Tero Hallikainen Chief Physician, Ph.D. Psychiatrist, Forensic Psychiatrist Niuvanniemi Hospital, Kuopio, Finland

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1 Tero Hallikainen Chief Physician, Ph.D. Psychiatrist, Forensic Psychiatrist Niuvanniemi Hospital, Kuopio, Finland

2 For the last 10 years in Niuvanniemi Hospital: a 12-bed special ward for treatment resistant children and adolescents under the age of 18 45% of patients suffer from Sch spectrum disorders 40% Conduct disorder 10% Mood disorders 5% Pervasive developmental disorder Court ordered forensic mental examinations Cases

3 Cases

4 A is a male of Finnish origin, the firstborn of four children. He comes from a stable working class family with fair income, with no drug problems nor serious mental disorder. A s early development was normal, but he preferred to play and spend his time alone. At comprehensive school he was bullied and finally left alone from the very beginning, from lower to upper grade. He insisted wearing same kind and colour of clothing all year round, and his diet was monotonous. Hobbies: violent pc games. Cases

5 No learning difficulties, a medium level pupil (7 /4-10). He started drinking and regular smoking at the age of 14. At the age of 15 A started experimenting cannabis ( pot ). His parents were worried because he was even more lonely and distant when growing older, and had no hobbies whatsoever. He agreed to visit out-patient clinic only once with his father, and could not be evaluated further. After comprehensive school he tried to study information technology with poor success. Cases

6 At the age of 16 A stabbed his schoolmate, his cannabis dealer. He felt cheated, and at the moment of stabbing was afraid of the victim, as well. He had been carrying a knife since the age of 14. He also had hidden knives and even a bayonet near his home, just in case. A was arrested immediately and admitted to prison psychiatric ward: He was diagnosed suffering from Adjustment disorder and after 10 days returned to prison without any medication. Cases

7 When released from remand imprisonment A was committed to adolescent psychiatric ward in his home town for six weeks: He suffered from emotional instability. He resisted psychological examination and structured diagnostic interview. A did not regret his crime but was planning a revenge, instead. Antipsychotic therapy was suggested. As A refused he was discharged to continue as an out-patient. Cases

8 A consulted psychologist once a month: He had no motivation for the treatment, neither showed any prominent symptoms. Child welfare organized two contact persons to meet A weekly and support his prosocial development. A year after the stabbing A set the victim s home on fire in the small hours. Fortunately, the family of five was saved. A was arrested immediately because of strong incriminating evidence. He has repeatedly pleaded not guilty. Cases

9 Arrested A spent a few days on the adolescent psychiatric ward, again: He was suffering from mild depression. He was discharged to prison. A month later A was admitted to prison psychiatric ward for 4 months: This time he was suffering from severe paranoia and strong delusions, and was clearly psychotic. Antipsychotic pharmacotherapy was initiated. Cases

10 In forensic mental examination 6 months after the arson: It was obvious that A had been suffering from prodromal or psychotic symptoms for two years before the arson, (depersonalisation, paranoid fears, choice of solitarity, loneliness). He received effective antipsychotic medication through the evaluation, and still suffered from voice hallucinations and depersonalisation. A showed normal cognitive performance, but no empathy for others, especially not for the victims of his crimes. Cases

11 Reserved, distant, angry, and in every sense of word odd, A was found to suffer from Paranoid schizophrenia. He was ordered to involuntary forensic in-patient treatment. The follow-up after the evaluation, and only partial treatment response to clozapine suggest a more or less chronic state of A s mental illness, despite his young age. Cases

12 Cases

13 B is a female of Finnish origin, the second of two daughters. At the upper grade she began to suffer from serious learning difficulties. She was bullied throughout the upper grade. Self-mutilation, suicidal ideation, school truancy, eating disorders, panic disorder, satanism. After a short out-patient evaluation B was committed to adolescent psychiatric ward at the age of 14, where she reported frequent commanding voice hallucinations. Cases

14 Her diagnosis after 2 months hospitalisation was Borderline personality disorder. The child welfare placed B at a reform school when she was discharged. B had three more short hospitalisations during the next year. She graduated from comprehensive school at the age of 16, and tried vocational training, with poor success. Strong suicidal ideation and acts lead to longish hospitalisation, but no psychotic disorder was diagnosed. Cases

15 Because of her resistant suicidality B was finally committed to high security hospital adolescent unit. When admitted, B spontaneously reported having heard commanding voices of Satan during the last few years. The male voices told her to kill fellow patients, and her therapist, or to commit suicide. Quickly, B was diagnosed to suffer from Schizoaffective sch. Clozapine was initiated as pharmacotherapy. She started to recover, but was suffering more or less from chronic Sch when she was referred to adult psychiatric ward in her hometown 5 months later. Cases

16 The real-life cases presented adolescents with chronic sch at the age of 18. In Finland we obviously are behind the schedule when diagnosing major mental disorder in children or adolescents. Why: Saving money by placing children untreated at home or at foster homes? Having pity on the parents or the psychotic child and not telling them the truth about the disorder? The professionals do not want to regocnize the risk of later psychosis associated with childhood developmental disorders??? ADHD, Conduct disorder, Depression, Eating disorder, Borderline disorder, Developmental disorder But not psychotic disorder? Cases

17 Evidence: The first psychotic episode in sch often causes the most severe permanent cognitive damage. We should make the greatest effort before and during the first episode, the impact of treatment on cognition is less crucial later on!!! Effective symptom relief and Continuous antipsychotic pharmacotherapy: Early use of clozapine LAIs - Long-acting injections of 2nd generation antipsychotics Cases

18 Tero Hallikainen, Chief Physician Niuvanniemi Hospital, Kuopio, Finland Cases