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 aware of child’s symptoms Let child see that you can emotionally cope with them: mirroring Understand intricacies of behavior within context of disorder & major events in child’s life Be involved in their treatment Know the child’s progress and how you can reinforce that between therapy sessions Be vigilant Pay attention to child’s mood states, occurrences of nightmares Don’t make them talk about their trauma, but let them know you’re there for them PSYCHIATRIC DIAGNOSES FOR ADULTS INVOLVED IN THE CHILD WELFARE SYSTEM: COMMON DIAGNOSES & HOW TO ADDRESS THEM
DANIELLE TODARO, PSY.D LICENSED PSYCHOLOGIST FORT BEND COUNTY BEHAVIORAL HEALTH SERVICES KITS CONFERENCE: JUNE 2017 SERIOUS MENTAL ILLNESS (SMI)
National Survey on Drug Use and Health defines SMI as: A mental, behavioral, or emotional disorder (excluding developmental and substance use disorders) Diagnosable currently or within the past year Meets diagnostic criteria specified within the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) now DSM-5 Resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities Major Depressive Disorder Bipolar Disorder Psychotic Disorders PREVALANCE OF SERIOUS MENTAL ILLNESS IN ADULTS
According to the National Survey on Drug Use and Health, in 2015 there were an estimated 9.8 million adults aged 18 or older in the United States with serious mental illness This number represented 4.0% of all U.S. adults In Texas between 2014-2015 3.34% of adults over the age of 18 were estimated to have a serious mental illness 4.22% for those between 18-25 years of age 3.18% for those over 26 years of age MAJOR DEPRESSIVE DISORDER (MDD) MDD
Depression is one of the most common mental disorders in the U.S. Affects more than 15 million American adults, or about 6.7% of the U.S. population age 18 and older While major depressive disorder can develop at any age, the median age at onset is 32.5 More prevalent in women than in men Most people have experienced some symptoms during their lifetime For diagnosis these symptoms must interfere with how one’s dialing living/functioning Symptoms generally must be present for at least a period of two weeks SYMPTOMS OF MDD
Persistent sad, anxious, or “empty” mood Feeling restless or having trouble sitting still Feelings of hopelessness or pessimism Difficulty concentrating, remembering, or making decisions Irritability Sleep disturbance (early-morning awakening, or Feelings of guilt, worthlessness, or oversleeping) helplessness Appetite and/or weight changes Loss of interest or pleasure in hobbies and Thoughts of death or suicide, or suicide activities attempts Decreased energy or fatigue Aches or pains, headaches, cramps, or digestive Moving or talking more slowly problems without a clear physical cause and/or that do not ease even with treatment MDD AND ANXIETY
It is not uncommon for someone with depression to also suffer from anxiety or vice versa Nearly one-half of those diagnosed with depression are also diagnosed with an anxiety disorder Depression and anxiety disorders are different, but people may experience similar symptoms such as nervousness, irritability, and problems sleeping and concentrating Many people who develop depression have a history of an anxiety disorder earlier in life TREATMENT OPTIONS FOR MDD
Antidepressant medications Medications to treat anxiety disorders may also be prescribed Individual or group counseling (“talk therapy”) Cognitive-behavioral therapy Lifestyle modifications Diet/Exercise Interacting with others Setting realistic goals Brain stimulation therapies (for very serious and/or treatment-resistant depression) BIPOLAR DISORDER BIPOLAR DISORDER
Serious mood disorder Sometimes referred to as “manic-depressive” illness Impacts one’s ability to perform daily functioning Affects approximately 5.7 million adult Americans, or about 2.6% of the U.S. population age 18 and older Median age of onset for Bipolar Disorder is 25 years Can start in early childhood or as late as the 40's and 50's BIPOLAR DISORDER
Causes unusual shifts in mood, energy and activity levels Manic: extremely “up,” elated, and energized behavior Hypomanic: Less severe manic episodes Depressed: sad, down or hopeless periods, lower energy and activity levels Mixed features: symptoms of both mania and depression are present SYMPTOMS OF BIPOLAR DISORDER
Manic Episode Depressive Episode Feel very up, high, or elated Feel very sad, down, empty, or hopeless Have a lot of energy Have very little energy Have increased activity levels Have decreased activity levels Feel “jumpy” or “wired” Sleep trouble (may sleep too little or too much) Have trouble sleeping More active than usual Feel like they can’t enjoy anything Talk really fast about a lot of different things Feel worried and empty Be agitated or irritable Have trouble concentrating Feel like their thoughts are going very fast (racing Forget things a lot thoughts) Think they can do a lot of things at once Eat too much or too little Do risky things, like spend a lot of money or have Feel tired or “slowed down” reckless sex May think about death or suicide TREATMENT OPTIONS FOR BIPOLAR DISORDER Medications generally used to treat bipolar disorder include: Mood stabilizers Atypical antipsychotics Antidepressants Individual or group counseling (“talk therapy”) Cognitive-behavioral therapy Tracking changes in mood, behavior, symptoms Inpatient hospitalization may be necessary at times PSYCHOTIC DISORDERS PSYCHOTIC DISORDERS
The word psychosis is used to describe a loss of contact with reality When someone becomes ill in this way it is called a psychotic episode Disruption to a person’s thoughts and perceptions Difficult to recognize what is real and what isn’t While everyone’s experience is different, most people say psychosis is frightening and confusing PSYCHOTIC DISORDERS Schizophrenia: Chronic and severe mental disorder that affects how a person thinks, feels, and behaves. Affects about 1% of Americans Schizoaffective Disorder: Characterized primarily by symptoms of Schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and/or depression Affects about .3% of Americans Psychotic symptoms can also be present in individuals with Bipolar Disorder and MDD POSTIVE SYMPTOMS OF PSYCHOTIC DISORDERS
Hallucinations: Thought disorder: Hearing voices, seeing things, or smelling Unusual ways of thinking things others can’t perceive Disorganized thinking Very real to the person experiencing it May speak in a way that is hard to May get commands to engage in certain understand acts/behaviors Thought blocking Delusions: Make up meaningless words Fixed, false beliefs Movement disorders: Don’t change even when the person who holds them is presented with new ideas or Repeat certain motions over and over facts Catatonia NEGATIVE SYMPTOMS OF PSYCHOTIC DISORDERS
Negative symptoms are disruptions to normal emotions and behavior Can be mistaken for depression or other conditions “Flat affect” (reduced expression of emotions via facial expression or voice tone) Reduced feelings of pleasure in everyday life Difficulty beginning and sustaining activities Reduced speaking COGNITIVE SYMPTOMS OF PSYCHOTIC DISORDERS
Poor ability to understand information and use it to make decisions Trouble focusing or paying attention Problems with working memory May struggle to complete tasks Lack of insight into illness TREATMENT OPTIONS FOR PSYCHOTIC DISORDERS
Antipsychotic medications: Coordinated Specialty Care: Some symptoms will respond more Integrates medication, psychosocial quickly to medication (agitated and therapies, case management, family hallucinations) some may improve involvement, education and within a few weeks employment services People may continue to have some Supportive peer counseling symptoms, but usually medication will reduce intensity Sometimes inpatient hospitalization is necessary Psychosocial Treatments: Learning and using coping skills to help people to pursue their life goals CO-OCCURRING DISORDERS
People with mental illness are more likely to experience an alcohol or substance use disorder About a third of all people experiencing mental illnesses and about half of people living with SMI People receive treatment for one disorder while the other disorder remains untreated May be less likely to engage in treatment for mental illness if abusing substances Concerns about increase in symptoms with substance use Interactions between substances and medications Increased risk for homelessness, incarceration, medical illnesses, suicide, or even early death People with co-occurring disorders are best served through integrated treatment WORKING WITH PARENTS WITH SMI
Awareness of how symptoms may be impacting parenting at that time Depression/psychosis: may have lack of energy or motivation Mania: may engage in impulsive/high-risk behavior Psychosis: may be disorganized, unable to follow through Medication compliance Assistance with getting connected to a psychiatric provider Reminders about importance of adhering to medication Suggest discussion with doctors WORKING WITH PARENTS WITH SMI
Parents may need to participate in individual counseling or family counseling Keep in mind that relapses in treatment may occur Just because they may be required, to participate in treatment, parents with a mental illness still may be resistant or believe they don’t need services Encourage peer support groups/peer counseling services as well May need to provide local resources for counseling services WORKING WITH PARENTS WITH SMI
Awareness regarding risk for suicide If a parent is in crisis use effective crisis communication skills Provide resources/encourage that they reach out to their treatment team Contact crisis intervention team or local law enforcement if necessary Keep in mind that hospitalizations may occur Phone calls/letters with children Psycho-education for the parent, children, guardians/foster parents, etc. on mental illness WORKING WITH PARENTS WITH SMI
Be aware of any stressors Problems with basic needs Financial issues Employment needs Transportation issues Stress may trigger symptoms or increase severity of symptoms Important to keep in mind that placing too many demands on a parent at once may unnecessarily induce stress WORKING WITH PARENTS WITH SMI
Encourage parent to identify and establish a stable support network Provide resources for support in their community Suggest healthy coping strategies to manage stress Encourage healthy diet, exercise and maintaining overall physical health WORKING WITH PARENTS WITH SMI
Parents with co-occurring substance abuse issues should be connected to integrated treatment services As with mental health issues, relapses in substance abuse treatment are common Parent should be encouraged and supported in the treatment process If inpatient treatment necessary Contact with children Family therapy QUESTIONS? REFERENCES & RESOURCES: CHILDREN
Behavioral Health Evolution: Treating Adolescent Conduct Disorder: http://www.bhevolution.org/public/treating_conductdisorder.page Center for Disease Control and Prevention-ADHD: https://www.cdc.gov/ncbddd/adhd/behavior-therapy.html Disruptive Behavior Disorders-SAMHSA: https://www.samhsa.gov/treatment/mental-disorders/disruptive- behavior-disorders Disruptive Mood Dysregulation Disorder: https://www.nimh.nih.gov/health/topics/disruptive-mood-dysregulation- disorder-dmdd/disruptive-mood-dysregulation-disorder.shtml Oxford University Press: https://blog.oup.com/2008/03/bipolar_children/ PTSD: National Center for PTSD- https://www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp The National Conference of State Legislatures: http://www.ncsl.org/research/human-services/mental-health-and- foster-care.aspx REFERENCES & RESOURCES: ADULTS
Anxiety and Depression Association of America: https://www.adaa.org/understanding-anxiety/depression Children of Parents With a Mental Illness: http://www.copmi.net.au/parents/parenting-with-a-mental- illness/understanding-mental-illness National Alliance on Mental Illness: https://www.nami.org/Learn-More/Mental-Health-Conditions National Institute of Mental Health: https://www.nimh.nih.gov/index.shtml National Institute of Mental Health: https://www.nimh.nih.gov/health/statistics/prevalence/serious-mental- illness-smi-among-us-adults.shtml Substance Abuse and Mental Health Services Administration: https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf Substance Abuse and Mental Health Services Administration: https://www.samhsa.gov/disorders/co- occurring