth Milhaupt, LCSW, Denver Health Mental Health Therapist
Place Bridge Academy SBHC, Denver, CO
The following personal financial relationships with
commercial interests relevant to this presentation existed
during the past 12 months:
“No relationships to disclose”
 Background
 Mental health referral process
 Susie’s story
 Mental health assessment
 Self-injurious behaviors vs. suicidal ideation
 Claire’s story
 De-escalating techniques
 Jacob’s story
 Questions
 After receiving a grant in 1987, Denver Health opened their
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first school based health center in the Denver Public
School District (DPS) at Abraham Lincoln High School in
1988.
In 1993, Denver Health partnered with the Mental Health
Corporation of Denver (MHCD) to provide comprehensive
mental health services to DPS.
Currently, there are 15 health centers located in Denver
Public Schools across Denver and we continue to grow.
Our centers provide primary care, mental health,
reproductive health education and insurance enrollment
assistance services to DPS students
Each center is staffed by medical and mental health
professionals that specialize in pediatrics and adolescent
medicine
Suicidal
Homicidal
Acutely Psychotic
Gravely Disabled
No improvement after 3 months
Symptoms worsen after 1 month
Medication change needed
Self harm thoughts/ behaviors
Comorbidity
Stable on medication
Mild to moderate symptoms
 Change in function
 Grades slip
 Truancy
 Self harm/ ideation
 Anger/ aggression
 Acting out
 Drug/ alcohol use
 Suicidal ideation/ homicidal ideation
 Self report of physical or emotional abuse
 Limited support system
 Withdraw socially/ activities
• 12-year-old Caucasian female presenting to clinic for sports physical.
• Depression questionnaire (PHQ-9) reveals symptoms of depression.
• Due to the positive depression screen the nurse practitioner performs a
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mental health evaluation.
Susie reports having difficulty falling asleep because she’s "thinking
about things."
Spends a lot of time by herself at home.
Susie reports not liking herself and doesn’t think she has a good future.
Brief risk assessment reveals she had suicidal thoughts a few months
ago but denies current thoughts.
NP notices a couple scars on Susie’s forearm and she admits to cutting
but hasn’t for a couple months.
Admits in the past her father would drink heavily and yell at her and
her mother. Reports having flashbacks and nightmares at least two
times a week.
Admits to having trouble in the hallways because she is easily agitated
and startles easily whenever she hears loud noises.
Mental Status Exam reveals Susie sometimes hears voices calling her
name and sometimes has visions of people.
• MOC admits her daughter’s behavior has worsened over past 3 months.
• All agree to initiate Prozac 10mg daily.
• At 2 week follow up, Susie says she continues to feel sad and all agree
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increase to Prozac 20mg.
Two weeks later, Susie reports some mood improvement but continues
to worry frequently and dose then increased to 30mg daily.
Susie reports being more irritable and agitated, school reports Susie
has started cussing out her teachers.
MOC reports Susie doesn’t sleep until midnight most evenings and is
more aggressive. Susie reveals she has started cutting again.
NP and MOC agree the Prozac is not helping.
The family doesn’t have insurance so NP recommends Celexa because it
is cost-effective.
A month later, virtually all of Susie’s aggressive and self-injurious
behaviors have ceased.
Susie referred to outpatient mental health for therapy and med
management.
Symptoms
Mood
Sleep
Appetite
Energy
Suicide/ homicidal
ideation
 Focus/ concentration
 Decreased interest/
anhedonia
 Feelings guilt,
hopelessness,
worthlessness
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Special Considerations
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Academic performance
Truancy
Drugs/ alcohol
Decreased motivation
Social isolation
Oppositional
Cutting
Somatic complaints
Eating disorder
Running away
Hearing voices
Visions
Risky Sex
 Irritable or cranky mood
 Boredom, loss of interest in sports, video games; giving
up favorite activities
 Failure to gain weight as normally expected; overeating
and weight gain especially in teens
 Changes in sleep patterns; delays in going to or falling
asleep; refusal to wake for school; early morning
awakening
 Difficulty sitting still, pacing, or very slowed down
with little spontaneous movement 1
 Persistently tired, feels lazy
 Self-critical; blaming oneself for things beyond one’s
control; “no one likes me, everyone hates me”; feels stupid
 Decline in performance in school due to decreased
motivation and ability to concentrate; frequent absences
 Frequent thinking and talking about death; writing about
death; giving away favorite toys or belongings 1
 Approximately 4% to 8% in adolescents with male to female
ratio of 1:2
 Approximately 2% in children with male to female ratio of 1:1 2
 Risk of depression increases by a factor of 2 to 4 after puberty
especially in females 3
 Cumulative incidence by age 18 is approximately 20% in
community samples 4
 Approximately 5% to 10% children and adolescents have
subsyndromal symptoms of MDD 5
Comorbidity is common; 40% to 90% of youth with
depressive disorder also have other psychiatric
disorders and up to 50% have two or more comorbid
diagnoses 5
Most frequent comorbid diagnoses are:
 Anxiety disorders
 Disruptive behaviors
 ADHD
 Substance use disorders 5
 Prozac (Fluoxetine) is the most studied and is the
only FDA approved antidepressant to treat MDD in
children younger than 7 years 6
 Zoloft (Sertraline) has shown to provide efficacy in
one of two randomized controlled trials (RCTs) 6
 Celexa (Citalopram) has one positive randomized
control trial for treatment of depression 6
Do not use doses higher than 40mg.
 Lexapro (Escitalopram) FDA approved for
treatment of depression ages 12-17 (some insurances
won't cover unless tried 2 other SSRI's) has two
positive randomized control trials 7
 Wellbutrin (Bupropion) no RCTs, small open-label studies have
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suggested effectiveness in treating adolescent depression,
Contraindicated with presence of seizure disorder and bulimia 5
Remeron (Mirtazepine) no RCT's
Effexor (Venlafaxine) shown to be superior to placebo in
adolescents but not children 6
Avoid Paxil; investigators found that suicidal thoughts and
attempts were roughly twice as high among children and
adolescents taking Paxil in the United Kingdom than among
those taking a placebo (3.2% vs. 1.5%) 8
Tricyclic Antidepressants (TCA's) are not recommended due
to lack of proved efficacy along with the risk of cardiac
arrhythmia, and can be fatal after an overdose 6
Monoamine Oxidase Inhibitors have a lack of published data
demonstrating efficacy in children and adolescents They also
have multiple significant drug and food interactions . 9
 Share decision making with client and family
 Review side effects: Most common with SSRI's
include gastrointestinal symptoms, sleep changes,
restlessness, headaches, diaphoresis, changes in
appetite, and sexual dysfunction 5
 Medication commitment
 Continue for at least 4-8 weeks
 See client after 2 weeks with therapist visiting in
between medication follow up appointments
 The Food and Drug Administration (FDA) published
in 2004 a "black box" warning on all antidepressants,
indicating an increased risk of suicidality in children
and adolescents given antidepressant medications
 The FDA found that after reviewing 23 clinical trials
with more than 4300 child and adolescent patients
being treated with 9 different antidepressants that the
rate of suicidal thinking and behaviors were 2% for
patients on placebo verses 4% among patients on
antidepressants
 No completed suicides occurred in these studies
 A more recent study found the risk to be around 3% in
those on medication and 2% in those on placebo 10
Since the FDA issued a black box warning, there
has been a decline in antidepressant use, but an
increase in completed suicides in adolescents in
both the United States and the
Netherlands. Although it is not clear how these
trends are related this is the first increase in
suicide rate reported in over a decade
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 The consequences of childhood and adolescent
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depression are serious
Patients may have ongoing problems in school, at
home, and with their friends
40% will go on to have a 2nd episode of depression in 2
years
Increased risk for substance abuse, eating disorders,
and teen pregnancy
It is estimated that depression increases the risk of a
first suicide attempt by at least 14 fold 8
With careful monitoring, the development of a safety
plan, and the combination of medication with
psychotherapy, the risk of suicide can be managed
 In 2009 the U.S Preventative Services Task Force
published a paper calling for an annual depression
screening for all teen ages 12-18
 The Institute of Medicine and National Research
Council also issued a paper calling for evidenced-based
screening of adolescents and highlights primary care
settings as a key location for screening
 PHQ-9 was developed by researchers at Columbia
University and is an easy and effective screening tool
Self-Injurious Behaviors
 “Self Injury is intentional, non-life
threatening, self effected bodily
harm or disfigurement of a socially
unacceptable nature, performed to
reduce psychological distress.” 12
 Self Injury is a coping mechanism; it
is an attempt to survive and manage
the affect of an overwhelming
experience or emotion.
Suicidal Ideation
 Must assess plan, means, and
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threatening, repeated pattern of
self-injury.
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intent
Intent is to escape pain or
terminate consciousness
There is rarely chronic
repetition; some repeatedly
overdose
Persistent feelings of
helplessness and hopelessness,
little or no future casting, all or
nothing thinking 13
Other lethal means
• 14 year old female presenting to the clinic for gastrointestinal distress
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for 3rd time this week
Claire seems very tense and agitated during evaluation
Claire reports feeling anxious about school and her mother often
Feels nauseous and has butterflies in her stomach; reports that her
body tenses and she has difficulty focusing.
Claire admits to spending two hours daily cleaning her house to "keep
her mind off of what happened in the past".
Claire reports being sexually assaulted a year ago by her stepfather.
Since then, reports having flashbacks, nightmares and insomnia
Avoids places, people, or things that remind her of the trauma and
sometimes has anger outbursts
Describes mood as either angry or sad most days and has feelings of
helplessness
Risk assessment reveals history of suicidal thoughts but denies any
current SI/HI.
• Prescribed Prozac 10mg daily to target her anxiety/ mood
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symptoms.
A month on the 10 mg dose, the medicine seems to help some
but she was still getting angry with her mother most days.
PA increases Prozac to 20mg daily.
Mother reports that Claire is still yelling at her, aggressive
towards her sisters, and seemed to be more restless around the
house.
PA, Claire, and mother agree to discontinue Prozac and is placed
on Zoloft 25mg daily.
Two weeks later Claire reports some reduced moodiness and
irritability and dose is increased to 50mg.
Six weeks later, Claire seems stable on the 50 mg. Clair and
mother report her mood symptoms have improved significantly.
Claire says she is happier and less irritable and school reports she
is completing her work more consistently.
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Symptoms
Worries
Obsessive thoughts
Nightmares
Avoidant behaviors
Panic attacks
Sleep
Focus/ concentration
Suicide/ homicidal
ideation
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Special Considerations
Somatic complaints
Social isolation
Truancy
Academic performance
Drugs/ alcohol
Decreased motivation
Oppositional
Hearing voices
Visions
 6 to 20% diagnosed with MH have a anxiety diagnosis
 One sample of adolescents and young adults indicated that the
overall lifetime prevalence of PTSD in the general youth
population was 9.2%.
 A recent national sample of adolescents (12–17 years old)
indicated that 3.7% of male and 6.3% of female adolescents met
full diagnostic criteria for PTSD.
 Children with PTSD often have comorbid psychiatric
conditions. PTSD commonly occurs in the presence of depressive
disorders, ADHD, substance abuse, and other anxiety disorders 14
 Prevalence rates for having at least one childhood anxiety
disorder vary from 6% to 20% over several large epidemiological
studies 15
 Anxiety disorders are highly comorbid with other anxiety
disorders and with other psychiatric disorders including
depression, ADHD and substance abuse.
 Other commonly co-occurring conditions include
oppositional defiant disorder, learning disorders, and
language disorders.
 Comorbid disorders may affect functioning and treatment
outcome. They should be assessed and may benefit from
being treated concurrently with the anxiety disorder.
 Clinical studies have shown that as many as one third of
children with ADHD have co-occurring anxiety disorders.
 Children with anxiety disorders are at greater risk of
alcohol abuse in adolescence. Comorbid alcohol
abuse/dependence in adolescents should be assessed and
considered in treatment planning with anxiety disorders 15
 Consider medication when (1) anxiety disorder symptoms are
moderate or severe (2) impairment makes participation in
psychotherapy difficult (3) psychotherapy results in partial
response 2
 Prozac (Fluoxetine) has one RCT for SAD, GAD, and SP 6 has
an open label study for Post Traumatic Stress Disorder (PTSD)
symptoms in Turkish children that were in an earthquake 14
 Zoloft (Sertraline) has one RCT for GAD 6 and one RCT for
GAD, SP, and SAD which showed that combination treatment
(psychotherapy plus medication) was more effective than
either medication or psychotherapy alone 16
 Luvox (Fluvoxamine) has one RCT for Separation anxiety
disorder (SAD), Generalized anxiety disorder (GAD), and
Social Phobia, (SP). Children and adolescents with less
comorbid depressive symptoms had the best response. 6
 Paxil (Paroxetine) has one RCT for Social Phobia 6
 Celexa (Citalopram) has an open label study that was
shown to be effective for Post Traumatic Stress
Disorder (PTSD) 9
 Effexor (Venalfaxine) has one RCT for GAD and SP 15
 Anafranil (Clomipramine) a TCA, has one RCT for
Obsessive Compulsive Disorder but not other childhood
anxiety disorders 15
 Other TCAs have not been found effective for childhood
anxiety disorders 15
 Buspar (Buspirone) may be an alternative to SSRI's for
GAD in youth but has no published controlled trials 15
 Benzodiazepines have not shown efficacy in controlled trials
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in childhood anxiety disorders. Have cognitive side effects
which may impair learning and school performance. Can cause
physical dependence. Contraindicated in adolescents with
substance abuse 15
Clonidine (Catapres) has 2 open studies that have been found
to decrease anxiety, impulsivity, and PTSD hyper arousal
symptoms in children with PTSD 14
Inderal (Propranolol) has an open study that showed a
decrease in re-experiencing and hyper arousal symptoms in
children with PTSD symptoms 14
Desyrel (Trazodone) no RCT’s often used for insomnia related
to depression or anxiety
Minipress (Prazosin) no RCT’s, positive case studies in
adolescents, used for nightmares and insomnia in adolescents
with PTSD 17
 Although all antidepressants have a black box warning, no
individual childhood anxiety study has found a statistically
significant increase in suicidal thoughts or behaviors 6
 The Research Units on Pediatric Psychopharmacology
Anxiety Study Group (RUPP) indicate that clinicians
should consider increasing SSRI doses for patients, if
significant improvement is not achieved by the 4th week of
treatment 15
 May consider a medication-free trial for children who have
a significant reduction in anxiety or depressive symptoms
(sxs) on an SSRI and maintain stability in these sxs for one
year. The trial off should be during a low stress period and
should be restarted if the child or adolescent relapses 15
 Tree Meditation
 Visual Container
 Deep Belly Breathing
 Light Stream
 Bilateral tapping
 Emotional Freedom
Technique (EFT)
 Diaphragmatic or belly breathing encourages full
oxygen exchange and is one of the body’s most
strongest abilities to self heal.
 Slows the heartbeat and can help to lower or stabilize
blood pressure 18
1.
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6.
Place hand on lower belly
Breathe in through nose for
count of 3 (blowing up belly
like a balloon)
Hold for a count of 2
Breathe out through mouth
for count of 5 (releasing air
in belly)
Repeat 5- 10 times
Can add visualization by
breathing in a color
representing calm and out a
color representing the
stressor, filling your body
with the calm color.
• 15-year-old high school sophomore seen in school clinic
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after getting into a physical altercation with a peer.
School reports he has been suspended three times this year.
Jacob admits to failing all of his classes.
Jacob and his mother confirm he has struggled
academically since the first grade.
Jacob struggles with completing assignments, is forgetful,
talks during class, is disorganized and engages in impulsive
behaviors.
Teachers have expressed some concern about ADHD
behaviors several times over the years.
Past PCP placed him on Strattera but discontinued usage
after two weeks with no marked improvement in behavior.
• Completed Vanderbilt scale showed high scores in
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inattention and hyperactivity.
NP prescribed Jacob Methylphenidate 10mg one tab po
BID.
At 2 week follow up, Jacob states his mood has been
fluctuating; he feels fine in the morning but gets more
irritable during lunch time.
Teachers report he is getting more work done in their
classes but is more disruptive and oppositional around
10:30 am and 2pm.
NP discontinued Methylphenidate and prescribed
Concerta 36 mg po q am.
Since starting the Concerta, Jacob’s academic performance
and behavior improved and he has received no school
disciplinary actions.
Symptoms
Special Considerations
 Focus/ concentration
 Academic performance
 Impulsivity
 Truancy
 Energy
 Substance use
 Oppositional behaviors
 Social isolation
 Disruptive behaviors
 Oppositional
 Mood
 ADHD symptom scale
 Sleep
 Low self-esteem
 Suicide/ homicidal
ideation
 Combined Type: 6 or more symptoms of both
hyperactivity-impulsivity and inattentive that have
persisted for at least six months.
Most children and adolescents with the disorder
have the Combined Type.
 Predominantly Inattentive Type: 6 or more symptoms
of inattention (fewer than six symptoms of
hyperactivity-impulsivity)
 Predominantly Hyperactive Type: 6 or more symptoms
of hyperactivity-impulsivity (fewer than six symptoms
of inattention)
 The prevalence of ADHD was found to be 6.7% by the
U.S. National Health Interview Survey. The Centers for
Disease Control and Prevention found the lifetime
childhood diagnosis of ADHD to be 7.8% 19
 It is commonly accepted that ADHD is more common
in boys than in girls, at a ratio ranging from 2.5: 1 to
5.6: 1 9
 It is well established that ADHD frequently is comorbid
with other psychiatric disorders.
 Studies have shown that 54% to 84% of children and
adolescents with ADHD may meet criteria for oppositional
defiant disorder (ODD); a significant portion of these
patients will develop conduct disorder.
 15% to 19% of patients with ADHD will start to smoke or
develop other substance abuse disorders. Depending on
the precise psychometric definition, 25% to 35% of patients
with ADHD will have a coexisting learning or language
problem and anxiety disorders occur in up to one third of
patients with ADHD 19
 Stimulants are 1st choice agents due to greatest efficacy with mild
tolerable side effects.
 Double blind, placebo controlled trials in both children and
adults 65% to 75% of subjects with ADHD were clinical
responders to stimulants compared to 4% to 30% of subjects
with placebo.
 Providers may choose methylphenidate or amphetamine since
evidence suggests both are equally efficacious. Use short acting
stimulants in small children (<16kg or < 35lbs) in weight. 19
 Advantages of sustained release medications: 1) once a day
dosing, 2) no interruptions for school, 3) periods of rebound
and irritability are avoided, 4) have been shown to be equally
efficacious as immediate release medications, 5) greater
convenience, 6) confidentiality, 7) better compliance, 8)
studies show long-acting Methylphenidate may improve
driving performance in adolescents compared to short acting
methylphenidate. 6
 Side effects of stimulants to monitor include: 1) decreased
appetite 2) sleep problems 3) irritability 4) headaches 5)
stomachaches 6) skin picking 7) may develop tics 9
 Although stimulants may lead to time –limited delay of growth
in some children, no long-term effects on growth of final adult
height are apparent. Children with stimulants achieve their
predicted adult size 9
 Monitoring of stimulants: before starting a
stimulant it is recommended to get a physical
exam, blood pressure, pulse, weight, and height. Once on a
stimulant check height, weight, blood pressure and pulse
initially after starting the medication, or when a change of dose
is made, and when dose is established then check every 3
months 6
 After starting the stimulant, may titrate upward every 1 to 3
weeks until symptoms of ADHD remit, or maximum dose is
reached, or side effects are too severe.
 Nonstimulant medications: Strattera (Atomoxetine), Wellbutrin
(Bupropion), and alpha-adrenergic agents like Tenex, Clonidine
and Intuniv
 Consider Strattera and other nonstimulant medications when: 1)
patient cannot tolerate stimulant therapy, 2) active substance
abuse, 3) have comorbid anxiety, 4) have cardiac problems but
still check with a cardiologist
 Studies show that although Strattera is superior to placebo at
week one of trials, the greatest effects were observed at week 6,
therefore it is important to maintain a full therapeutic dose for at
least several weeks to obtain the full effect 19
 Stimulants should not be used in children and adolescents with
preexisting heart disease or symptoms suggesting significant
cardiovascular disease unless cleared and evaluated by a
cardiologist. This may include: history of severe palpitations,
fainting, exercise intolerance not accounted for by obesity, or
strong family history of sudden death, postoperative tetralogy of
Fallot, coronary artery abnormalities, and subaortic stenosis 19
DSM-IV TR and V: DSM-V was released at the annual APA’s meeting May 2013.
 Depressive Disorders DSM-IV diagnoses:
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http://www.psyweb.com/mdisord/jsp/gendepress.jsp
Anxiety Disorders DSM-IV diagnoses:
http://www.psyweb.com/mdisord/jsp/anxd.jsp
ADHD DSM-IV diagnosis: http://www.ldawe.ca/DSM_IV.html
New info added to the ADHD diagnosis in the DSM-V:
http://www.dsm5.org/Documents/ADHD%20Fact%20Sheet.pdf
Other changes from DSM-IV TR to DSM-V:
http://www.dsm5.org/Pages/RecentUpdates.aspx
Vanderbilt Assessment Scales (VAS) as referenced in the ADHD vignette:
 VAS assessment and follow up forms for Parent and Teacher in English and
Spanish: http://www.mahec.net/ic/forms.aspx
De-Escalating Techniques:
 Tapping, container & light stream:
http://www.eftuniverse.com/index.php?option=com_content&view=article
&id=9082:three-strategies-for-closing-incompletesessions&catid=47:refinements-to-eft&Itemid=3212
 Kristie Ladegard, MD
kristie.ladegard@dhha.org
 Monica Morris, LCSW
monica.morris2@dhha.org
 Elizabeth Milhaupt, LCSW
elizabeth.milhaupt@dhha.org
 Denver Health School Based Health
Centers: 303-602-8958
1
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2 Birmaher
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Forest Laboratories, Inc. (December 2012). Lexapro Prescribing Information.
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8
American Academy of Child and Adolescent Psychiatry. (2010) FDA Action on
Paxil.
http://www.aacap.org/cs/root/resources_for_families/psychiatric_medication/fda
_action_on_paxil
9 Dulcan K. Mina, Wiener M. Jerry (2006) Essentials of Child and Adolescent
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10 Bridge JA, Iyengar S, Salary CB., Barbe P, Birmaher B, Pincus HA, Ren L, & Brent
DA. (2007). Clinical response and risk for reported suicidal ideation and suicide
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controlled trials. Journal of the American Medical Association 297: 1683-1696
11 Gibbons RD, Brown CH, Hur K, Marcus SM, Bhaumik DK, ErkensJA, Herings
RMC, Mann JJ, Early Evidence on the Effects of Regulators’ Suicidality Warnings
on SSRI Prescriptions and Suicide in Children and Adolescents American Journal
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12 Walsh, B. W. (2006) Treating Self Injury: A practical guide, Guilford Press
13 Walsh, B. W & Rosen, P. (1988). Self mutilation: Theory, research, and
treatment. New York: Guilford Press.
14 American Academy of Child and Adolescent Psychiatry (2010), Practice
Parameter for the Assessment and Treatment of Children and Adolescents with
Post Traumatic Stress Disorder. Journal of the American Academy of Child and
Adolescent Psychiatry, (49)4 414-430
15 American
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Psychiatry (46)3 267-283
16 Compton S et.al. (2010), Child Adolescent Anxiety Multimodal Study (CAMS);
rationale, design, and methods. Child and Adolescent Psychiatry Mental Health 4:1
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Stress Disorder. Journal of Child and Adolescent Psychopharmacology Volume
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