Child Planning: A Treatment Planning Overview for Children with Depression

Transcription

1 COURSES ARTICLE - THERAPYTOOLS.US Child Planning: A Treatment Planning Overview for Children with Depression A Treatment Overview for Children with Experiencing Depression Duration: 3 hours Learning Objectives: Obtain a basic understanding of how to identifying, causes, symptoms of children with lying problems or history, and learn different options to complete a treatment plan that includes: a. Behavioral Definitions b. Long Term Goals c. Short Term Goals d. Strategies to Achieve Goals e. DSM V diagnosis Recommendations ***For a full list of 21 short term goals with dozens strategies listed next to each goal check the Child Treatment App for Windows or Apple PC and Android Devices, under our main menu Windows-Apple Apps. Download the Free Demo to Evaluate*** Course Syllabus:

2 Introduction Symptoms Causes Diagnosis and Treatment Steps to Develop a Treatment Plan that includes Behavioral Descriptors, Long Term Goals, Short Term Goals, Interventions/Strategies and DSM V CODE Paired with ICD_9 and 10-CM Codes for ODD Sample Treatment Plan Introduction: What is Depression? The word depression can be misleading. Everyone has felt depression at times over such challenging situations as a setback in one s career or the ending of an important relationship. For most people, the sadness is temporary. Clinical depression (major depressive disorder) is more than just a temporary feeling. It is relatively long-lasting, can get worse over time, and significantly interferes with a person s daily activities. Depression is the most common mental health disorder after anxiety disorders. It affects 7% of adults in the United States in any given year, with a lifetime prevalence of 21% of all Americans. According to the World Health Organization, it is the leading cause of worldwide disability. Men and women may experience depression differently. Women are affected at twice the rate of men, while men with depression are more likely to die by suicide. There are also gender differences in the way symptoms are experienced. It is possible to conclude that about the same rates of children of teenages face depression in their lives at one time or another. Depression is a serious mood disorder that can take the joy from a child s life. It is normal for a child to be moody or sad from time to time. You can expect these feelings after the death of a pet or a move to a new city. But if these feelings last for weeks or months, they may be a sign of depression. Experts used to think that only adults could get depression. Now we know that even a young child can have depression that needs treatment to improve. As many as 3 in 100 young children and 9 in 100 teens have serious depression. Still, many children don't get the treatment they need. This is partly because it can be hard to tell the difference between depression and normal moodiness. Also, depression may not look the same in a child as in an adult.

3 Symptoms: Leaning to the identify the symptoms of depression in children is essential for a mental health clinician. Talking to the child to learn how or she is feeling is the first step. What are the symptoms? Many adults and children feel sadness or mild depression in certain situations and circumstances. For a diagnosis of major depressive disorder to be made, a qualified health professional must: evaluate the symptoms and course of the illness over a period of at least two weeks rule out causes by other medical conditions, other psychiatric disorders, substance use, and grief in response to a significant loss Symptoms of depression include: Changes in appetite -- either increased appetite or decreased Changes in sleep -- sleeplessness or excessive sleep Continuous feelings of sadness or hopelessness Difficulty concentrating Fatigue and low energy Feelings of worthlessness or guilt

4 Impaired thinking or concentration Deterioration in Academic Performance Increased sensitivity to rejection Irritability or anger Physical complaints (such as stomachaches or headaches) that do not respond to treatment Reduced ability to function during events and activities at home or with friends, in school or during extracurricular activities, or when involved with hobbies or other interests Social withdrawal No eye contact Unresolved Grief Use of Alcohol-Drugs Indecision pattern Vocal outbursts or crying feelings of sadness, loneliness, or emptiness that last most of the day for several days on

5 end loss of interest or pleasure in activities that used to be enjoyable (anhedonia) tiredness and chronic low energy difficulty thinking clearly, concentrating, making decisions or remembering feelings of worthlessness and guilt feelings of irritability, frustration or anger that are out of proportion with the circumstances restlessness and agitation sleep disturbances, including sleeping too much and sleeping too little (insomnia) loss of weight, or weight gain Recurrent thoughts of death or suicide, as well as suicide attempts or plans The symptoms of depression are often overlooked at first. It can be hard to see that symptoms are all part of the same problem. Also, the symptoms may be different depending on how old the child is. Very young children may lack energy and become withdrawn. They may show little emotion, seem to feel hopeless, and have trouble sleeping. Grade school children may have a lot of headaches or stomachaches. They may lose interest in friends and activities that they once liked. Some children with severe depression may see or hear things that aren't there (hallucinate) or have false beliefs (delusions). Teens may sleep a lot or move or speak more slowly than usual. Teens with severe depression may hallucinate or have delusions.

6 Depression can range from mild to severe. A child who feels a little "down" most of the time for a year or more may have a mild, ongoing form of depression called dysthymia (say "dis-thy-mee-uh"). In its most severe form, depression can cause a child to lose hope and want to die. Causes: Depression has no single cause. Both genetics and the environment play a role, and some children may be more likely to become depressed. Depression in children can be triggered by a medical illness, a stressful situation, or the loss of an important person. Children with behavior problems or anxiety also are more likely to get depressed. Sometimes, it can be hard to identify any triggering event. The causes of childhood depression are unknown. It could be caused by any combination of factors that relate to physical health, life events, family history, environment, genetic vulnerability, and biochemical disturbance. Just what causes depression is not well understood. But it is linked to an imbalance of brain chemicals that affect mood. Things that may cause these chemicals to get out of balance include due to stressful events, such as: changing schools, going through a divorce, or having a death in the family. Due to some medicines, such as steroids or narcotics for pain relief. Family history, inherited

7 Diagnosis and Treatment: When possible, treatment for depression childhood depression should include both psychotherapy and medication. In milder forms of depression, it is reasonable to start with a psychotherapy, but treatment with a medication and psychotherapy should be considered for moderate to severe forms of major depression. Before starting treatment, a doctor will discuss its risks and benefits, as well as how the treatment should be monitored. Usually one of the first steps in treating depression is education for the child and his or her family. Teaching both the child and the family about depression can be a big help. It makes them less likely to blame themselves for the problem. Sometimes it can help other family members see that they are also depressed. Counseling may help the child feel better. The type of counseling will depend on the age of the child. For young children, play therapy may be best. Older children and teens may benefit from cognitive-behavioral therapy. This type of counseling can help them change negative thoughts that make them feel bad. Medicine may be an option if the child is very depressed. Combining antidepressant medicine with counseling often works best. A child with severe depression may need to be treated in the hospital. There are some things that parents can be trained to do at home to help a child start to feel better: Urge the child to get regular exercise, See that the child eats a healthy diet, See that the child gets enough sleep. See that the child takes any medicine as prescribed and goes to all follow-up appointments.

8 Make time to talk and listen to the child. Ask how he or she is feeling. Express love and support. Remind the child that things will get better in time. The use of Antidepressants in Treatment: Antidepressant medicines often work well for children who are depressed, but there are some important things to know about them: Children who take antidepressants should be watched closely. These medicines may increase the risk that a child will think about or try suicide, especially in the first few weeks of use. Learn the warning signs of suicide Common warning signs of suicide in children who are depressed include: Talking, drawing, or writing about death.

9 Giving away belongings. Withdrawing from family and friends. Having a way to do it, such as a gun or pills. A child may feel better within 1 to 3 weeks of taking antidepressant medicine. But it can take as many as 6 to 8 weeks to see more improvement. Keep track of the use of antidepressants, making sure the child takes antidepressants as prescribed and keeps taking them so they have time to work. A child may need to try several different antidepressants to find one that works. If there no notice of any improvement by 3 weeks, follow up with the Doctor. Do not let a child suddenly stop taking antidepressants. This could be dangerous. Only taper off the dose slowly to prevent problems, under Doctor s supervision. Even when working with children it is important to become familiarity with all types of Mood Disorders as they related to the symptoms presented by the child: Major Depressive Disorder what most people think of as clinical depression (see above). Persistent Depressive Disorder (formerly dysthymia ) continuous long-term depression that lasts for two years or longer. Seasonal Affective Disorder (SAD) a period of major depression that usually occurs during winter months when days are shorter. SAD is a potential feature of major depressive disorder and is not considered a separate diagnosis. Postpartum Depression (PPD) an episode of major depression that occurs in some women following childbirth. About half of all cases of PPD actually begin before childbirth. Like SAD, PPD is a feature of major depressive disorder. Bipolar Disorder (formerly manic depression ) a serious disorder involving major mood swings that include emotional highs (mania or hypomania) and lows (depression). Although people diagnosed with bipolar disorder may at times experience severe depression, the treatment for bipolar is very different from that for major depressive disorder.

10 Situational Depression not a formal diagnosis, feature or disorder, but commonly used to describe the depressed mood or sadness many people feel when dealing with a stressful life event, such as a death in the family, divorce, or sudden unemployment. It is important to note that Depression and depression-like symptoms can also be caused by or linked to substance use, use of some medications, or the physical effects of a medical condition. Major depression and related disorders are frequently seen with other mental health conditions, known as co-occurring disorders. The most frequent are: anxiety disorders, substance use disorders, eating disorders and medical illnesses. Steps to Develop a Treatment Plan: The foundation of a good treatment plan is based on the gathering of the correct data. This involves following logical steps the built-in each other to help give a correct picture of the problem presented by the client or patient: The mental health clinician must be able to listen, to understand what are the struggles the client faces. this may include: issues with family of origin, current stressors, present and past emotional status, present and past social networks, present and past coping skills, present and past physical health, self-esteem, interpersonal conflicts financial issues cultural issues There are different sources of data that may be obtained from a: clinical interview,

11 Gathering of social history, physical exam, psychological testing, contact with client s or patient s significant others at home, school, or work The integration of all this data is very critical for the clinician s effect in treatment. It is important to understand the client s or patient s present awareness and the basis of the client's struggle, to assure that the treatment plan reflects the present status and needs of the client or patient. There 5 basic steps to follow that help assure the development of an effective treatment plan based on the collection of assessment data. Step 1, Problem Selection and Definition: Even though the client may present different issues during the assessment process is up to the clinician to discern the most significant problems on which to focus during treatment. The primary concern or problem will surface and secondary problems will be evident as the treatment process continues. The clinician may must be able to plan accordingly and set some secondary problems aside, as not urgent enough to require treatment at this time. It is important to remember that an effective treatment plan can only deal with one or a few problems at a time. Focusing in too many problems can lead to the lost of direction and focus in the treatment. It is important to be clear with the client or patient and include the client s or patient s own prioritization of the problems presented. The client s or patient s cooperation and motivation to participate in the treatment process is critical. Not aligning the client to participate my exclude some of the client s or patient s needs needing immediate attention. Every individual is unique in how he or she presents behaviorally as to how the problem affects their daily functioning. Any problems selected for treatment will require a clear definition how the problem affects the client or patient. It is important to identify the symptom patterns as presented by the DSM-5 or Diagnostic and Statistical Manual or the International Classification of Diseases (ICD).

12 CHILD DEPRESSION BEHAVIORAL DESCRIPTOR: 1. Refusal to communicate or little or no eye contact. 2. Use of street drugs to elevate mood or unresolved grief issues. 3. Frequent verbalizations of low self-esteem or low energy. 4. Increased sleep or reduced appetite. 5. Poor concentration and indecision o feelings of hopelessness, worthlessness, or inappropriate guilt. 6. Sad or flat affect or suicidal thoughts and/or actions. 7. Preoccupation with the subject of death. 8. Irritable mood. 9. Isolation from family and/or peers or deterioration in academic performance. 10. Lack of interest in previously enjoyed activities. Step 2, Long Term Goal Development: This step requires that the treatment plan includes at least one broad goal that targets the problem and the resolution the problem. These long term goals must be stated in non-measurable terms but instead indicate a desired positive outcome at the end of treatment. LONG TERM GOALS FOR CHILDHOOD DEPRESSION: 1. Increase positive mood and usual energy for activities and socialization. 2. Renew an interest in academic achievement, social involvement, and eating patterns, 3. Increase a show of a occasional expressions of joy and zest for life. 4. Lower irritability and increase normal social interaction with family or friends. 5. Acknowledge present depression and identify its roots and causes to help lead to

13 normalization of the emotional state. Step 3, Objective or Short Term Goal Construction: Objectives or short term goals must be stated in measurable terms or language. They must clearly specify when the client or patient can achieve the established objectives. The use of subjective or vague objectives or short term goals is not acceptable. Most or all insurance companies or mental health clinics require measurables objectives or short term goals. It is important to include the patient s or client s input to which objectives are most appropriate for the target problems. Short term goals or objectives must be defined as a number of steps that when completed will help achieve the long-term goal previously stated in none measurable terms. There should be at least two or three objectives or short-term goals for each target problem. This helps assure that the treatment plan remains dynamic and adaptable. It is important to include Target dates. A Target day must be listed for each objective or short-term goal. If needed, new objectives or short-term goals may be added or modified as treatment progresses. Any changes or modifications must include the client s or patient s input. When all the necessary steps required to accomplish the short-term goals or objectives are achieved the client or patient should be able to resolve the target problem or problems. If required all short term goals or objectives can be easily modify to show evidence based treatment objectives. The goal of evidence based treatment objectives (EBT) is to encourage the use of safe and effective treatments likely to achieve results and lessen the use of unproven, potentially unsafe treatments. To use EBT in treatment planning state restate short term goals in a way that steps to complete that goal and achieve results. For example, the short term goal 13. Increase positive self-descriptive statements. Can be restated as; By the end of the session the patient or client will list at least 5 positive self descriptions of himself or herself, and assess how they can help alleviate the presenting problem Remember, that it must be stated in a way one can measure effectiveness. It is important to note that traditional therapies usually rely more heavily on the relationship between therapist and patient and less on scientific evidence of proven practices. EXAMPLES OF SHORT TERM GOALS FOR CHILDHOOD DEPRESSION:

14 1. Identify and lower anger and irritability as evidenced by friendly, pleasant interactions with family and friends. 2. Express negative feelings through art therapy. 3. Identify and list any losses that have been experienced and the feelings related with those losses. 4. Identify and explore acceptable life changes that would result in a reduction of sadness and an increase in hope. 5..Identify and express feelings of sadness, hurt, and anger in play therapy. Step 4, Strategies or Interventions: Strategies or interventions are the steps required to help complete the short-term goals and long-term goals. Every short term goal should have at least one strategy. In case, short term goals are not met, new short term goals should be implemented with new strategies or interventions. Interventions should be planned taking into account the client s needs and presenting problem. EXAMPLES OF INTERVENTIONS FOR CHILDHOOD DEPRESSION: 1. Use family therapy to facilitate the minor's expression of any conflict with family members. 2. Encourage minor to carry pleasant social interactions between friends or family members. 3. Use art therapy (drawing, coloring, painting, collage, sculpture) to help minor express depressive feelings. 4. Use artistic expressions of minor as the roots for further elaboration of emotions and their causes. 5. Ask minor to draw pictures of experiences that create to feelings of sadness and hurt, and process these feelings in therapy. Step 5, Diagnosis:

15 The diagnosis is based on the evaluation of the clients present clinical presentation. When completing diagnosis the clinician must take into account and compare cognitive, behavioral, interpersonal, and emotional symptoms as described on the DSM-5 Diagnostic Manual. A diagnosis is required in order to get reimbursement from a third-party provider. Integrating the information presented by the DSM-5 diagnostic manual and the current client s assessment data will contribute to a more reliable diagnosis. it is important to note that when completing a diagnosis the clinician must have a very clear picture all behavioral indicators as they relate to the DSM-5 diagnostic manual. DSM V CODE Paired with ICD_9-CM COdes: Possible Diagnostic Suggestions for Children Suffering Depression: (Parenthesis Represents ICD-10-CM Codes Effective ). Major Depressive Disorder Single episode (F32.0) Mild (F32.1) Moderate (F32.2) Severe (F32.3) With psychotic features (F32.4) In partial remission (F32.5) In full remission (F32.9) Unspecified Recurrent episode (F33.0) Mild (F33.1) Moderate (F33.2) Severe (F33.3) With psychotic features (F33.41) In partial remission

16 (F33.42) In full remission (F33.9) Unspecified (F34.1) Persistent Depressive Disorder (Dysthymia) Specify if: In partial remission, In full remission Specify if: Early onset, Late onset Specify if: With pure dysthymic syndrome; With persistent major depressive episode; With intermittent major depressive episodes, will current episode; With intermittent major depressive episodes, without current episode Specify current severity: Mild, Moderate, Severe Depressive Disorder Due to Another Medical Condition Specify if: (F06.31) With depressive features (F06.32) With major depressive-like episode (F06.34) With mixed features 311 (F32.8) Other Specified Depressive Disorder 311 (F32.9) Unspecified Depressive Disorder Problems Related to Family Upbringing V (Z62.820) Parent-Child Relational Problem V61.8 (Z62.891) Sibling Relational Problem V61.8 (Z62.29) Upbringing Away From Parents V (Z62.898) Child Affected by Parental Relationship Distress Other Problems Related to Primary Support Group V (Z63.5) Disruption of Family by Separation or Divorce V61.8 (Z63.8) High Expressed Emotion Level Within Family V62.82 (Z63.4) Uncomplicated Bereavement

17 Child Maltreatment and Neglect Problems Child Physical Abuse Child Physical Abuse, Confirmed (T74.1 2XA) Initial encounter (T74.1 2XD) Subsequent encounter Child Physical Abuse, Suspected (T76.12XA) Initial encounter (T76.1 2XD) Subsequent encounter Child Sexual Abuse Child Sexual Abuse, Confirmed (T74.22XA) Initial encounter (T74.22XD) Subsequent encounter Child Sexual Abuse, Suspected (T76.22)(A) Initial encounter (T76.22XD) Subsequent encounter Child Neglect Child Neglect, Confirmed (T74.02XA) Initial encounter (T74.02XD) Subsequent encounter Child Psychological Abuse Child Psychological Abuse, Confirmed (T74.32XA) Initial encounter (T74.32XD) Subsequent encounter Child Psychological Abuse, Suspected (T76.32XA) Initial encounter

18 (T76.32XD) Subsequent encounter Bipolar 1 Disorder Current or most recent episode manic (F31.1 1) Mild (F31.12) Moderate (F31.13) Severe Sample Treatment Plan: Present Behavioral Descriptors of Problem: 1. Frequent verbalizations of low self-esteem or low energy. 2. Poor concentration and indecision o feelings of hopelessness, worthlessness, or inappropriate guilt. Long Term Goals: 1. Increase a show of a occasional expressions of joy and zest for life. 2. Lower irritability and increase normal social interaction with family or friends. 3. Acknowledge present depression and identify its roots and causes to help lead to normalization of the emotional state. Short Term Goals Objectives: 1. Learn to replace negative self talk with positive thoughts. 2. Identify and lower anger and irritability as evidenced by friendly, pleasant interactions with family and friends.

19 Strategy or Intervention for Goal 1: 1. Encourage minor to carry pleasant social interactions between friends or family members. 2. Use art therapy (drawing, coloring, painting, collage, sculpture) to help minor express depressive feelings. 3. Assess the emotional pain from past experiences that may contributes to the feelings of hopelessness and low self-esteem. 4. Encourage minor to respectfully express emotional needs to family members and significant others. 5. Use play therapy to allow minor the expression of feelings toward self and others. Strategy or Intervention for Goal 2: 1. Use family therapy to facilitate the minor's expression of any conflict with family members. 2. Have minor produce a kinetic family drawing to help assess the factors contributing to depression. 3. Use family therapy to facilitate the minor's expression of conflict with other family members. 4. Teach parents how to encourage, support, and tolerate the minor's respectful expression of thoughts and feelings. DSM V Diagnosis: (F32.1) Major Depressive Disorder - Moderate V (Z63.5) Disruption of Family by Separation or Divorce

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