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Differential Diagnoses for Youth with Psychiatric Disorders

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Differential Diagnoses for Youth with Psychiatric Disorders PSYCHIATRIC DISORDERS FOR CHILDREN & ADOLESCENTS IN THE CHILD WELFARE SYSTEM: COMMON DIAGNOSES & HOW TO ADDRESS THEM TONYA MARTIN, PSY.D. LICENSED PSYCHOLOGIST FORT BEND COUNTY BEHAVIORAL HEALTH SERVICES KITS CONFERENCE: THURSDAY, JUNE 22, 2017 PREVALENCE OF MENTAL HEALTH DISORDERS IN CHILD WELFARE SYSTEM Up to 80% of children in foster care = significant mental health issues Compared to 18-22% of general population Prescribed psychiatric medications at much higher rate American Academy of Pediatrics, Healthy Foster Care Initiative Mental and behavioral health is “greatest unmet health need for children and teens in foster care.” Factors contributing History of complex trauma Frequently changing situations and transitions Broken family relationships Inconsistent and inadequate access to mental health services Over-prescription of psychiatric medications (NATIONAL CONFERENCE OF STATE LEGISLATURES, 2016) COMMON MENTAL HEALTH DISORDERS IN CHILD WELFARE SYSTEM Attention-Deficit/Hyperactivity Disorder (ADHD) Conduct Disorder (CD) & Oppositional Defiant Disorder (ODD) Adjustment Disorder Disruptive Mood Dysregulation Disorder (DMDD) Post-Traumatic Stress Disorder ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) SYMPTOMS, TREATMENT, & HOW PARENTS CAN HELP THEIR CHILDREN COPE ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) Difficulty maintaining attention Severe impulsivity Tendency to lose focus on uninteresting activities ADHD DEFINED Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development Not just oppositional behavior, defiance, or failure to understand tasks or instructions The term “ADD” technically no longer exists ADHD, type specified Combined Presentation, Predominantly inattentive presentation, Predominantly hyperactive/impulsive presentation ADHD CONT’D Associated Behaviors Often fail to pay attention to details and making careless mistakes Rarely following instructions carefully and completely losing or forget things like toys, or pencils, books, and tools needed for a task Often skip from one uncompleted activity to another. Often forgetful in daily activities Often does not listen when spoken to directly Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort TREATMENT FOR ADHD Psychiatric Medication Ritalin, Adderall, Concerta, Intuniv Younger than 6-years-old-> recommended that they do NOT receive meds Behavior Therapy Goal: Modify the child’s behavior Cognitive-Behavioral Therapy (CBT) Combo of behavior therapy and medication = most effective WHAT CAN PARENTS DO TO ADDRESS ADHD BEHAVIORS? Set boundaries and rules, BE CONSISTENT in enforcing them Consistent & effective disciplinary strategies Manage inattention problems by giving time limits for tasks Set reward systems Coordinate with child’s school to make sure similar rules/discipline format being followed Provide specific praise and attention for appropriate behaviors (praising good behavior often) and not providing attention for mild, annoying but not harmful behaviors (choosing your battles) Use developmentally appropriate directions and commands Plan ahead when working with children in public places CONDUCT DISORDER & OPPOSITIONAL DEFIANT DISORDER SYMPTOMS, TREATMENT & HOW PARENTS CAN HELP THEIR CHILDREN COPE CONDUCT DISORDER (CD) Repeated violation of rules or rights of others Lack of concern about feelings of others Lack of remorse *Well documented risk factor for PTSD* CONDUCT DISORDER Repetitive & persistent pattern of behavior -> basic rights of others or rules are violated in any of four basic areas: Aggression to people and animals Destruction of property Deceitfulness or Theft Serious Violations of Rules Onset Childhood, Adolescent, & Unspecified Onset CONDUCT DISORDER Associated Behaviors Early smoking, drinking or drug use Early sexual activity Frequent tantrums and arguments Consistent hostility toward authority figures (May have) difficulties in: Academic achievement Interpersonal relationships Drug and alcohol use OPPOSITIONAL DEFIANT DISORDER Often angry & irritable Actively defies rules Argumentative with others (authority figures & peers) May be vindictive OPPOSITIONAL DEFIANT DISORDER (ODD) Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness Angry/Irritable Mood Often loses temper Is often touchy or easily annoyed Is often angry and resentful Argumentative/Defiant Behavior Often argues with authority figures or, for children and adolescents, with adults Often actively defies or refuses to comply with requests from authority figures or with rules Often deliberately annoys others Often blames others for his or her mistakes or misbehavior ODD CONTINUED Vindictiveness Has been spiteful or vindictive at least twice within the past 6 months Warning Signs/Associated Features Constant problematic interactions with others Don’t view themselves angry, oppositional, or defiant Justify behavior-> response to unreasonable demands Disruption in caregivers during childhood Harsh, inconsistent, or neglectful child-rearing practices TREATMENT FOR CD & ODD Difficult to treat! But not impossible… Parent Management training Can be more effective for young children Parent-Child Interaction Therapy (PCIT) Family Behavioral Therapy Multi-systemic Therapy (MST) Consistently supported in research as one of the best interventions for CD Peers School Neighborhood Family TREATMENT CONTINUED Emphasis on building empathy (CD) Skills training Cognitive-Behavioral Therapy Social Skills training Aggression replacement training/Anger management Medication Not effective alone HOW CAN PARENTS COPE WITH CHILDREN WHO HAVE CD/ODD? Probably among most challenging for parents/foster parents Remain consistent with therapy These are not “just bad kids” Develop warm, nurturing relationships with their children Counteract how behavior may have been learned in first place Replace harsh parenting with consistent discipline that sets boundaries for misbehavior Use positive parenting methods to reward good behavior (SAMHSA, 2017) ADJUSTMENT DISORDERS & DISRUPTIVE MOOD DYSREGULATION DISORDER SYMPTOMS, TREATMENT & HOW PARENTS CAN HELP THEIR CHILDREN COPE ADJUSTMENT DISORDERS Emotional or behavioral symptoms in response to identifiable stressor occurring within 3 months Clinically Significant Out of proportion to severity or intensity of stressor Types Depressed mood Anxiety Mixed anxiety & depressed mood Disturbance of conduct Mixed disturbance of emotions and conduct Unspecified DISRUPTIVE MOOD DYSREGULATION DISORDER (DMDD) Two phases of manifestations Frequent temper outbursts Chronic, severe, persistently irritable or angry mood present between the severe temper outbursts Account for over-use of Bipolar Disorder dx DMDD: BEHAVIORS Severe recurrent temper outbursts manifested verbally and/or behaviorally that are grossly out of proportion in intensity or duration to situation or provocation Temper outbursts inconsistent with developmental level Temper outbursts occur, on average, three or more times per week Mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others Age of onset is before 10 Dx should not be made before age 6 or after age 18 TREATMENT FOR ADJUSTMENT DISORDERS AND DMDD Adjustment Disorders Depends on symptoms E.g., if depressed, therapist will focus on decreasing depressive symptoms & processing separation DMDD Combination of Psychotherapy and meds = best outcome CBT Parent training Computer-based training (NIMH, 2017) HOW DO PARENTS HELP CHILDREN COPE WITH MOOD DISORDERS? Be vigilant about changes in child’s mood Know triggers for change, how often, what behavior they exhibit when they feel sad, mad, irritated, etc. Reinforce their treatment Keep a mood log Plan ahead Avoid unnecessary situations that could lead to a meltdown (when possible) Keep them active In activities Physically active Research-> physical activity combatting depression Decrease family conflicts Have a crisis plan in place (OXFORD UNIVERSITY PRESS, 2008) POST-TRAUMATIC STRESS DISORDER SYMPTOMS, TREATMENT & HOW PARENTS CAN HELP THEIR CHILDREN COPE POSTTRAUMATIC STRESS DISORDER (PTSD) Frequent Nightmares Flashbacks Tendency to startle easily (hypervigilance) PTSD DEFINED Exposure to actual or threatened traumatic event & symptoms related to that event, which impact daily functioning Intrusion/re-experiencing of event Avoidance of reminders of event Disturbance in thinking and mood (around time of event) Marked disturbance in arousal and reactivity Children 6 years and younger Similar to above; either Avoidance of Stimuli or Disturbance in Thinking and Mood Exhibit symptoms differently Trauma-specific reenactment during play PTSD CONT’D Associated Behaviors Developmental regression (e.g. loss of language in young children) Difficulty in regulating emotion Difficulty in maintaining stable interpersonal relationships Dissociative symptoms TREATMENT FOR PTSD Many different treatment modalities Cognitive Behavioral Therapy (CBT) Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) Eye-Movement Desensitization and Reprocessing (EMDR) Various techniques for distress tolerance Yoga Tapping Psychiatric medication Selective Serotonin Reuptake Inhibitors-SSRIs (Antidepressant medication) HOW CAN PARENTS HELP THEIR CHILD COPE WITH PTSD SYMPTOMS? Be
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