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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 TheoryBasic human need

Hardwired to attach to a primary caregiver

1st 3 years plus fetal stage of development are critical

Sensitive period that becomes less plastic w/ age

Multigenerational Transmission Process◦ 75-80% prediction rate!

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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….

Caregivergratifies need

Trust experience

Baby has a need

Attachment Cycle

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)

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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

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Treatment Of Attachment DisordersEffective interventions includes providing a secure and nurturing environment, exposure positive parenting practices, and opportunities to develop interpersonal trust and social relationships.

TreatmentMultimodal 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

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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 FactorsSTRUCTURE:◦ 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 FactorsSUPPORT 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

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

What Works cont…

◦Safe environment◦Constancy◦Boundaries◦Limits◦Collaborative work w/ parents◦Supportive work w/ parents

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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

DEPRESSIONChild Sign of Depression◦ Drop in Grades

◦ Concentration Problems

◦ Psychomotor Agitation

◦ Mood Swings

◦ Aggressive Behavior

◦ Interpersonal Conflict

◦ High Boredom/Apathy

Childhood DepressionLack Defense Mechanisms

Lack Coping Skills

Dependent Upon Others for Security & Stability

Vulnerable Population

Adolescent DepressionAny 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.

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Adolescent DepressionAny 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 DMDDMultimodal 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?

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ODD and TreatmentODD 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 FocusImproving 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 ParentsThe 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 powerPower 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

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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 behaviorDecreasing 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 BehaviorBe 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 PushingI 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 askOnce 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 CooperationIn two parent households, BOTH parents must agree, be involved and committed to making the necessary changes involved in dealing with the oppositional child

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Remain Calm and In controlIssue 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 lovedTell them that they are loved at least FOUR times a day.

Build their Self EsteemChildren 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 childLearn how to play The Wii

Do something they want to do

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Talk with your child but mostly Listen

Active listening

Don’t sweat the small stuffYour 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

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ADHD Diagnostic ConsiderationsPrevalence Rates◦ Roughly 2-18%

◦ Over and Under diagnosed

◦ 4:1 Males to Females

Comorbidity High◦ ODD 50%+

◦ Anxiety & Depression

Diagnostic ConsiderationsBEWARE 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

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

How are ADHD and Executive Functioning related?

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

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What is Executive FunctioningExecutive 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 interventionsSimon says don’t do it

The Distraction Zapper

The On Off switch

Red Light, Green Light

The stay on track Map

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Shifting Focus: Play InterventionsThe 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 DisordersA 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

DifferentialsIntellectual/Developmental Disabilities

Down’s Syndrome

Fragile X Syndrome

Trauma

Expressive Language Disorder

Mixed Receptive-Expressive Language Disorder

Many Others

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Epidemiological DataOnce Considered Rare

Currently: 1:88 Children (1:54 Males)

S. Korea: 1:38

Identical Twin Concordance: 90%

Longitudinal DataRates Increased 78% from 2002-2012

Rates Increased 23% from 2006-2012

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 ConsiderationsParent 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 InterventionsCircumvent 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 InterventionsPicture 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

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Specific InterventionsWork 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 Disorderscommonly seen in childhoodGeneralized Anxiety Disorder

Post Traumatic Stress Disorder

Social Phobia

School Phobia

Obsessive Compulsive Disorder

Separation Anxiety Disorder

Preferred TreatmentCognitive Behavioral Therapy◦ Systematic Desensitization

◦ Play Therapy

◦ Parent and child education

◦ Medication

◦ Exposure with Response Prevention

Systematic DesensitizationGradual 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.

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PTSD TreatmentCognitive 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