Download Diagnoses in Foster Care

Client Psychiatric Issues for CEOs Presented by

Daniel M. Marble, LCSW Social Service Consultant And The Western Child Welfare Law Center 11/10/02

Client Psych Issues--Dan Marble

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Introduction Today you will gain a functional understanding regarding the establishment and support of the agency’s treatment philosophy and milieu. Allow you to better recognize the pathology of your client population so that you can establish better risk management procedures. Allow you to employ policy and budgetary decisions which support treatment priorities. 11/10/02

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Overview and Objectives Examine major pathology types.  Program Milieu  Course Objectives 

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Major Pathology Types Among Foster Children Attachment Disorder  ADD/ADHD  Depression/loss/morning  Others 

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ATTACHMENT

“The Tie that Binds” An Overview of Attachment Disorder

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Attachment A lasting psychological connection between human beings.  The emotional bond that grows between child and caretaker.  Begins in utero and develops over time.  Infants are predisposed to attach.  It exists in a continuum-no perfect attachment or total lack of attachment. 

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Attachment Disorder Causes Abuse: physical/emotional/sexual  Neglect  Sudden separation-primary caregiver  Inadequate or changing daycare  Undiagnosed or painful illness 

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Symptoms of Attachment Disorder in Older Children Act superficial and phony-(strangers and those they feel they can manipulate)  Avoid eye contact unless lying or conning  Indiscriminate affection with strangers  Lack of ability to feel\empathize/care  Extreme control problems/sneaky  Leave a trail of destruction-pets and all possessions  Constant lying Client Psych Issues--Dan Marble 11/10/02 

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More Symptoms-Older Children Highly impulsive  Learning disorders-my way or the highway  No cause and effect thinking  Little or no conscience  Abnormal eating patterns  Other kids avoid them (3Cs) conscience, control, cruelty  Speech (Interrupt, noise and control) 11/10/02 Client Psych Issues--Dan Marble 

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Still More Symptoms Inappropriately demanding  Abnormal speech patterns  Lie (False allegations, believed =power)  Divide and conquer (Mom vs. Dad)  Abuse their caregivers 

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Techniques to Enhance Attachment Holding and touching  Reciprocal games and activities  Teaching emotions  Assessing/discussing attachment  Looking for opportunities to nurture  Clarification of life events  Promoting family identification discipline 11/10/02  Firm, consistent Client Psych Issues--Dan Marble 

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Holding and Touching As much physical contact as the child can tolerate  Snuggling while reading or watching TV  Parents should wear soft clothing and short sleeves for as much skin to skin contact as possible  At meals the child can sit between two nurturing parents 

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Reciprocal Games and Activities Hide and seek  Feeding each other  Singing together  Dancing and moving together in unison  Use movies and stories to describe attachment, such as Dumbo  Face painting 

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Teaching Emotions Look for opportunities to comment on the child’s feelings  Point out congruent facial expressions  Stand in front of a mirror and make faces representing various feelings 

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Assessing/Discussing Attachment Discussions about how it feels to belong or not to belong to a family  Talk about closeness and trusting  When the child lies, talk about how this represents their inability to trust you  Represent trusting as feeling strong enough to trust 

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Looking for Opportunities to nurture Notice times when the child is hurt or sick or frightened and come to their aid  Make a big deal out of bandaging and kissing a skinned knee  Rock, hold and comfort 

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Clarification of Life Events Make sure the child knows about its history  Help the child build a photo album about their past life  Gather and tell stories about past events in the child’s life  Help put together a Life History Book 

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Promoting Family Identification Develop and talk about family rituals around holidays, birthdays  Make family rituals out of everyday events such as bed time or meals 

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Firm, Consistent Discipline This is one of the primary attachment techniques  Keep the environment as stable and organized as possible  Do not use physical or separation or isolation types of punishment  Time outs should be in a chair in the same room as the adult  The “one minute scolding” 

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Treatment Approach AREAS OF REEDUCATION Adult-child relationships

AD CHILD’S CURRENT VIEW

GOAL OF TREATMENT

Relationships are Will be able to form adversarial trusting relationships with adults

The acceptability Powerless over Learn acceptable their feelings ways to express of feelings and feelings certain behaviors 11/10/02 Client Psych Issues--Dan Marble

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Treatment Approach The worth of an individual

See self as defective and worthless

Internalize feelings of self worth

Working together Defiant because as part of a family they feel that if or group they obey, they have “lost.”

Will learn that relationships require working together

Ways to care for and about oneself

Learn independence & how provide for own needs

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Focus on self as a helpless victim. Work against self Client Psych Issues--Dan Marble

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Treatment Approach Ways to care for and about others

Ways to have fun

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Others are competition rather then people to honor & respect

Explore relationships based on cooperation rather then competition Feel that fun is Expand view of fun about being to include art, entertained, getting reading & activity, something or etc. winning Client Psych Issues--Dan Marble

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Patience Pays Off Be prepared for the process to take longer then you thought  Be prepared for setbacks  Be prepared for the many breakthroughs that will make your staff feel like it was all worth it 

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ADD/ADHD An Overview of Types And Treatment

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Definitions Attention Deficit Hyperactivity Disorder: A diagnostic label given children and adults who have significant problems in four main areas of their lives:  Inattention  Impulsivity  Hyperactivity  Boredom 

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More Definitions ADD is not the result of “bad parenting” or obnoxious willful defiance on the part of the child.  It is a medical condition caused by genetic factors that result in neurological differences.  It affects one or two areas of the brain. 

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Important Characteristics It is pervasive across all areas of life.  The problems are apparent before age 7.  Anti-social behaviors are common.  60% also have oppositional defiant disorder 

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Dr. Daniel Amen’s Six Types 1. Classic Type  2. Inattentive ADD  3. Over focused or Cingulate Function ADD  Limbic Systems Functions ADD  5.Temporal Lobe ADD  6. Ring of Fire Add 

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1. Classic ADD Symptoms Restlessness  Hyperactivity  Inability to focus  Lack of planning  Excessively Talkative 

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Classic ADD Treatment Medications Antidepressants  Tofranil  Effexor  Stimulants  Adderall  Dexadrine  Ritalin 

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2. Inattentive ADD Symptoms Short attention span for routine matters.  Distractible  Poor follow-through  Spacey  Internally Preoccupied  Sluggish 

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Inattentive ADD Treatment

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Same as Type 1

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3. Over focused ADD Symptoms Difficulty shifting attention  Stuck on thoughts  Stuck on behaviors  Can become oppositional-wanting to continue repetitive behavior.  Holds grudges  Ritualistic  May mimic OCD 

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Over focused ADD Treatment

Paxil  Zoloft  Prozac 

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Limbic Systems Add Treatment Imipramine  Wellbutrin 

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5. Temporal Lobe ADD Symptoms     

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Memory Problems Spaciness/confusion Emotional Instability Difficulty reading social cues Difficulty with use of language plus auditory and visual processing Physical symptoms Mild paranoia/anxiety Aggressive Client Psych Issues--Dan Marble

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Temporal Lobe ADD Treatment Usual Stimulants  Anticonvulsants  Depakote  Dilantin  Must have close physical monitoring 

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6. Ring of Fire ADD Symptoms  

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Overly Aggressive Overly focused Violent behavior Social problems Very verbal May appear bipolar Hyperactive

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Hypersensitive to: light, sound, taste, and/or touch.

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Impulsivity Distractible Addictive and criminal behavior Oppositional

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Ring of Fire ADD Treatment Anticonvulsants  Antipsychotics  Risperdal 

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Additional Helpful Considerations

Attention to diet  Attention to education  Alternative natural medications  Summer drug holidays 

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Diet/Health Plenty of protein  Cut simple carbohydrates and caffeine  Plenty of exercise 

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Educational Changes Address learning disabilities  IEP and 504 Accommodations Less homework More time on tests Tests given verbally Work closely with teachers 

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Medication Adjustments In mild cases there is some success with Attend and Extress  Summer drug holidays 

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Counseling 

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ADD/ADHD clients have usually gone undiagnosed for some time. The results are residual feelings of being dumb, bad and rejected. They often dislike school as it represents failure. It is improper to treat with medication alone. Counseling is needed to address these residual issues.

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DEPRESION An Overview Types And Treatment

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Causes   

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Chemical/Biological An imbalance of serotonin and receptors Genetic Depressed parent=child is 3X the risk Environmental Traumatic events Peer or family conflict

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Symptoms in Children  

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Irritability Anxiety Symptoms Temper Tantrums Unexplained aches and pains Difficulty thinking Sleep Problems

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Low self esteem Feelings of guilt and hopelessness Constant Fatigue/Lacks Energy Hearing voices Feeling Suicidal

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Symptoms in Adolescence Sleeping too much  Weight gain or loss  Difficulty thinking and making decisions  School failure  Feeling friendless  Suicidal thoughts/Attempts  Delusions 

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Types of Depression Endogenous Internally produced  Exogenous Externally produced  Major Depression  Manic Depressive Disorder 

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Treatment Psychotherapy  Medication  Milieu  Environmental Manipulation 

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CONDUCT DISORDERS An Overview Types and Treatment

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Definition 

Repetitive Persistent Behavior Pattern

Impairment in:  Social  Academic  Family Functioning 

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Types

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Conduct Disorder

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Oppositional-Defiant Disorder

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With Co-morbid Disorders

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Symptoms of Conduct Disorder Aggressive behavior Bullying, Intimidation, Threats  Non-Aggressive behavior Deliberate destruction of property  Deceitfulness or Theft Lying, conning, breaking and entering  Serious Rule Violations Run away, truancy 

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Symptoms of Oppositional Defiant Disorder Often loses temper  Often argues with adults  Defies or refuses to comply  Deliberately annoys  Blames others for mistakes  Touchy/easily annoyed by others  Angry resentful  Spiteful and vindictive 

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Treatment: Containment through Communication    

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Planned Responses Behavior Modification Group Therapy Medication Clonidine, Risperidal, Zyprexa, seroquel

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Management Early intervention  Cover as much of the child’s day as possible  Include all caregivers  Consistent over time and environments  Long term treatment  Cover all aspects of the problem  Address all co-morbidities: Depression, drug abuse, ADHD 

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OTHER COMMON DISORDERS AMONG CLIENTS An Overview Physical Educational Sever Psychiatric

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Less Common Disorders Obsessive compulsive disorder (OCD)  Tourettes Syndrome  Seizure disorders  Bipolar disorder  Learning Disabilities  Schizophrenia 

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Program Milieu

Administrative & Budgetary Support  Staff Development  Staff Attitudes  Communication and Coordination 

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