Treatment of Disorders of Childhood & Adolescence

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1 Treatment of Disorders of Childhood & Adolescence Attachment: An enduring emotional bond characterized by a tendency to maintain closeness and warmth with a particular person, particularly when under distress. Attachment Theory Basic human need Hardwired to attach to a primary caregiver 1 st 3 years plus fetal stage of development are critical Sensitive period that becomes less plastic w/ age Multigenerational Transmission Process 75-80% prediction rate! 1

2 Attachment Theory Cont Reciprocally reinforced cycle: Baby acts in reinforcing way to caregiver This continues the caregiver s behaviors that meet the child s emotional and physical needs for safety and stability Therefore reinforces baby s continued behaviors and so on. Baby has a need Attachment Cycle Trust experience Caregiver gratifies need Breakdown in reciprocity at any point can cause problems Attachment Theory cont Success or failure in meeting the needs determines the internal working model for views of self, others and the world We use these models to self-regulate, face the world, choose actions and form attitudes. Actions are chosen to influence surroundings in a way that generates responses that reinforce their working models (self-fulfilling prophecies) 2

3 What do we get from secure attachment? What do we get from secure attachment? Learn basic trust and reciprocity with others Explore and learn w/ feelings of safety and security Develop the ability to self-regulate Emotional regulation Impulse control Foundation for core self and self-identity Competency Self worth Dependence vs. Autonomy Prosocial moral framework Defense against stress and trauma Resiliency Resourcefulness Common Diagnoses Associated w/ Disrupted/Disordered Attachment PTSD ODD Failure to thrive Conduct Disorder Bipolar Disorder Child/Adolescent Antisocial Behavior Selective mutism Axis II Disorders (including Borderline Personality Disorder and Antisocial Personality Disorder) Depression Anxiety Drug/Alcohol Abuse and Dependencies Areas of Functional Impairments & Symptoms cont Cognition: Negative Cognitive Triad Lack cause & effect thinking Attention Problems Learning Problems Interpersonal: Lack Trust Intense Need for Control Manipulative Primary Process Lying Unstable Relationships Indiscriminate Affection Blaming Others Victimized Victimizes Areas of Functional Impairments & Symptoms cont Physical: Poor Hygiene Poor Reaction to Touch Elimination Issues Feeding Issues Accident Prone High pain tolerance Genetic Predispositions Moral/Spiritual: Lack of Empathy Lack of Faith Lack of Remorse Lack of Meaning Lacking other Pro-Social Values Identification w/ Evil and Other Anti-Social Values Attachment Disorders Reactive Attachment Disorder RAD Disinhibited Social Engagement DSED 3

4 Treatment Of Attachment Disorders Effective interventions includes providing a secure and nurturing environment, exposure positive parenting practices, and opportunities to develop interpersonal trust and social relationships. Treatment Multimodal Treatment Family Therapy is Key Individual Therapy Medication Management Case Management Services Curative Factors LOVE: Warm accepting & nurturing Provide loving social cues (eye contact, smiles, laughter) Cuddle time Nourishment Genuine care, concern and commitment Curative Factors ATTUNEMENT: In sync with child s needs, emotions and working model Send messages that you can provide what the child needs based on accurate understanding of the world through their eyes 4

5 Curative factors EMPATHY: Empathic to the child, not angry, hostile or distant Curative Factors POSITIVE AFFECT: Experience and display positive emotions with the child Let them know you will not allow them to control your feelings Curative Factors STRUCTURE: Reestablish authority (who is in control?) Consistency and follow through are important, however sometimes you can be inconsistent with results. Unwavering structure with expectable consequences Consequences without warnings and second chances Consequences are the child s choice for deciding not to comply, not something mean caregiver is doing to them Highly structured routine Provide them time to learn self-control No responsibility without demonstrating responsibility REMEMBER: Firm but not harsh Curative Factors SUPPORT CHILD: Provide support according to what they need and at their developmental level As the focus moves from rules, expectations and consequences begin to support independent achievement Praise behaviors briefly. Do not overpraise or make global positive statements about the child Accepting the child s past and family as a part of them (Does not include acceptance of what they did to the child) Encourage talks about events and feelings pertinent to the child Listen Curative Factors What Works cont SUPPORT PARENT: Assist parents to remain open, accepting and attuned Support parents, validate and link to others when at all possible Use respite when overwhelmed Avoid unnecessary power struggles (You Will Lose) Be aware of your own weaknesses and triggers Learn to recognize that the behavior is directed at the role (caregiver) not the person Use collaborative multi-systemic approach Safe environment Constancy Boundaries Limits Collaborative work w/ parents Supportive work w/ parents 5

6 What Doesn t Work: Traditional therapies Anger Blaming the parents Global Praise Seeing the child as victim Equality Rewards & other behavioral incentives Withholding love Punishment Timeout Grounding Deprivation Childhood DEPRESSION DEPRESSION Child Sign of Depression Drop in Grades Concentration Problems Psychomotor Agitation Mood Swings Aggressive Behavior Interpersonal Conflict High Boredom/Apathy Childhood Depression Lack Defense Mechanisms Lack Coping Skills Dependent Upon Others for Security & Stability Vulnerable Population Adolescent Depression Any given time 3-5% 20% have had a MDD episode by 18 Females 2-3xs more likely Often Co-Morbid Anxiety Creates Additional Risk Factors Substance Use Suicide/Self Harm Additional Depressive Episodes Treatment for Depression Cognitive Behavioral Therapy/Positive Psychology Younger Children Play Therapy/Art Therapy Medication Management: However, there are significant concerns about selective serotonin reuptake inhibitors (SSRIs) increasing suicidality. They have been found to be superior to cognitive behavioral therapies for severe depression. 6

7 Adolescent Depression Any given time 3-5% 20% have had a MDD episode by 18 Females 2-3xs more likely Often Co-Morbid Anxiety Creates Additional Risk Factors Substance Use Suicide/Self Harm Additional Depressive Episodes Disruptive Mood Regulation Disorder (DMDD): DMDD is characterized by chronic irritability and severe mood dysregulation, including recurrent episodes of temper triggered by common childhood stressors. Anger reactions are significantly exaggerated in both intensity and duration. DMDD is considered a depressive disorder although behavior symptoms, they are reflective of an irritable, angry or sad mood state. Symptoms need to exist beyond age 6 and behaviors and the diagnosis has to be made before the age of 18. Treatment DMDD Multimodal Therapy: Family Therapy focused on parenting skills and working with parents on issues related to not personalizing their child s behavior. Individual Therapy focusing on emotional regulation and coping skills Medication Management Case management services ODD ODD Who is the Oppositional Child? 7

8 ODD and Treatment ODD is a relational Disorder and therefore the most appropriate Treatment is family therapy. Individual can be combined to increase coping skills. Age 3 to 7: Parent Child Interactional Therapy (PCIT) 1, 2, 3 Magic 3 to early Teen Family Therapy focusing on parenting strategies that do not reinforce oppositional behavior. Treatment Focus Improving the quality of the parent child relationship Helping parents develop parenting strategies that do not reinforce the oppositional behavior May explore possible underlying reasons for oppositional behavior What creates or reinforces oppositional behavior What Makes a child Oppositional First and Foremost the oppositional behavior pays off with some type of reward. Examine the focus of the Child Vs. the Focus of the Parents The parents focus is on the resolution of the dispute. The child s focus is not on the outcome of the argument but on winning the argument. Winning does not necessarily mean that the outcome of the argument leads to desired objects or activities. For the oppositional child winning means that he or she is able to demonstrate his or her power. Power can be demonstrated in many ways. Child s demonstration of power Power can be demonstrated in many ways: The child s ability to make the parent angry Cause an argument between mother and father Delay going to an appointment or completing a task Increasing the tension in the house 8

9 What is the Pay off for Oppositional Behavior? Avoidance Conditioning: when a person learns to avoid an aversive consequence by doing something. Such as we get up and go to work to avoid losing our home. The oppositional child controls the house with the regular application of aversives, the oppositional child gains power. Which results in avoiding confrontation. Changing Oppositional behavior Decreasing emotional responsivity of the parent: What are your buttons and plan for an appropriate way to respond to button pushing. Don t mistake love with dependence Refuse to discuss anything with the child when they are irrational and abusive Be positive and supportive until a child tries to push a button or use an irrational argument Changing oppositional Behavior Be firm and consistent in enforcing rules AVOID Physical Punishment Make a list or rules with corresponding consequences Consequences should not require action on the child Attempt to make consequences natural and logical Do not play let s make a deal Button Pushing I don t care I don t love you You don t love me You re a horrible mother You never help me Be Careful what you ask Once you have issued a rule or instruction you shouldn t back down It is important to give commands with respect and you can add please and thank you. Parental Cooperation In two parent households, BOTH parents must agree, be involved and committed to making the necessary changes involved in dealing with the oppositional child 9

10 Remain Calm and In control Issue consequence for misbehavior when your certain you feel calm and have control of your emotions. Remember that you love your child but that you hate their behavior What you did was wrong, but I can t understand why a smart/good/wonderful kid like you would do that. Non contingent spontaneous rewards Occasionally give them a reward for no reason at all. Tell Them that they are loved Tell them that they are loved at least FOUR times a day. Build their Self Esteem Children who are confident in themselves are less likely to feel threatened and become angry. Support your child s interest and help them gain mastery in something. Spend Time with your child Learn how to play The Wii Do something they want to do 10

11 Talk with your child but mostly Listen Active listening Don t sweat the small stuff Your child will make mistakes or behave in ways which you may not agree. You must ask yourself whether or not intervention is warranted Don t expect miracles Change is not immediate but incremental! ADHD ADHD ADHD 11

12 ADHD Diagnostic Considerations Prevalence Rates Roughly 2-18% Over and Under diagnosed 4:1 Males to Females Comorbidity High ODD 50%+ Anxiety & Depression Diagnostic Considerations BEWARE the differentials Depression Anxiety Trauma Oppositional Defiant Autistic Spectrum Under Stimulated Over Stimulated Sensory Deficits BEWARE the subtypes Helping developing Compensatory skills Explore what a client can do, what he can t do and want he can do with assistance. Treatment Best Practices How are ADHD and Executive Functioning related? Combination of: Outpatient Therapy: helping child develop compensatory skills, building self esteem and managing anxiety and depression Parent/Child Education: Cant's vs. Won't Medication Dietary Control does NOT ordinarily work As executive functions develop, children become less controlled by external sources and more capable at regulating and directing their own behavior. ADHD represents a delay in the development of this shift from outer to inner control 12

13 What is Executive Functioning Executive Function is a term used to describe a unique set of mental abilities. They are a collection of related yet distinct abilities that allow the individual to direct and regulate his or her own behavior. Commonly cited Executive Functions: Working memory: holding information in the mind for the purpose of completing a task or activity. Initiating: beginning a task or activity Behavioral Inhibition: not acting on impulse, appropriately stopping one s activity. Emotional Control: modulating one s emotions appropriately to the situation. Internalized Speech: using self talk to guide one s behavior Commonly cited Executive Functions cont Switching focus: shifting from agenda A to agenda B; ability to move from one situation, activity or aspect of a problem to another as the situations demands. Goal orientation: establishing an image of the goal in the one s mind and using that internal image to direct one s behavior. Self-Monitoring: checking on one s actions during an activity to assure attainment of a goal. Planning: anticipating the future, setting goals, develop steps ahead of time. Commonly cited executive functions cont Organizing: establishing order in an activity or space, carrying out a task in a systematic manner. Sense of time: keeping track of the passage of time and altering one s behavior in relation to time. Foresight: ability to plan for the future. Working Memory: Play Interventions Simon Says Pay attention The Morning DJ Don t Forget Cue Cards Wrist Lists Secret Signal Cues Inhibition (Don t do it!): Play interventions Simon says don t do it The Distraction Zapper The On Off switch Red Light, Green Light The stay on track Map 13

14 Shifting Focus: Play Interventions The Team Player Attention Please The Cool down Goal Orientation Make your own game plan Encouraging words cue cards Beat Clock Medication 101 Important Decision Types of meds? Abuse potential? Side effects? Where do I go? Autism Spectrum Disorder Autism Spectrum Disorders A group of disorders encompassing several DSM IV TR diagnoses involving developmental delays Autistic Disorder Asperger s Disorder Pervasive Developmental Disorder NOS Now combined into one diagnosis Must be present by age 3 Differentials Intellectual/Developmental Disabilities Down s Syndrome Fragile X Syndrome Trauma Expressive Language Disorder Mixed Receptive-Expressive Language Disorder Many Others 14

15 Epidemiological Data Once Considered Rare Currently: 1:88 Children (1:54 Males) S. Korea: 1:38 Identical Twin Concordance: 90% Longitudinal Data Rates Increased 78% from Rates Increased 23% from CA Reports 12x Number of Kids Receiving Services from 20 yrs. Ago WHY? Better Detection Rates Other Theories: Genetic Predisposition Combines w/ Environment Symptoms/Genome linked to GI, Immunological and Neurological Factors Environmental Teratogens (Toxins) Much higher mitochondrial dysfunction Accelerated head growth Unique patterns of metabolic activity, poor connectivity involving the amygdala, correlations with certain biochemical in the amygdala and the severity of symptoms, abnormally high levels of serotonin and decreasing size of the occipital cortex Treatment Considerations Parent Education Connect w/ Support Groups Early Intervention: by 5, best if by 3 Very Behaviorally Based Interventions: ABA Play Project Circumvent Language Barrier when Possible Exploit Visual Learning: Social Modeling Groups Medication Certain SSRI s Certain Atypical Antipsychotics Specific Interventions Circumvent language barrier when possible Written itineraries, agendas, etc. Keep instructions direct, short and clear mean what you say, say what you mean Avoid slang, idioms & metaphors Specific Interventions Picture card systems/visual examples of the desired goal Allow time to process, wait ~6 seconds Show/tell them what you WANT them to do. Avoid blaming or criticizing parents 15

16 Specific Interventions Work at understanding WHY an inappropriate behavior is occurring BEFORE trying to intervene Environmental variables: Where, when, with whom, materials?, activities? Severity Frequency Intensity What are the triggers: ie. Boredom, told no, etc. What do they really want or need? Anxiety & Trauma Anxiety Disorders commonly seen in childhood Generalized Anxiety Disorder Post Traumatic Stress Disorder Social Phobia School Phobia Obsessive Compulsive Disorder Separation Anxiety Disorder Preferred Treatment Cognitive Behavioral Therapy Systematic Desensitization Play Therapy Parent and child education Medication Exposure with Response Prevention Systematic Desensitization Gradual exposure to anxiety producing stimuli with the goal of decreasing the emotional and physiological reactivity. Hierarchy of Anxiety Producing Situations Often start with imagined exposure Teach and coach relaxation techniques Progressive muscle relaxation Deep breathing Guided imagery Post Stress Traumatic Disorder: 6 years and under In children 6 years spontaneous and intrusive dreams may not seem distressing and maybe be expressed as play reenactment With children under 6 years old it may not be possible to ascertain that the frightening content is related to the traumatic event. 16

17 PTSD Treatment Cognitive Behavioral Therapy-TF(Children and Adolescents) Much as w/ GAD Rescripting Play Therapy Can include experiential techniques EMDR/Hypnosis Not effective w/ ongoing & sustained trauma 17