Youth Crime: Incarceration is too costly

The long-term cost of incarcerating the nation’s youth is between $8 and  $21 billion, according to a report out Tuesday. The Justice Policy Institute’s “Sticker Shock: Calculating the Full Price Tag for Youth Incarceration” says Florida’s base cost is $55,000 dollars per juvenile per year. From there, the number increases. According to the Justice Police Institute’s executive director, Marc Schindler, the total cost of detaining juveniles is about more than running juvenile detention centers. It also includes lost future earnings, tax payments from confined youth, future reliance of formerly confined youth on public assistance. Previous studies suggest that kids locked up for minor crimes might go down a worse path;  the incarceration of youth increases the likelihood that they will commit new offenses, and this Justice Policy study considers the costs of those harmed by these new offenses.

Juvenile Detention: Its costs go beyond the costs of running the detention facility.

Juvenile Detention: Its costs go beyond the costs of running the detention facility.

 

FACTSHEET: The tip of the iceberg: What taxpayers pay to incarcerate youth Sticker Shock: Calculating the Full Price Tag for Youth Incarceration

Family Focused Therapy Improves Mood Symptoms in Children & Adolescents At Risk for Bipolar Disorder

A study published in the February 2013 issue of the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) found that children and adolescents with major depression or subthreshold forms of bipolar disorder — and who had at least one first-degree relative with bipolar disorder — responded better to a 12-session family-focused treatment than to a briefer educational treatment.

The study, led by David J. Miklowitz, Ph.D., of the UCLA School of Medicine, and Kiki D. Chang, M.D., of Stanford University School of Medicine, identified 40 youth (average age 12 years) who were at risk for developing bipolar disorder.

SAMPLE:

  • The participants had diagnoses of any of the following:
    • major depressive disorder
    • cyclothymic disorder
    • bipolar disorder, not otherwise specified (NOS) (brief and recurrent episodes of mania or hypomania that did not meet full diagnostic criteria for bipolar disorder)
  • All participants had at least one first-degree relative (usually a parent) with bipolar I or II disorder.
  • Of the 40 participants, 60% were taking psychiatric medications upon entry, and continued taking recommended medications throughout the study.
  • Half of the participants were recruited and treated at the University of Colorado, Boulder, and half at Stanford University.

STUDY DESIGN:

The investigators randomly assigned the 40 participants to:

  • family-focused treatment, high-risk version (FFT-HR), consisting of 12 family sessions over 4 months of psychoeducation (learning strategies to manage mood swings), communication skills training, or problem-solving skills training

or

  • 1-2 family informational sessions (educational control, or EC).

 

FINDINGS:

  • Participants in the FFT-HR condition recovered from their initial depressive symptoms in an average of 9 weeks, compared to 21 weeks in the EC condition.
  • Participants who received FFT-HR also had more weeks in full remission from mood symptoms over the study year.
  • Improvements in mania symptoms on the Young Mania Rating Scale were greater in the FFT-HR group as well.
  • The study participants who lived in families that were rated high in expressed emotion, a measure of critical comments or emotional overprotectiveness in parents, took almost twice as long to recover from their mood symptoms as those in families rated low in expressed emotion.
  • A secondary analysis indicated that youth from high expressed emotion families who were treated with FFT-HR spent more weeks in remission over the year than those treated with EC.

Dr. Miklowitz cautioned that the length of follow-up (1 year) was too short to determine whether these children would develop full bipolar disorder. “Nonetheless,” he said, “catching bipolar disorder at its earliest stages, stabilizing symptoms that have already developed, and helping the family to cope effectively with the child’s mood swings may have downstream effects that improve the long-term outcomes of high-risk children.”

Bipolar Disorder and Borderline Personality: Similar and Different

Bipolar disorder and borderline personality disorders are both characterized by unstable moods and impulsive actions, but they are different diagnoses, and have different recommended treatments.

Bipolar disorder and borderline personality disorder often get confused with each other.  I often see patients who tell me a family member has been diagnosed with bipolar disorder, and when we review the DSM criteria for bipolar disorder and borderline personality disorder, it appears that borderline personality disorder better explains their family member.

Now, a study from Rhode Island Hospital may explain why this confusion sometimes occurs:

A widely-used screening tool for the diagnosis of bipolar disorder may actually be identifying borderline personality disorder.

In the article that appears online in the Journal of Clinical Psychiatry, the researchers question the effectiveness of the Mood Disorder Questionnaire (MDQ). The MDQ is the most widely-used and studied screening tool for bipolar disorder. It is a brief questionnaire that assesses whether a patient displays some of the characteristic behaviors of bipolar disorder.
The study consisted of the following:

  • The research team interviewed nearly 500 patients using the Structured Clinical Interview for Diagnostic Statistical Manual IV (DSM-IV) and the Structured Interview for DSM-IV for personality disorders.
  • The patients were also asked to complete the MDQ.

After scoring, the researchers found that:

  • Patients with a positive indication for bipolar disorder using the MDQ were as likely to be diagnosed with borderline personality disorder as bipolar disorder when using the structured clinical interview.
  • Borderline personality disorder was four times more frequently diagnosed in the group who screened positive on the MDQ.

While only a qualified clinician can make a diagnosis bipolar disorder or borderline personality disorder, there are some differences that clinicians use to make this determination:

  • Persons with bipolar disorder will have episodes of depression, and episodes of euphoria or irritability, and even periods of normal mood in between. There are other associated symptoms that go along with the mood changes, such as low energy, and behavioral changes.
  • People with bipolar disorder will cycle between these mood states over months to even years. Rarely, the mood states change more rapidly. But in borderline personality disorder, the shifts in mood are far more rapid—even several times a day.
  • People with borderline personality disorder are more affected by what is happening in their life at any moment, and how they feel about it, and they react to it. They are particularly sensitive to abandonment, or fears of abandonment.
  • The ups and downs in borderline personality disorder are not all-encompassing mood shifts of mania and depression. Instead, they have specific feelings that fluctuate: fear, anger, sadness, disgust, love, in a sort of all-or-nothing, black and white way.

Childhood Bipolar Disorder is NOT Bipolar

Childhood Bipolar Disorder is not Bipolar? DSM-V and the new Temper Dysregulation Disorder with Dysphoria

Written by Nestor Lopez-Duran PhD on Wednesday, February 10.2010 from childpsych.org

Today the American Psychiatric Association released a draft of the major changes that are expected in the new version of the Diagnostic and Statistical Manual of Mental Disorder – 5th Edition (DSM-V). While most people in the field will be underwhelmed by the relatively minor changes,  there are a few areas where the DSM-V will likely make some drastic changes.  Today most of the news coverage was focused on the proposed changes to the Autism diagnosis, which has raised some heated debate in the autism community. However, there is another major change that has received little, if any, attention: the clarification that a syndrome that in recent years has been labeled childhood bipolar disorder is actually NOT bipolar disorder. Instead, a new disorder category was created: Temper Dysregulation Disorder with Dysphoria (TDD).

Let me start by explaining that the creation of TDD does NOT deny the existence of classic bipolar disorder in childhood. That is, although extremely rare, bipolar disorder can occur in children and adolescents, and it looks very much like adult bipolar.  Instead, TDD was created to capture a valid syndrome with characteristics and outcomes that are different than those of bipolar disorder. The available scientific data supports the position that the TDD syndrome is NOT simply the manifestation of bipolar disorder in childhood. This means that thousands of children that have been diagnosed with childhood bipolar disorder may not have bipolar and instead have a completely different syndrome now called Temper Dysregulation Disorder with Dysphoria.

So what is TDD?

Here is the proposed criteria for TDD:

A. The disorder is characterized by severe recurrent temper outbursts in response to common stressors.

1.  The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property.

2.  The reaction is grossly out of proportion in intensity or duration to the situation or provocation.

3.  The responses are inconsistent with developmental level.

BFrequency: The temper outbursts occur, on average, three or more times per week.

CMood between temper outbursts:

1.  Nearly every day, the mood between temper outbursts is persistently negative (irritable, angry, and/or sad).

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

DDuration: Criteria A-C have been present for at least 12 months.  Throughout that time, the person has never been without the symptoms of Criteria A-C for more than 3 months at a time.

E. The temper outbursts and/or negative mood are present in at least two settings (at home, at school, or with peers) and must be 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, and the abnormally elevated or expansive mood was accompanied by the onset, or worsening, of three of the “B” criteria of mania (i.e., grandiosity or inflated self esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal directed activity, or excessive involvement in activities with a high potential for painful consequences; see pp. XX). Abnormally elevated mood should be differentiated from developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation.

I.  The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder (e.g., Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder) and are not better accounted for by another mental disorder (e.g., Pervasive Developmental Disorder, post-traumatic stress disorder, separation anxiety disorder). (Note: This diagnosis can co-exist with Oppositional Defiant Disorder, ADHD, Conduct Disorder, and Substance Use Disorders.) The symptoms are not due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition.

The syndrome captured by section A-C (frequent and intense temper outbursts, happening several times per week in the context of negative emotionality) is the core of the symptoms that has been incorrectly interpreted as indicative of childhood bipolar disorder.  Section H is very interesting. It states that this diagnosis is not appropriate if the person has experienced classic mania (e.g., bnormally elevated or expansive mood), as in such a case the diagnosis of bipolar is likely more accurate.

So why did the DSM-V decide that this syndrome is not simply bipolar disorder of childhood?

1. Lack of continuity to bipolar.

If TDD is simply the expression of bipolar disorder during childhood, then children diagnosed with this condition would eventually develop symptoms of classic bipolar disorder as they reach adulthood. The data do not support this hypothesis. That is, children who display the TDD syndrome in childhood (and are often incorrectly diagnosed as bipolar) are not more likely to develop classic bipolar disorder later in life as their peers (see Brotman et al., 2006; Leibenluft et al, 2006; Stringaris et al, 2009).  Instead, these children are more likely to develop depression, not bipolar!

2. Different Biological Markets.

Youth who are diagnosed with classic bipolar differ significantly from those who have a TDD-like syndrome (see Brotman et al, 2010; Guyer et al, 2007; Rich et al, 2008).  If TDD is simply bipolar, then the biomarkers of TDD should be similar to those of bipolar, but this is not the case.

3. Different Demographic Factors.

If TDD is simply bipolar, then the gender distribution of TDD should be similar to that of bipolar. This does not appear to be the case. Specifically, there is no gender differences in the rate of classic bipolar; male and females are equally likely to develop the condition. However, the TDD-like syndrome is disproportionately observed in boys rather than girls.

4. A need for a new category that would impact treatment and research.

In theory, the presence of TDD will educate clinicians, researchers, and the public that this syndrome is not simply a version of bipolar disorder. This would facilitate research on the causes, features, and treatments for this condition. This has major implications for treatment. For example, the standard treatment for bipolar disorder does NOT seem to work in children that have the TDD syndrome (Dickstein et al, 2009). By explicitly stating that TDD is not bipolar, researchers would be less likely to approach the search for treatments from a “bipolar framework”, which would potentially facilitate the discovery of more effective interventions.

I am actually glad about this change as it will have a clear impact on clinical practice and research that will most likely benefit the children affected with this condition.

References:

Brotman MA, Schmajuk M, Rich BA, Dickstein DP, Guyer AE, Costello EJ, Egger HL, Angold A, Pine DS, & Leibenluft E (2006). Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children. Biological psychiatry, 60 (9), 991-7 PMID: 17056393

Dickstein DP, Towbin KE, Van Der Veen JW, Rich BA, Brotman MA, Knopf L, Onelio L, Pine DS, Leibenluft E (2009): Randomized double-blind placebo-controlled trial of lithium in youth with severe mood dysregulation. J Child Adolesc Psychopharm 19: 61-73

Guyer AE, McClure EB, Adler AD, Brotman MA, Rich BA, Kimes AS, Pine DS, Ernst M, Leibenluft E (2007): Specificity of face emotion labeling deficits in childhood psychopathology. Journal of Child Psychiatry and Psychology, 48:863-71

Leibenluft E, Charney DS, Towbin KE, Bhangoo RK, Pine DS (2003): Defining clinical phenotypes of juvenile mania. Am J Psychiatry 160: 430-437

Rich BA, Grimley ME, Schmajuk M, Blair KS, Blair RJR, Leibenluft E (2008): Face emotion labeling deficits in children with bipolar disorder and severe mood dysregulation. Development and Psychopathology 20: 529-546

Stringaris A, Cohen P, Pine DS, Leibenluft E (2009): Adult outcomes of adolescent irritabilty: A 20-year community follow-up. Am J Psychiatry 166: 1048-54