Clients

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Clients Children How Can We Support
Them?Clinical Considerations

• Presenter
• Arthur Krzyzanowski, Psy.D.
• Childrens Research Triangle
• akrzyzanowski_at_cr-triangle.org

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Risk Factors for Children of Substance Abusing
Women

• Prenatal Alcohol and/or Drug Exposure
• Inadequate Prenatal Care
• Genetic Predisposition to
• - Substance abuse
• - Mood Disorders
• - More severe mental illness
• Environmental Stress (ex poverty, crime)
• Greater risk for neglect and sexual, physical and
  psychological harm

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Prenatal Substance Exposure

• According to a recent study
• 40,000 children/year are diagnosed with FAS
• Still, 95 of children with FAS go undiagnosed
• NOTE A negative toxicology screening at birth
  does not mean there was no prenatal alcohol/drug
  exposure.
• Lupton, C., Burd, L., Harwood, R. (2004).
  Cost of Fetal Alcohol Spectrum Disorders.
  American Journal of Medical Genetics, 127C (1),
  42-50.

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Diagnostic Considerations

• Attention Deficit/Hyperactivity Disorder
• Mood Disorders
• Behavior Disorders
• Post Traumatic Stress Disorder
• Anxiety Disorders
• Attachment Disorders
• Language Based Disorders
• Learning Disabilities
• Pervasive Developmental Disorders

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Diagnostic Considerations

• Attention Deficit/Hyperactivity Disorder
• (Cluster 1)
• Mood Disorders (Cluster 2)
• Behavior Disorders (Cluster 3)
• Post Traumatic Stress Disorder (Clusters 4 5)
• Anxiety Disorders (Cluster 7)
• Attachment Disorders (Cluster 8)
• Language Based Disorders (Cluster 8)
• Learning Disabilities (Cluster 8)
• Pervasive Developmental Disorders (Cluster 8)

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Co-morbidity/Dual Diagnoses

• Often there is significant overlap between
  clusters, with the manifest symptoms often
  secondary to some other underlying concern.
• DX Conduct Disorder ? Learning Disability
• DX ADHD ? Sensory Integration Disorder
• DX ODD ? Executive dysfunction
• DX Intermittent Explosive Disorder ? PTSD
• DX Substance Abuse ? Any of the above

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Treating the Whole Child

• The emergence of behavioral, emotional, physical
  and/or social problems in the children we serve
  is over-determined!
• The childs development and functioning are
  influenced by risk factors stemming from
• The Child
• The Parent/Family System
• Society/Environment

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Child Risk Factors

• Exposure to Toxins In Utero
• Inadequate Prenatal Care
• Pre-maturity
• Birth Anomalies/Defects
• Chronic or Serious Illness
• Temperament
• Mental Retardation/Low Cognitive Abilities
• Childhood Trauma
• Insecure Attachments
• Anti-Social Peer Group

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Parental Risk Factors

• Active Substance Abuse
• Maltreatment and Trauma
• Parents Own History of Loss and Trauma
• Insecure Attachment
• Single Parenthood (With Lack of Support)
• Harsh, Inconsistent or Inadequate Parenting
• Family Disorganization
• Social Isolation

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Parent Risk Factors (Cont.)

• High Parental Conflict
• Domestic Violence
• Separation/Divorce
• Parental Psychopathology
• Illness
• Death of Family Member
• Foster Care Placement

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Social/Environmental Risk Factors

• Poverty
• Lack of Access to Medical Care/Social Services
• Parental Unemployment
• Homelessness
• Inadequate Childcare
• Exposure to racism

• Poor Schools
• Frequent Residence Change
• Environmental Toxins
• Dangerous Neighborhood
• Community Violence

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Child Protective Factors

• Good Health
• Personality Factors
• Above Average Intelligence
• History of Adequate Development
• Hobbies/Interests
• Good Peer Relationships

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Parental/Family Protective Factors

• Secure Attachments
• Parents Supportive of Child
• Household Structure, Monitoring, Rules
• Support/Involvement of Extended Family
• Stable Parental Relationship
• Parents Model Competence/Coping Skills
• Family Expectations of Pro-social Behavior
• High Parental Education Level

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Social/Environmental Protective Factors

• Middle Class or Above SES
• Access to Health Care/Social Services
• Consistent Parental Employment
• Adequate Housing
• Family Religious Participation
• Good Schools
• Supportive Adults Outside of Family

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Identifying Needs and Accessing Appropriate
Services

• Appropriate Interventions start with accurate and
  comprehensive assessments
• Medical and Psychological Assessment
• Academic Achievement
• Occupational Therapy
• Physical Therapy
• Developmental Therapy (Ages 0-3)
• Speech/Language Therapy

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Supporting the Children

• Trans-Disciplinary Approach
• A childs problems are over-determined, so their
  treatment needs to be multi-faceted, with risk
  factors from several directions simultaneously.
• Providers work collaboratively, each bringing
  their expertise to bear in addressing the childs
  needs
• Contrasting the traditional medical model with
  its reliance on hierarchy (M.D., Ph.D., MSW,
  OT/PT)
• No one provider has all the answers. We each hold
  a piece of the puzzle.

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Possible Treatment Providers

• Addiction Counselor(s)
• Court System
• Occupational Therapist
• Pediatrician
• Physical Therapist
• Psychiatrist(s)/Neurologist(s)
• Psychologist(s)/Neuropsychologist(s)
• Social Worker(s)
• Speech/Language Therapist
• Teachers/Educational Specialists

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Intervention Strategies

• An ounce of prevention is worth a pound of
  cure.
• Parents Recovery (Pregnancy Post-partum)
• Parent Education, Training and Support
• Prenatal and Perinatal Care
• Early Intervention Services for the infant

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Maximizing the Impact of Interventions

• Intervention strategies that
• address multiple risk factors rather than
  focusing on only one factor
• Provide the child and family support in a variety
  of settings
• Work with the family and child over time (2-5
  years) and
• Are initiated as early as possible in the
  infants life
• have the greatest potential for positively
  affecting the outcome of an at-risk childs
  development.

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O-3/Early Intervention Services

• Medical
• Developmental Therapy
• Occupational Therapy
• Physical Therapy
• Speech/Language Therapy
• Social/Emotional Development

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Sensory Integration (SI) Disorder

• Deficits in processing and modulating incoming
  sensory information
• FAS/FASD students are more or less sensitive to
  stimuli
• Lower threshold Easily overwhelmed
• Higher threshold Under-responsive
• Treated through Occupational Therapy with a SI
  focus
• Classroom accommodations available to facilitate
  attention and on task behavior within the
  classroom

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Impact of Sensory Processing Problems

• May result in considerable agitation and
  discomfort (both physical emotional)
• May increase distractibility and irritability
• Disruptions often lead to impairments in social,
  emotional and cognitive functioning

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Treatment Techniques

• Picking the right therapy for my child
• Attachment Therapies
• - Theraplay
• - Dyadic Developmental Psychotherapy
• Experiential Therapies
• Family/Parent-Child Therapy
• Behavior Modification Therapy
• Parent Psycho-education

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Basic Assumptions of Theraplay www.theraplay.org

• Playful, joyful, empathic, attuned responsiveness
• Creation of a more positive relationship between
  children their parents is possible!

• Roots of development of self esteem lie in the
  early years, thus returning to the derailed
  developmental stage is essential

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Dyadic Developmental PsychotherapyDaniel A.
Hughes PhD www.danielahughes_at_homestead.com

• Exploration of shame with empathy
• Co-regulation of affect
• Therapist and parent maintain attitude PACE
  (Playful, Accepting, Curious, Empathic)

• Treatment is directive and client-centered
• Parent is present during sessions
• Playful interactions focused on positive
  affective experiences
• Nonverbal as well as verbal communication

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Experiential Therapies

• Self-regulation Combining Sensory Integration
  into Psychotherapy www.alertprogram.com
• Narrative therapy Creating a coherent
  autobiographical narrative for the child
  www.familyattachment.com

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Parent Psycho-education

• Effects of mothers substance abuse (prenatal and
  post-partum) on their childs development
• Age-Appropriate developmental expectations
• Parenting skills for the behavioral and/or
  emotional disturbed child
• Advocating for services from the larger community

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Behavioral Consultation

• Identify the problem behaviors
• Frequency
• Duration
• Latency
• Intensity
• Context (Precipitating Sustaining factors)
• Identify the students strengths

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Behavioral Consultation (Cont.)

• Concretely define targeted behavior(s) to be
  eliminated
• Identify substitute behavior or required level of
  performance
• Always state behavioral goals in the positive
  (Johnny will do) rather than the negative
  (Johnny will not). Be explicit with the
  student as to the behavior expected.

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Behavioral Consultation (Cont.)

• Develop Preventative and Reactive Strategies to
  deal with the behavior(s)
• Develop a means of assessing behavior change
• Assessing consultant effectiveness

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School-Based Assessments

• Parent meeting with teachers, administration and
  associated services
• Multi-disciplinary team meetings IFSP and IEP
  Development and Reviews
• Academic Assessment
• Psychological Assessment (including IQ)
• Speech/Language Therapy
• Occupational Therapy
• Physical Therapy
• Social Work

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A Parable about Problem-Solving

• A person standing near a river hears a call for
  help and sees someone drowning. He jumps in and
  pulls the struggling swimmer out of the water and
  resuscitates him. As he finishes resuscitating
  the first swimmer, a second cries out. Again, he
  enters the water and with great effort hauls the
  second drowning person ashore. A third person
  calls out for help and he jumps to the rescue and
  nearly drowns in the effort, but manages to pull
  the third person out of the river. An admiring
  crowd has gathered when a fourth person calls for
  help and our hero walks away. Where are you
  going? What about this person who is drowning?
  He turns and says, Im tired of rescuing people
  from the river. Im going upstream to find out
  whos pushing them in!
• Quoted from McGourty Chasnoff (2003). Power
  Beyond Measure. Chicago, IL NTI Publishing.

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