Presented By: Susan Silva, LCSW Forensic Interviewer The Children s Advocacy Center of Green River District

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1 Presented By: Susan Silva, LCSW Forensic Interviewer The Children s Advocacy Center of Green River District

2 What are Mental Illnesses? Mental Illness is a disorder of the brain that disrupts a person s thinking, feelings, mood, ability to relate to others, and daily functioning. Mental Illnesses are brain disorders that often result in a diminished capacity for coping with the ordinary demands of life

3 CHILDRENS MENTAL HEALTH DISORDERS About 1 in 5 American Children suffer from a diagnosable mental illness during a given year Nearly 5 million American Children and Adolescents suffer from a serious mental illness- one that significantly interferes with their day-to-day life. U.S. Surgeon General

4 Serious Emotional Disturbance The term serious emotional disturbance is used in a variety of Federal Statutes in reference to children under the age of 18 with a diagnosable mental health problem that severely disrupts their ability to function socially, academically and emotionally. The term does not signify any particular diagnosis, rather it is a legal term that triggers a host of mandated services to meet the needs of these children.

5 MAJOR MENTAL ILLNESSES AND BEHAVIORAL DISORDERS THAT AFFECT CHILDREN

6 Anxiety Disorders Post Traumatic Stress Disorder (PTSD) Depression/Mood Disorders Attention Deficit Disorders (ADD/ADHD) Bipolar Disorder

7 DSM IV TR Published in 2000

8 The DSM-IV-TR is the most current version of the American Psychiatric Association s Diagnostic and Statistical Manual of Mental Disorders (DSM) It is the standard classification of mental disorders used by mental health professionals in the U.S. DSM-IV-TR has been designed to use across settings inpatient outpatient partial hospital clinic private practice primary care

9 WHO USES THE DSM IV-TR? Mental health and Health Professionals: Psychiatrists Psychologists Social Workers Nurses Occupational & Rehabilitation Therapists Counselors

10 THE DSM IV-TR CONSIST OF 3 MAJOR COMPONENTS The diagnostic classification The diagnostic criteria set The description text

11 Diagnostic Classification The diagnostic classification is the list of mental disorders that are officially part of the DSM system. Making a DSM diagnosis consist of selecting those disorders from the classification that best reflect the signs and symptoms that are affecting the individual being evaluated. With each diagnostic label is a diagnostic code used by clinicians, hospitals and agencies. Codes come from the ICD-9-CM, used in the U.S. by all healthcare professionals.

12 Diagnostic Criteria Sets For each disorder in the DSM, a set of diagnostic criteria indicate what symptoms MUST be present (and for how long) in order to qualify for a diagnosis. It also identifies those symptoms that MUST NOT be present in order to qualify for a particular diagnosis. These criteria are used as guidelines to be informed by clinical judgment to formulate a diagnosis.

13 Descriptive Text The third component of the DSM is the descriptive text that accompanies each disorder with headings : Diagnostic Features Sub-types and/or Specifiers Recording Procedures Associated Features and Disorders Specific Culture, Age and Gender Features Prevalence Course Familial Pattern Differential Diagnosis

14 Multiaxial System of Assessment A multiaxial system is an assessment on several axes the different domains of information that may help the clinician plan treatment and predict outcome of treatment. There are five axes included in the DSM-IV-TR multiaxial classification.

15 The Multiaxial System of Assessment 5 Axes A multiaxial system is an assessment on several axes-the different domains of information that may help the clinician plan treatment and predict outcome. There are 5 axes included in the DSM-IV-TR multiaxial classification: Axis I: Clinical Disorders Other Conditions that may be a focus of Clinical Attention Mood Disorders Anxiety Disorders Adjustment Disorders Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence (Excluding Mental Retardation on Axis II)

16 Multiaxial System cont d. Axis II : Personality Disorders Mental Retardation A Personality Disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. Personality Disorders: prominent maladaptive personality features and defense mechanisms

17 Multiaxial System cont d. Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder Antisocial Personality Disorder Borderline Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder Personality Disorder (NOS) Not Otherwise Specified

18 Multiaxial System cont d. Mental Retardation The essential feature of Mental Retardation is significantly - general intellectual functioning that is accompanied by significant limitations in adaptive functioning in at least 2 skill areas : communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health and safety. The onset must occur before 18 years of age. Significantly sub-average intellectual functioning is defined as an IQ of about 70 or below.

19 Multiaxial System cont d. Axis III : General Medical Conditions A General Medical Condition can be directly etiological to the development or worsening of mental symptoms and that the mechanism for this effect is PHYSIOLOGICAL. Examples: Endocrine, Nutritional & Metabolic Diseases Immunity Disorders Diseases of the Nervous System Diseases of the Digestive System Diseases of the Respiratory System Injury & Poisoning

20 Multiaxial System cont d. Axis IV : Psychosocial and Environmental Problems Examples: Familial or Interpersonal Stressors A negative life event Environmental Deficiency Problems with a primary support group Educational Problems Housing Problems Economic Problems Problems related to interaction with the legal system/crime

21 Multiaxial System cont d. Axis V : Global Assessment of Functioning (GAF) Axis V is for reporting the clinician s judgment of an individual s overall level of functioning. GAF=, followed by a GAF rating from 0-100, followed by the time period reflected by the rating in the parenthesis: (Current) (Highest level in past year) (At Discharge)

22 Depression/Mood Disorders Depression in children may include: apathy, irritability and persistent sadness. A depressed child may seem bored and unusually irritable; there may be changes in school performance, sleep & behaviors. Types of Depression: Dysthymia Major Depression

23 Dysthymia A chronic type of depression, a person s moods are regularly low Low dark, sad mood nearly every day for at least 2 years Symptoms are less severe than with Major Depression Feelings of hopelessness Insomnia or hypersomina Low energy or fatigue Low self-esteem Poor appetite or overeating Poor concentration

24 Major Depression Symptoms Consistently low or irritable mood Loss of pleasure in usual activities Trouble sleeping or excessive sleeping Dramatic change in appetite; weight increase or decrease Fatigue-lack of energy Feelings of worthlessness, self-hate and inappropriate guilt Extreme difficulty in concentration Slowed or agitated physical movements Inactivity and with-drawl from usual activities Feelings of hopelessness and helplessness Recurring thoughts of death or suicide 5 or more symptoms must be present for at least 2 weeks

25 Attention Deficit Disorder (ADD/ADHD) The main features are INATTENTION, HYPERACTIVITY and IMPULSILITY. In general, impulsiveness and hyperactivity are observed before one notices the lack of attention, which often appears later

26 3 Subtypes of ADHD: Hyperactive- Impulsive type symptoms of hyperactivity and impulsivity have been shown for at least 6 months to an extent that it is disruptive and inappropriate for the individuals developmental level. Predominantly Inattentive type: Inattention for at least 6 months to extent that it is disruptive and inappropriate for the child s development level Combined Type: Combination of Symptoms for at least 6 months

27 Attention Deficit Disorder The cause of Attention Deficit Disorder in Children is currently unknown. It s speculated that some subtle brain damage may be responsible occurring in the womb shortly after birth, or dietary intolerance, or an unknown viral infection affecting the brain Attention Deficit Disorder in children is one of the short attention span, impulsiveness, and hyperactivity that starts before age 7. Attention deficit disorder is more common in boys, especially first born boys. Remission or symptom reduction may happen around 12 years old with overactivity being the first to go followed by distractibility.

Symptoms of ADD/ADHD Hyperactive Emotional outbursts Short attention span Unable to finish things Does not listen when spoken to Does not follow instructions Dislikes tasks that require concentration

28 Symptoms of ADD/ADHD Hyperactive Emotional outbursts Short attention span Unable to finish things Does not listen when spoken to Does not follow instructions Dislikes tasks that require concentration Carless mistakes in school work Loses things Easily distracted Forgetfulness Fidgets with hands or fee while seated Runs about or climbs excessively as if driven by a motor Talking excessively Blurts out answers before questions are finished Butts into conversations or games Poor school performance and learning problems Poor social skills

29 Problems related to ADD/ADHD Learning Disabilities-20-30% of these children have a learning disability. Difficulty understanding certain sounds or words difficulty expressing oneself in words. Reading or spelling disabilities and problems working arithmetic disorders. 8% of elementary school children. A child with ADHD may struggle with learning, but he/she can often learn once successfully treated for ADD/ADHD

Often refuses to follow directions given by an adult, fails to comply with adult requests. Often annoys others deliberately.

30 Oppositional Defiant Disorder ½ of all children with ADHD are affected especially boys Symptoms of ODD Often gets angry and loses temper (short fuse). Often argues, especially with adults and those in authority. Often refuses to follow directions given by an adult, fails to comply with adult requests. Often annoys others deliberately. Often blames misbehavior or mistakes on others. Often is annoyed by others, seems touchy. Often is angry, resentful. Often shows vindictive or spiteful behavior.

31 Conduct Disorder A repetitive and persistent patter of behavior in which the basic rights of others or major age- appropriate social norms or rules are violated. Symptoms of Conduct Disorder Frequent bullying or threatening Often starts fights Used a weapon that could cause serious injury Physical cruelty to people Physical cruelty to animals Theft with confrontation Forced sex upon someone

32 Bi-Polar Disorder or Manic Depression Bipolar Disorder is a serious mental illness. It can run in families, and usually starts in late adolescent or early adulthood. Because there are some symptoms that can be present in both ADHD and Bi-Polar Disorder it is often difficult to differintate between the two conditions. People who have Bi-Polar have dramatic mood swings. People who have Bi-Polar Disorder can go from overly energetic high or irritable to sad and hopeless and the back again. There can be normal moods in between.

33 Bi-Polar or Manic Depression The Up feeling is called MANIA and the down feelings is Depression!! Bi-Polar Disorder in children often involves a faster cycling of the extreme mood states, even within one hour. Children may also experience the symptoms of mania and depression simultaneously. Experts describe this pattern as a CHRONIC MOOD DYSREGULATIONS.

34 Bi-Polar or Manic Depression The symptoms which can overlap between ADHD and Bi-polar disorder include high levels of energy and reduced need for sleep. But elated mood and grandiosity an inflated sense of superiority are distinctive signs of Bi-Polar Disorder.

Anxiety Disorders Anxiety is the fearful anticipation of further danger or problems accompanied by an intense unpleasant feeling (DYSPHORIA) or physical symptoms.

35 Anxiety Disorders Anxiety is the fearful anticipation of further danger or problems accompanied by an intense unpleasant feeling (DYSPHORIA) or physical symptoms. Anxious children are often overly tense or uptight. Some may seek a lot of reassurance, and their worries may interfere with activities in their daily life. Anxious children have many worries about things before they happen. They may have repetitive, unwanted thoughts (obsessions) or actions (compulsions). Fears of embarrassment or making mistakes Low self-esteem and lack self-confidence These fears cause significant distress and interfere with usual activities. Also, restlessness, fatigue, difficulty concentrating, irritability and muscle tension

36 Anxiety Disorders cont d. Anxiety in children may present as: Separation Anxiety Disorder : Excessive anxiety concerning separation from home or from those to whom the child is attached Generalized Anxiety Disorder: Excessive anxiety and worry about events or activities with difficulty controlling these worries Phobias: Persistent, irrational fears of a specific object, activity or situation (heights, flying, animals, seeing blood) These intense fears cause the child or adolescent to avoid the object, activity, or situation.

37 Anxiety Disorders cont d. Panic Disorder: The presence of recurrent, unexpected panic attacks and persistent worries about having attacks. Panic attacks refer to the sudden onset of intense apprehension, fearfulness or terror, often associated with feelings of impending doom. Also, there may be shortness of breath, chest pain or discomfort, choking or smothering sensations, and fear of going crazy or losing control.

38 Anxiety Disorders cont d. Post Traumatic Stress Disorder All children & adolescents experience stressful events which can affect them both emotionally and physically. A child or adolescent who experiences a catastrophic event may develop ongoing difficulties known as Post Traumatic Stress Disorder (PTSD). A diagnosis of PTSD means that an individual experienced an event that involved a threat to one s own or another s life or physical integrity and that this person responded with intense fear, helplessness, or horror. J.Hamblen,PhD&E.Barnett,PhD

39 Anxiety Disorders cont d. PTSD In a fact sheet from the National Center for PTSD on PTSD in Children and Adolescents, Dr. Jessica Hamblen & Dr. Erin Barnett provide the following statistics: Child protection services in the U.S. receive approximately 3 MILLION referrals each year, representing 5.5 MILLION children. Those figures may only represent a portion of the child maltreatment cases that occur; researchers estimate that two-thirds of maltreatment cases are unreported.

40 Anxiety Disorders cont d. Of those cases referred, about 30% are substantiated and occur in the following frequencies: 65% NEGLECT 18% PHYSICAL ABUSE 10% SEXUAL ABUSE 7% PSYCHOLOGICAL ABUSE In addition, anywhere from 3 to 10 million children are exposed to DOMESTIC VIOLENCE each year, 40-60% of which cases also involve CHILD PHYSICAL ABUSE.

PTSD cont d. How many children develop PTSD? Studies of the general population have examined rates of exposure and PTSD in children and adolescents.

41 PTSD cont d. How many children develop PTSD? Studies of the general population have examined rates of exposure and PTSD in children and adolescents. Results from these studies indicate that 15-43% of girls and 14-43% of boys experience at least one traumatic event. Of those children and adolescents who have experienced a trauma, 3-15% of girls and 1-6% of boys could be diagnosed with PTSD.

42 PTSD cont d. A child s risk of developing PTSD is related to the seriousness of the trauma, whether the trauma is repeated, the child s proximity to the trauma, and his/her relationship to the victim(s). Following the trauma, children may initially show agitated or confused behavior. They may also show intense fear, helplessness, anger, sadness, horror or denial. A child or adolescent who experiences traumatic or catastrophic event(s) may develop ongoing difficulties.

43 PTSD cont d. A child with PTSD may also re-experience the traumatic event(s) by: Having frequent memories of the event(s), or in young children, play in which some or all of the trauma is repeated over and over Having upsetting and frightening dreams Acting or feeling like the experience is happening again Developing repeated physical or emotional symptoms when the child is reminded of the event(s)

44 PTSD cont d. Children with PTSD may also show the following symptoms: Worry about dying at an early age Losing interest in activities Showing more sudden and extreme emotional reactions Showing irritability or angry outbursts Having problems concentrating Acting younger than their age (clingy or whiny behavior, thumb sucking) Showing increased alertness to the environment Repeating behavior that reminds them of the trauma

45 PTSD cont d. The symptoms of PTSD may last from several months to many years. COMPLEX PTSD CHRONIC TRAUMA The diagnosis of PTSD accurately describes the symptoms that result when a person experiences a short-lived trauma. Chronic Traumas continue or repeat for months or years at a time.

46 Complex PTSD Clinicians and researchers have found that the current PTSD diagnosis often does not capture the severe psychological harm that occurs with prolonged, repeated trauma. Dr. Judith Herman of Harvard University suggests that a new diagnosis, COMPLEX PTSD, is needed to describe the symptoms of long-term trauma. Another name sometimes used to describe this cluster of symptoms is: Disorders of Extreme Stress Not Otherwise Specified (DESNOS).

Complex PTSD cont d. Dr. Herman notes that during long-term traumas, the victim is generally held in a state of captivity, PHYSICALLY or EMOTIONALLY.

47 Complex PTSD cont d. Dr. Herman notes that during long-term traumas, the victim is generally held in a state of captivity, PHYSICALLY or EMOTIONALLY. In these situations the victim is under the CONTROL of the perpetrator and unable to flee. Examples of such traumatic situations include: Concentration camps Prisoner of War camps Prostitution brothels Long-term domestic violence Long-term child physical abuse Long-term child sexual abuse Organized child exploitation rings

48 Acute Stress Disorder Acute Stress Disorder (ASD) is an anxiety disorder characterized by a cluster of dissociative & anxiety symptoms that occur within a month of a traumatic stressor. It was added to the DSM-IV-TR to distinguish time-limited reactions to trauma from the farther-reaching and longer-lasting PTSD. ASD, like PTSD, begins with exposure to an extremely traumatic, horrifying, or terrifying event. Unlike PTSD, however, ASD emerges sooner & abates more quickly; it id also marked by more dissociative symptoms.

49 Acute Stress Disorder cont d. Symptoms: Acute stress disorder may be diagnosed in individuals who have lived through or witnessed a traumatic event to which they responded with intense fear, horror, or helplessness, and are currently experiencing 3 or more of the following DISSOCIATIVE symptoms: Psychic numbing Being dazed or less aware of surroundings Derealization Depersonalization Dissociative amnesia

BDS-2 QUICK SCORE SCHOOL VERION PROFILE SAMPLE

BDS-2 QUICK SCORE SCHOOL VERION PROFILE SAMPLE BEHAVIOR DIMENSIONS SCALE-2 Name of student: Andrea Thomas School: Midvale High School Class: Science City: Midvale SCHOOL VERSION RATING FORM PROFILE SHEET Gender: Female Grade: State: NY Subscales SUMMARY