COMMON DIAGNOSES FOR CHILDREN IN CARE

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COMMON DIAGNOSES FOR CHILDREN IN CARE

• DEENA MCMAHON
• MCMAHON COUNSELING CONSULTATION SERVICES LLC
• 651-210-0335 FAX [phone]
• dmcmahon_at_mcmahonccs.net

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SEE THE CHILD

• No matter what the diagnosis or symptoms, there
  is a child behind all of those labels. See the
  child first, not the diagnosis.
• No matter what label you give the behaviors, you
  still have to manage the child.

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WHAT IS MENTAL HEALTH?

• There is no such thing as perfect mental health.
• It changes and evolves over our life span.
• Children with mental health problems are still in
  an intense growth spurt.
• There are significant cultural differences in how
  we assess, cope with and treat.

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THE CULTURE OF MENTAL HEALTH

• One childs community may value the symptoms
  another community is trying to medicate away.
• Know how problematic or accepted a behavior or
  symptom set in the childs community is.
• Be careful not to minimize or normalize too
  often.

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BUILDING TRUST

• The way we build relationships with hurt children
  depends on their developmental stage, where they
  are, where they should be, and what they missed
  out on.
• We will seldom teach a child to respect us when
  they cant trust.

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IMPACT OF NEGLECT/ABUSE

• Children who have been neglected or abused will
  go through the developmental milestones
  differently, at almost every stage.
• Each child will address these past hurts
  differently.
• They are hard wired differently

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ITS NOT ABOUT YOU!

• These children have behaviors and thoughts that
  seem as though they are purposefully trying to
  make life difficult.
• Keep in mind that children with mental health
  challenges often are very limited in their
  ability to make good choices.
• They have diminished capacity.

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POTPOURRI

• Autism Spectrum
• Depression/Anxiety
• Post Traumatic Stress Disorder
• Attention Deficit Disorder
• Oppositional Defiant Disorder
• Reactive Attachment Disorder
• Fetal Alcohol Spectrum Disorder

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ASD - UNCLEAR ORIGINS

• Most researchers believe that it is caused by a
  combination of genetic vulnerabilities and
  environmental triggers.
• It can be inherited. Some families seem to be
  especially vulnerable, with several children with
  ASD.
• It is a neurologically based disorder of
  development.

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SYMPTOMS

• Tactile defensiveness
• Easily over stimulated
• Perseveration
• Spinning, head banging, rocking
• Difficulty communicating
• Difficulty with transitions
• Impaired motor skills - clumsy

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CLINICAL CHARACTERISTICS

• Deviations or abnormalities in three broad
  domains
• Social relatedness and social skills
• Use of language for communication
• Stylistic and repetitive, perseverative behaviors
  with an intense and narrow range of interest

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INTERVENTIONS

• Identify the childs strengths and interests and
  use what motivates them.
• Create opportunities for choice making and the
  need for a break.
• Try to honor refusals when possible.
• Dont ask them to earn the thing they need to
  regulate themselves.

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SLOW DOWN

• Slow down activities to allow time to process,
  plan and choose the next step.
• Allow more time for transitions.
• Speak more slowly, speak less.
• Take time to read the childs cues, signals and
  provide support.

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TREATMENT

• The physical environment matters a great deal.
• Break tasks down into manageable steps.
• Follow a routine with predictable structure.
• Have realistic expectations.
• Dont assume they feel, think, desire and care
  less than typical children.

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PROGNOSIS

• There is no known cure.
• New research supports the possibility of
  dramatically improved understanding of this
  disorder.
• It is typically a lifelong disorder, with the
  need for adaptive strategies throughout the
  lifespan.

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WHAT CAREGIVERS REPORT

• Finding good services and competent professional
  helpers is as stressful as the disorder itself.
• Caregivers need tremendous care and support.
• Siblings in the home have many losses.
• The family defines itself based on ASD.

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CO-OCCURRING DISORDERS

• They look highly anxious they are.
• They qualify for non-verbal learning disorder
  diagnosis.
• They can and are frequently oppositional and
  defiant.
• Treatment modalities for autism take precedence.
  As a diagnosis, autism would be considered
  primary.

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MEDICATION

• Many children with ASD do use medication for
  sleep, for anxiety, for improved focus.
• There is no medication for ASD that will make it
  go away but sometimes symptoms can be
  alleviated with medication.

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DEPRESSION

• There is no one cause for depression. It ranges
  from severe (Major Depression) to more mild
  (Dysthymia). It can be chronic or acute.
• It affects about one in five teens.
• It can occur at any age.
• It looks different in different people and at
  different stages of development.

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CAUSES

• Major depression is a brain-based illness.
• There is no one single cause.
• It is not necessarily related to a major life
  event or stressor, but many times it is.

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CLINICAL CHARACTERISTICS OF DEPRESSION

• Changes in sleep
• Changes in appetite
• Impaired concentration, short-term memory, lack
  of focus and decision making
• Loss of energy
• Loss of interest
• Low self esteem
• Feelings of hopelessness

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PROGNOSIS

• A combination of medication and supportive
  therapy is effective.
• Most people have more than one
• episode of major depression.
• 80 of brain-based episodes of depression respond
  favorably to treatment.

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WHAT YOU MAY SEE

• Lack of sleep
• Lack of good diet
• Lack of any routine
• Unreasonable fearfulness, avoidance of a
  situation, unwillingness to try new things.

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THREATS OF SUICIDE

• Know when to call for help
• Know how to intervene
• Always take it seriously
• Let a professional help
• Always let others know the child is making these
  threats

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A CRY FOR HELP?

• How do you know the child may mean it?
• Is it the same as SIB (self injurious behaviors
  such as cutting, burning?
• Does the child have confidentiality when they do
  self harm? Does the caregiver?

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INTERVENTIONS

• These kids are volatile
• They appear defiant in their stance and often are
  passive aggressive or aggressive as a way to
  manage
• They have VERY low self esteem
• They have no insight into why they behave the way
  they do
• They are often self-defeating.

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CONTRIBUTING FACTORS

• Genetics a family history of mood disorders,
  which means a biological vulnerability.
• Alcohol abuse/use and other drugs.
• Major loss or changes in life.
• Chronic stress.
• Personality characteristics such as low self
  esteem, dependency on others or negative view of
  the world.

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ANXIETY

• Almost one in five children are born with
  anxiety.
• Their brain is hard wired differently.
• Many of the symptoms can be mistaken for
  depression.

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SYMPTOMS OF ANXIETY

• Moody
• Irritable
• Sullen, withdrawn
• Lack of ability to regulate emotions
• Frequent crying/tantrums
• Loss of friends and lack of pleasure
• Intense anger/rage

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TREATMENT

• Most effectively treated with medication and
  therapy
• Accurate and early diagnosis
• Therapy
• Cognitive/behavioral
• Interpersonal psychotherapy to focus on emotional
  and relationship disturbance
• Support services within the community

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MEDICATION

• Both anxiety and depressive disorders typically
  respond well to medications.
• It may take some time to find the right dosage,
  and the right medication.
• What may work for a time, may gradually decrease
  in effectiveness.

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PAY ATTENTION

• Very young children can suffer from depression
  know what that looks like.
• Keep a notebook or journal, document.
• Spend time with other children of the same age
  and notice differences.
• Ask for advice, try different things for a
  different response.

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ONE SIDED RELATIONSHIPS

• They will not ask for help.
• They may often refuse help.
• Their rejection is often a test of your
  commitment.
• It may also be about their level of
  discouragement.
• They believe they cant succeed.

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RE-TEACH AND PRE-TEACH

• Understand object permanence and use of pictures,
  phone calls, objects to reassure
• Help the child gain confidence by doing things
  they like and are good at
• Let them know that failure is not to be feared
  and practice is what kids do to learn new stuff

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POST-TRAUMATIC STRESS DISORDER

• PTSD is an increasingly common diagnosis given to
  children who have been in the child welfare
  system, but overall, is rare.
• By virtue of losing their families, they have
  endured extreme distress and prolonged lack of
  security and safety.

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CAUSES

• It is an anxiety disorder that occurs after a
  person experiences or witnesses a traumatic event
  that they perceive as life threatening to self or
  others.
• Most of the children that we see have extreme or
  layered trauma that is, one trauma after
  another.

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CONTRIBUTING FACTORS

• Seriousness of trauma
• Repeated trauma or single episode
• Childs proximity to the trauma
• Childs relationship to the victim
• Childs relationship to the perpetrator
• Parental reaction

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SYMPTOMS

• Symptoms can occur directly after the event or
  much later, for no obvious reason. They can last
  from a few months to years. The victim
  re-experiences the event in a way that makes them
  relive the trauma, with an emotional response as
  if it were occurring in the present.

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SYMPTOMS

• Intense fear, sleeplessness, intrusive thoughts,
  memories or pictures in the mind
• Dreams related to the event
• Anxiety
• Hyper vigilance, exaggerated startle response,
  often seem hyperactive
• Frequent physical complaints
• Reenactment of the event in play or work

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SYMPTOMS CONTINUED

• Confusion, disorganized thoughts, difficulties
  concentrating
• Anger and irritability
• Freezing, dissociation (fight or flight)
• Night terrors, trouble falling, staying asleep
• Regression
• Auditory learning problems

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TREATMENT

• Early intervention is important.
• Support from parents, school and peers is
  important.
• Child needs to believe they are safe.
• Rituals to reestablish feeling a sense of control
  are helpful.
• Psychotherapy, individual, family, group.

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THERAPY

• Allows the child a safe way to discuss, show,
  express their trauma story.
• Does not expect the child to tell their story
  repeatedly, to a variety of people.
• Does not assume a child will use words or
  language to express trauma.
• Can retraumatize the child.

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PROGNOSIS

• This is a disorder that can be treated, managed
  and eventually be put to rest. Later in life, it
  is possible to re-experience early traumatic
  memories. Some individuals will need episodic
  treatment throughout their life cycle.

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TANTRUM OR FLASHBACK?

• You may not always know what the child is
  reacting to.
• Punitive consequences are pointless.
• They need to know they wont always feel and act
  the way they do now.

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PTSD OR ODD? FIGHT OR FLIGHT?

• Is the child defiant or frozen
• The child can act as though they had no
  conscience
• The child will dissociate seems like they are
  not there with you.
• The child will have trouble learning in school

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INTERVENTIONS

• Stay calm
• Find the time
• Have a plan for the meltdown
• Get some history, if possible
• Encourage the child to have a buddy
• Know what comforts the child

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PRE-TEACHING

• What will you do next time?
• What else can you do, options?
• That was then, this is now, you are bigger,
  stronger, have more help.
• How did you feel and was your response helpful?

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TIMING IS EVERYTHING

• Strike when the iron is cold
• Dont intervene when the child is highly
  emotional.
• Connect the behavior to the here and now, not the
  past.
• Make the child think instead of feel.

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MEDICATION

• Many children use a sleep aid to help them relax
  at night.
• Sometimes an anti anxiety or anti depressant is
  useful.
• They mimic the symptoms of ADHD but a stimulant
  medication is not a good idea.

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FAMILY RESPONSE

• You may lose confidence.
• You may become anxious about when the next event
  will happen.
• Siblings will wonder why they are not treated the
  same.

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ATTENTION DEFICIT HYPERACTIVE DISORDER

• More common in boys than girls.
• Very treatable.
• Rapidly increasing in many countries.

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DIAGNOSING

• Frequently misdiagnosed.
• Needs to be observed in several life domains
  school, home, community.
• Collateral information from parents and teachers
  is essential.
• Use of the Connors or CBCL is standard.

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THE HIGH ENERGY CHILD

• Hyperactivity usually emerges as a diagnosis when
  children reach middle school
• They need things broken into small steps.
• They cant get organized
• They need to be good at something
• Transitions will be hard, they need time

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LESS IS GOOD

• Reduce stimulation
• Limit their options and choices
• Touch, look at, show the child. Be with them.
  They are not good listeners.
• Give them extra time.
• Communication with the school is essential.

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CAUSES

• Unknown.
• 40 of children with this disorder have a parent
  who also exhibits symptoms it is a heritable
  disorder.
• Can be mild to severe.
• You know severe when you see it!!!

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SUB TYPES

• Attention deficit
• Impulsivity
• Hyperactivity
• These can occur distinctly or be combined.

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SYMPTOMS

• Lack of attention, inability to stay focused on
  activities that are not novel or interesting.
• Makes careless mistakes.
• Seems tuned out or easily distracted.
• Poor organization.
• Impulsive/cant sit still, fidgets.
• Poor social skills can be volatile

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CLINICAL CHARACTERISTICS

• Can be observed in all major life domains.
• Becomes more problematic during middle school
  years.
• Child experiences failure and frustration in
  spite of efforts and desire to improve.
• Teachers and parents view child as choosing to
  fail or not paying attention.

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TREATMENT

• Medication. There are several good ones, all
  well researched. You may need to fiddle to find
  the right one.
• Cognitive/Behavioral therapy to develop coping
  strategies.
• Psycho education with child and parents to
  develop routines and skills.

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TREATMENT

• ADHD children perform better with familiar,
  consistent, structured routines with positive
  reinforcements and real consequences for negative
  behavior.
• Structure and routine are very helpful, as is
  planning ahead and learning to anticipate.
  (Adaptive strategies)

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MEDICATION

• Medication is the single most effective method of
  treatment. These include stimulants and non
  stimulants.
• Aderol, Strattera, Ritalin.
• With social skills training only, the disorder is
  significantly harder to treat.

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CHILDS PROGNOSIS

• With effective treatment, this is a highly
  manageable disorder.
• Child can achieve success with adaptive
  strategies, good support and medication.

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WHAT ARE ADAPTIVE STRATEGIES?

• Lists
• A learning buddy
• Pictures instead of words
• Routines for key parts of the day
• Good relationships with the school
• Places to put things every day such as bins,
  boxes, drawers etc

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YOUR PROGNOSIS

• You may get irritated with this child often
• If you even THINK about raising the intensity and
  becoming reactive you may sink the boat
• You may be the only rational person in the
  conversation dont lose that thought!

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CHALLENGES

• Know that the child is probably not intentionally
  being disrespectful.
• Give them feedback AFTER the event.
• Punitive consequences will fail to shape their
  behavior, as they do not choose to get off task.
• They are smarter than they seem and do not like
  being the way they are.

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OPPOSITIONAL DEFIANT DISORDER

• This is a recurring pattern of negative, hostile,
  disobedient and defiant behavior in a child or
  adolescent, lasting for at least six months
  without serious violation of the basic rights of
  others.
• These children rate high on the PITB scale.

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CAUSES

• More common in boys than girls and typically
  begins by age 8.
• Gradual onset, usually occurring at home first
  and then affecting other domains.
• The childs temperament and the parents response
  to the child.

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SYMPTOMS

• Spiteful, vindictive.
• Persistently stubborn.
• Wont negotiate. Their way is the only way.
• Tests limits.
• Ignores orders, requests.
• Will not accept blame.
• Loves to argue.
• Deliberately annoying, swears, aggressive
  language.

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CLINICAL CHARACTERISTICS

• Low self esteem.
• Distressed peer relationships.
• High value on being in control.
• Lack of success in school settings.
• Compliance is seen as giving in .

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TREATMENT

• Individual, group and/or family therapy.
• For child, a peer group that focuses on role
  play, friendship development, problem solving,
  anger control, relaxation and self talk.
• For parents, it is stress management and
  providing structure and positive limits.

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CAREGIVERS

• The ODD child requires a caregiver/teacher with
• A good support system
• Personal self control
• Effective communication
• PATIENCE!!!

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INTERVENTIONS

• Use of positive, tangible rewards.
• Identify the target behavior.
• Set up rewards and consequences.
• Have fair reinforcers that are meaningful.
• Understand how fear and anxiety may be underlying
  causes of opposition.

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CHALLENGES

• They want the fight, dont give it to them.
• They want a power struggle, you will always lose.
• They want engagement to get off the real subject,
  stay focused.
• They think they gain status through public
  defiance so be careful

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PROGNOSIS

• Child often outgrows this behavior.
• Left unaddressed, the behavior may become
  increasingly aggressive and more problematic
  (conduct disorder).
• Developmentally, many of the behaviors and
  symptoms are culturally normed for our society,
  relative to adolescent development.

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IMPACT ON SIBLINGS

• They become deeply resentful
• They do not like these children
• They wont bring their friends home
• They may make fun or tease this child
• They may blame you for being too soft

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THE CONTEXT OF THE CHILD

• Our children are looking for ways to be in
  charge.
• Adolescents often feel things are out of control.
• Our society values and rewards those who appear
  to have power.
• We do not know how to give power to children in
  safe or healthy ways.

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CO-OCCURRING DISORDERS

• Many of these children have attention or focus
  problems.
• Many of these children do struggle with
  depression but mask it in anger.
• Many of these children have been victims and are
  trying to find some control.

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REACTIVE ATTACHMENT DISORDER

• The most extreme form of attachment disorder.
• Attachment disorder occurs on a continuum, with
  RAD, or disorganized attachment disorder being
  the most severe, and rare.

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WHAT IS ATTACHMENT?

• A brain based process
• It is neurobiological in nature
• It is essential for all children
• Disrupted attachments are common for children in
  care who have had many moves, traumas and mental
  health disorders.

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THE WHOLE CHILD

• Children with RAD have suffered harm in many ways
  which include
• Neurological
• Psychological
• Physiological
• Socially
• Emotionally

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WHAT ABOUT DUAL DIAGNOSIS?

• There is almost always more than one thing going
  on in the mental health arena of the children we
  work with.

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IDEAS

• Be consistent
• Attention is all there is, not good or bad
• Look at the child, touch the child, be sad for
  the child when giving a consequence.
• Dont ask why, use how, what
• Use words to identify feelings

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SYMPTOMS DISTURBED ATTACHMENT PATTERNS

• Hyper-vigilance.
• Poor physical/emotional boundaries.
• Overly needy or overly self reliant.
• Lacks ability to self regulate emotional states.
• Distressed peer and family relationships.
• Eating/sleeping/hoarding/stealing issues.

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ANXIOUS/COMPULSIVE
BEHAVIORS

• Lying
• Stealing
• Hoarding
• Chatting non-stop
• Self harm and mutilation
• Addiction

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TREATMENT

• Therapy for this disorder is relationship based.
  Best practice includes the primary caregiver to
  facilitate a connection that is reciprocal and
  safe.
• It is typically long term and family centered.
• Multisensory modalities are most effective it is
  about doing, not talking.

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PROGNOSIS

• These children can and do get better.
• It has everything to do with good care giving
  relationships that are available to support the
  childs healing. The child will not get better
  because they choose to.

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SIMPLE THINGS TO DO

• Use rewards that are powerful and meaningful.
• Give feedback often, to let your child know how
  they are doing.
• Help the child anticipate and plan.
• Expect that your child will have good days and
  bad days so will you.
• Use positives and praise more than negatives and
  punishments.

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DO

• Keep in mind that, most of the time, you are
  dealing with a biological, neurological problem,
  not a character defect.
• Talk less, do more, meet behavior with behavior.
• Maintain a sense of humor and be patient.
• Have a clinical or parent support group.
• Forgive the child and yourself, every day.

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FETAL ALCOHOL SPECTRUM DISORDER

• When mom drinks during pregnancy the forming
  brain can be severely impaired.
• It is permanent
• It causes many problems for the child life long
  and for the childs family.

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WHEN FASD MEETS RAD

• These two disorders are often seen in tandem.
• This is a very challenging condition to treat and
  to live with.
• Most children with FASD have some level of
  difficulty in forming strong, reciprocal
  attachments.
• Many RAD children have been prenatally exposed to
  AOD.

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TREATMENT

• Support and educate the caregiver.
• Find a specialist.
• High structure, repetition, nurture and parenting
  for life is required.
• It is often difficult to discern which disorder
  is presenting and it often does not matter treat
  the behavior and the core issue.

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CARE ABOUT THE CAREGIVER

• Grief continues to be the most common reaction
  from parents who are raising children with mental
  illness.
• This response is largely unrecognized and
  untreated and commonly misinterpreted as parental
  pathology.

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SHAME

• There are no social or religious rituals to offer
  consolation.
• Mental illness carries a social stigma.
• There is an ongoing sense of aloneness and
  isolation, with difficulty in finding and
  sustaining a support group.
• Raising special needs children is hard on the
  caregivers primary relationship.

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GUILT

• Caregivers unjustly blame themselves and wonder
  what they have done or left undone and feel
  inadequate to the task.
• Caregivers are often blamed, overtly or in
  subtle ways, for the behaviors and problems their
  children experience.

95
KNOW YOUR RESOURCES

• Childrens mental health case management
• The police, doctor, personal care attendant
• The school
• Social Services
• Your mental health professional

96
GET A GOOD ASSESSMENT

• Having the child assessed by an expert, such as a
  child psychiatrist is often important, especially
  when considering use of medication.

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REMAIN HOPEFUL

• Believe in the power of the human spirit
• Believe in the hopefulness of childhood
• Believe in yourself and what you bring to the
  process

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CELEBRATE

• The system does work for children
• YOU do make a difference
• They will always remember you, any way you work
  it.