11/10/02Client Psych Issues--Dan Marble1 Client Psychiatric Issues for CEOs Presented by Daniel M. Marble, LCSW Social Service Consultant And The Western

11/10/02 Client Psych Issues--Dan Marble 1

Client Psychiatric Issues for Client Psychiatric Issues for CEOsCEOs

Client Psychiatric Issues for Client Psychiatric Issues for CEOsCEOs

Presented byPresented by

Daniel M. Marble, LCSWDaniel M. Marble, LCSWSocial Service ConsultantSocial Service Consultant

AndAnd

The Western Child The Western Child Welfare Law Welfare Law

CenterCenter


IntroductionIntroductionIntroductionIntroduction

Today you will gain a functional understanding Today you will gain a functional understanding regarding the establishment and support of the regarding the establishment and support of the

agency’s treatment philosophy and milieu.agency’s treatment philosophy and milieu.

Allow you to better recognize the pathology of your Allow you to better recognize the pathology of your client population so that you can establish better client population so that you can establish better

risk management procedures.risk management procedures.

Allow you to employ policy and budgetary Allow you to employ policy and budgetary decisions which support treatment priorities. decisions which support treatment priorities.


Overview and ObjectivesOverview and ObjectivesOverview and ObjectivesOverview and Objectives

Examine major pathology types.Examine major pathology types. Program MilieuProgram Milieu Course ObjectivesCourse Objectives


Major Pathology Types AmongMajor Pathology Types AmongFoster ChildrenFoster Children

Major Pathology Types AmongMajor Pathology Types AmongFoster ChildrenFoster Children

Attachment DisorderAttachment Disorder ADD/ADHDADD/ADHD Depression/loss/morningDepression/loss/morning OthersOthers


ATTACHMENTATTACHMENTATTACHMENTATTACHMENT

““The Tie that Binds”The Tie that Binds”

An Overview of Attachment DisorderAn Overview of Attachment Disorder


AttachmentAttachmentAttachmentAttachment

A lasting psychological connection between A lasting psychological connection between human beings.human beings.

The emotional bond that grows between The emotional bond that grows between child and caretaker.child and caretaker.

Begins in utero and develops over time.Begins in utero and develops over time. Infants are predisposed to attach.Infants are predisposed to attach. It exists in a continuum-no perfect It exists in a continuum-no perfect

attachment or total lack of attachment.attachment or total lack of attachment.


Attachment Disorder CausesAttachment Disorder CausesAttachment Disorder CausesAttachment Disorder Causes

Abuse: physical/emotional/sexualAbuse: physical/emotional/sexual NeglectNeglect Sudden separation-primary caregiverSudden separation-primary caregiver Inadequate or changing daycareInadequate or changing daycare Undiagnosed or painful illnessUndiagnosed or painful illness


Symptoms of Attachment Symptoms of Attachment Disorder in Older ChildrenDisorder in Older ChildrenSymptoms of Attachment Symptoms of Attachment

Disorder in Older ChildrenDisorder in Older Children

Act superficial and phony-(strangers and those they Act superficial and phony-(strangers and those they feel they can manipulate)feel they can manipulate)

Avoid eye contact unless lying or conningAvoid eye contact unless lying or conning Indiscriminate affection with strangersIndiscriminate affection with strangers Lack of ability to feel\empathize/careLack of ability to feel\empathize/care Extreme control problems/sneakyExtreme control problems/sneaky Leave a trail of destruction-pets and all possessionsLeave a trail of destruction-pets and all possessions Constant lyingConstant lying


More Symptoms-Older ChildrenMore Symptoms-Older ChildrenMore Symptoms-Older ChildrenMore Symptoms-Older Children

Highly impulsiveHighly impulsive Learning disorders-my way or the highwayLearning disorders-my way or the highway No cause and effect thinkingNo cause and effect thinking Little or no conscienceLittle or no conscience Abnormal eating patternsAbnormal eating patterns Other kids avoid them (3Cs) conscience, Other kids avoid them (3Cs) conscience,

control, crueltycontrol, cruelty Speech (Interrupt, noise and control)Speech (Interrupt, noise and control)


Still More SymptomsStill More SymptomsStill More SymptomsStill More Symptoms

Inappropriately demandingInappropriately demanding Abnormal speech patternsAbnormal speech patterns Lie (False allegations, believed =power)Lie (False allegations, believed =power) Divide and conquer (Mom vs. Dad)Divide and conquer (Mom vs. Dad) Abuse their caregiversAbuse their caregivers


Techniques to Enhance Techniques to Enhance AttachmentAttachment

Techniques to Enhance Techniques to Enhance AttachmentAttachment

Holding and touchingHolding and touching Reciprocal games and activitiesReciprocal games and activities Teaching emotionsTeaching emotions Assessing/discussing attachmentAssessing/discussing attachment Looking for opportunities to nurtureLooking for opportunities to nurture Clarification of life eventsClarification of life events Promoting family identificationPromoting family identification Firm, consistent disciplineFirm, consistent discipline


Holding and TouchingHolding and TouchingHolding and TouchingHolding and Touching

As much physical contact as the child can tolerateAs much physical contact as the child can tolerate Snuggling while reading or watching TVSnuggling while reading or watching TV Parents should wear soft clothing and short sleeves Parents should wear soft clothing and short sleeves

for as much skin to skin contact as possiblefor as much skin to skin contact as possible At meals the child can sit between two nurturing At meals the child can sit between two nurturing

parentsparents


Reciprocal Games and ActivitiesReciprocal Games and ActivitiesReciprocal Games and ActivitiesReciprocal Games and Activities

Hide and seekHide and seek Feeding each otherFeeding each other Singing togetherSinging together Dancing and moving together in unisonDancing and moving together in unison Use movies and stories to describe Use movies and stories to describe

attachment, such as Dumboattachment, such as Dumbo Face paintingFace painting


Teaching EmotionsTeaching EmotionsTeaching EmotionsTeaching Emotions

Look for opportunities to comment on the Look for opportunities to comment on the child’s feelingschild’s feelings

Point out congruent facial expressionsPoint out congruent facial expressions Stand in front of a mirror and make faces Stand in front of a mirror and make faces

representing various feelingsrepresenting various feelings


Assessing/Discussing Assessing/Discussing AttachmentAttachment

Assessing/Discussing Assessing/Discussing AttachmentAttachment

Discussions about how it feels to belong or Discussions about how it feels to belong or not to belong to a familynot to belong to a family

Talk about closeness and trustingTalk about closeness and trusting When the child lies, talk about how this When the child lies, talk about how this

represents their inability to trust yourepresents their inability to trust you Represent trusting as feeling strong enough Represent trusting as feeling strong enough

to trustto trust


Looking for Opportunities to Looking for Opportunities to nurturenurture

Looking for Opportunities to Looking for Opportunities to nurturenurture

Notice times when the child is hurt or sick Notice times when the child is hurt or sick or frightened and come to their aidor frightened and come to their aid

Make a big deal out of bandaging and Make a big deal out of bandaging and kissing a skinned kneekissing a skinned knee

Rock, hold and comfortRock, hold and comfort


Clarification of Life EventsClarification of Life EventsClarification of Life EventsClarification of Life Events

Make sure the child knows about its historyMake sure the child knows about its history Help the child build a photo album about Help the child build a photo album about

their past lifetheir past life Gather and tell stories about past events in Gather and tell stories about past events in

the child’s lifethe child’s life Help put together a Life History BookHelp put together a Life History Book


Promoting Family IdentificationPromoting Family IdentificationPromoting Family IdentificationPromoting Family Identification

Develop and talk about family rituals Develop and talk about family rituals around holidays, birthdaysaround holidays, birthdays

Make family rituals out of everyday events Make family rituals out of everyday events such as bed time or mealssuch as bed time or meals


Firm, Consistent Discipline Firm, Consistent Discipline Firm, Consistent Discipline Firm, Consistent Discipline

This is one of the primary attachment techniquesThis is one of the primary attachment techniques Keep the environment as stable and organized as Keep the environment as stable and organized as

possiblepossible Do not use physical or separation or isolation types Do not use physical or separation or isolation types

of punishmentof punishment Time outs should be in a chair in the same room as Time outs should be in a chair in the same room as

the adultthe adult The “one minute scolding”The “one minute scolding”


Treatment ApproachTreatment ApproachTreatment ApproachTreatment Approach

AREAS OF AREAS OF

RE-RE-EDUCATIONEDUCATION

AD CHILD’S AD CHILD’S CURRENT CURRENT

VIEWVIEW

GOAL OF GOAL OF TREATMENTTREATMENT

Adult-child Adult-child relationshipsrelationships

Relationships are Relationships are adversarialadversarial

Will be able to form Will be able to form trusting relationships trusting relationships with adultswith adults

The acceptabilityThe acceptability

of feelings and of feelings and certain behaviorscertain behaviors

Powerless over Powerless over their feelingstheir feelings

Learn acceptable Learn acceptable ways to express ways to express feelingsfeelings



The worth of an The worth of an individualindividual

See self as See self as defective and defective and worthlessworthless

Internalize Internalize feelings of self feelings of self worthworth

Working together Working together as part of a family as part of a family or groupor group

Defiant because Defiant because they feel that if they feel that if they obey, they they obey, they have “lost.”have “lost.”

Will learn that Will learn that relationships relationships require working require working togethertogether

Ways to care for Ways to care for and about oneselfand about oneself

Focus on self as a Focus on self as a helpless victim. helpless victim. Work against selfWork against self

Learn Learn independence & independence & how provide for how provide for own needsown needs



Ways to care for Ways to care for and about othersand about others

Others are Others are competition rather competition rather then people to then people to honor & respecthonor & respect

Explore Explore relationships based relationships based on cooperation on cooperation rather then rather then competitioncompetition

Ways to have funWays to have fun Feel that fun is Feel that fun is about being about being entertained, getting entertained, getting something or something or winningwinning

Expand view of fun Expand view of fun to include art, to include art, reading & activity, reading & activity, etc.etc.


Patience Pays OffPatience Pays OffPatience Pays OffPatience Pays Off

Be prepared for the process to take longer Be prepared for the process to take longer then you thoughtthen you thought

Be prepared for setbacksBe prepared for setbacks Be prepared for the many breakthroughs Be prepared for the many breakthroughs

that will make your staff feel like it was all that will make your staff feel like it was all worth itworth it


ADD/ADHDADD/ADHD

An Overview of TypesAn Overview of Types

And TreatmentAnd Treatment


DefinitionsDefinitionsDefinitionsDefinitions

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

InattentionInattention ImpulsivityImpulsivity HyperactivityHyperactivity BoredomBoredom


More DefinitionsMore DefinitionsMore DefinitionsMore Definitions

ADD is not the result of “bad parenting” or ADD is not the result of “bad parenting” or obnoxious willful defiance on the part of obnoxious willful defiance on the part of the child.the child.

It is a medical condition caused by genetic It is a medical condition caused by genetic factors that result in neurological factors that result in neurological differences.differences.

It affects one or two areas of the brain.It affects one or two areas of the brain.


Important Characteristics Important Characteristics Important Characteristics Important Characteristics

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


Dr. Daniel Amen’s Six Dr. Daniel Amen’s Six Types Types

Dr. Daniel Amen’s Six Dr. Daniel Amen’s Six Types Types

1. Classic Type1. Classic Type 2. Inattentive ADD2. Inattentive ADD 3. Over focused or Cingulate Function 3. Over focused or Cingulate Function

ADDADD Limbic Systems Functions ADDLimbic Systems Functions ADD 5.Temporal Lobe ADD5.Temporal Lobe ADD 6. Ring of Fire Add6. Ring of Fire Add


1. Classic ADD 1. Classic ADD SymptomsSymptoms

1. Classic ADD 1. Classic ADD SymptomsSymptoms

RestlessnessRestlessness HyperactivityHyperactivity Inability to focusInability to focus Lack of planningLack of planning Excessively TalkativeExcessively Talkative


Classic ADD Treatment Classic ADD Treatment Medications Medications

Classic ADD Treatment Classic ADD Treatment Medications Medications

AntidepressantsAntidepressants TofranilTofranil EffexorEffexor StimulantsStimulants AdderallAdderall DexadrineDexadrine RitalinRitalin


2. Inattentive ADD 2. Inattentive ADD Symptoms Symptoms

2. Inattentive ADD 2. Inattentive ADD Symptoms Symptoms

Short attention span for routine matters.Short attention span for routine matters. DistractibleDistractible Poor follow-throughPoor follow-through SpaceySpacey Internally PreoccupiedInternally Preoccupied SluggishSluggish


Inattentive ADDInattentive ADD Treatment Treatment

Inattentive ADDInattentive ADD Treatment Treatment

Same as Type 1Same as Type 1


3. Over focused ADD3. Over focused ADD Symptoms Symptoms

3. Over focused ADD3. Over focused ADD Symptoms Symptoms

Difficulty shifting attentionDifficulty shifting attention Stuck on thoughtsStuck on thoughts Stuck on behaviorsStuck on behaviors Can become oppositional-wanting to Can become oppositional-wanting to

continue repetitive behavior.continue repetitive behavior. Holds grudgesHolds grudges RitualisticRitualistic May mimic OCDMay mimic OCD


Over focused ADD Over focused ADD Treatment Treatment

Over focused ADD Over focused ADD Treatment Treatment

PaxilPaxil ZoloftZoloft ProzacProzac


Limbic Systems Add Limbic Systems Add Treatment Treatment

Limbic Systems Add Limbic Systems Add Treatment Treatment

ImipramineImipramine WellbutrinWellbutrin


5. Temporal Lobe ADD5. Temporal Lobe ADD Symptoms Symptoms

5. Temporal Lobe ADD5. Temporal Lobe ADD Symptoms Symptoms

Memory ProblemsMemory Problems Spaciness/confusionSpaciness/confusion Emotional InstabilityEmotional Instability Difficulty reading social cuesDifficulty reading social cues Difficulty with use of language plus auditory Difficulty with use of language plus auditory

and visual processingand visual processing Physical symptomsPhysical symptoms Mild paranoia/anxietyMild paranoia/anxiety AggressiveAggressive


Temporal Lobe ADDTemporal Lobe ADD Treatment Treatment

Temporal Lobe ADDTemporal Lobe ADD Treatment Treatment

Usual StimulantsUsual Stimulants AnticonvulsantsAnticonvulsants DepakoteDepakote Dilantin Dilantin Must have close physical monitoringMust have close physical monitoring


6. Ring of Fire ADD6. Ring of Fire ADD Symptoms Symptoms

6. Ring of Fire ADD6. Ring of Fire ADD Symptoms Symptoms

Overly AggressiveOverly Aggressive Overly focusedOverly focused Violent behaviorViolent behavior Social problemsSocial problems Very verbalVery verbal May appear bipolarMay appear bipolar HyperactiveHyperactive

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

touch.touch.

ImpulsivityImpulsivity DistractibleDistractible Addictive and criminal Addictive and criminal

behaviorbehavior OppositionalOppositional


Ring of Fire ADD Ring of Fire ADD Treatment Treatment

Ring of Fire ADD Ring of Fire ADD Treatment Treatment

AnticonvulsantsAnticonvulsants AntipsychoticsAntipsychotics RisperdalRisperdal


Additional Helpful Additional Helpful Considerations Considerations

Additional Helpful Additional Helpful Considerations Considerations

Attention to diet Attention to diet Attention to educationAttention to education Alternative natural medicationsAlternative natural medications Summer drug holidaysSummer drug holidays


Diet/HealthDiet/HealthDiet/HealthDiet/Health

Plenty of proteinPlenty of protein Cut simple carbohydrates and caffeineCut simple carbohydrates and caffeine Plenty of exercisePlenty of exercise


Educational ChangesEducational ChangesEducational ChangesEducational Changes

Address learning disabilitiesAddress learning disabilities IEP and 504 AccommodationsIEP and 504 Accommodations

Less homeworkLess homework

More time on testsMore time on tests

Tests given verballyTests given verbally

Work closely with teachersWork closely with teachers


Medication AdjustmentsMedication AdjustmentsMedication AdjustmentsMedication Adjustments

In mild cases there is some success with In mild cases there is some success with Attend and ExtressAttend and Extress

Summer drug holidays Summer drug holidays


CounselingCounselingCounselingCounseling

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


DEPRESIONDEPRESIONDEPRESIONDEPRESION

An OverviewAn Overview

Types Types

And TreatmentAnd Treatment


CausesCausesCausesCauses

Chemical/BiologicalChemical/Biological An imbalance of serotonin and receptorsAn imbalance of serotonin and receptors GeneticGenetic Depressed parent=child is 3X the risk Depressed parent=child is 3X the risk EnvironmentalEnvironmental Traumatic eventsTraumatic events Peer or family conflictPeer or family conflict


Symptoms in ChildrenSymptoms in ChildrenSymptoms in ChildrenSymptoms in Children

IrritabilityIrritability Anxiety SymptomsAnxiety Symptoms Temper TantrumsTemper Tantrums Unexplained aches Unexplained aches

and painsand pains Difficulty thinkingDifficulty thinking Sleep ProblemsSleep Problems

Low self esteemLow self esteem Feelings of guilt and Feelings of guilt and

hopelessnesshopelessness Constant Constant

Fatigue/Lacks EnergyFatigue/Lacks Energy Hearing voicesHearing voices Feeling SuicidalFeeling Suicidal


Symptoms in AdolescenceSymptoms in AdolescenceSymptoms in AdolescenceSymptoms in Adolescence

Sleeping too muchSleeping too much Weight gain or lossWeight gain or loss Difficulty thinking and making decisionsDifficulty thinking and making decisions School failureSchool failure Feeling friendlessFeeling friendless Suicidal thoughts/AttemptsSuicidal thoughts/Attempts DelusionsDelusions


Types of DepressionTypes of DepressionTypes of DepressionTypes of Depression

EndogenousEndogenous

Internally producedInternally produced ExogenousExogenous

Externally producedExternally produced Major DepressionMajor Depression Manic Depressive DisorderManic Depressive Disorder


TreatmentTreatmentTreatmentTreatment

PsychotherapyPsychotherapy MedicationMedication MilieuMilieu Environmental ManipulationEnvironmental Manipulation


CONDUCT DISORDERSCONDUCT DISORDERSCONDUCT DISORDERSCONDUCT DISORDERS


Types Types

and and

TreatmentTreatment


DefinitionDefinitionDefinitionDefinition

Repetitive Persistent Behavior PatternRepetitive Persistent Behavior Pattern

Impairment in:Impairment in: SocialSocial AcademicAcademic Family FunctioningFamily Functioning


TypesTypesTypesTypes

Conduct DisorderConduct Disorder

Oppositional-Defiant DisorderOppositional-Defiant Disorder

With Co-morbid DisordersWith Co-morbid Disorders


Symptoms of Conduct DisorderSymptoms of Conduct DisorderSymptoms of Conduct DisorderSymptoms of Conduct Disorder

Aggressive behaviorAggressive behavior

Bullying, Intimidation, ThreatsBullying, Intimidation, Threats Non-Aggressive behaviorNon-Aggressive behavior

Deliberate destruction of propertyDeliberate destruction of property Deceitfulness or TheftDeceitfulness or Theft

Lying, conning, breaking and enteringLying, conning, breaking and entering Serious Rule ViolationsSerious Rule Violations

Run away, truancy Run away, truancy


Symptoms of Symptoms of Oppositional Defiant Disorder Oppositional Defiant Disorder

Symptoms of Symptoms of Oppositional Defiant Disorder Oppositional Defiant Disorder

Often loses temperOften loses temper Often argues with adultsOften argues with adults Defies or refuses to complyDefies or refuses to comply Deliberately annoysDeliberately annoys Blames others for mistakesBlames others for mistakes Touchy/easily annoyed by othersTouchy/easily annoyed by others Angry resentfulAngry resentful Spiteful and vindictiveSpiteful and vindictive


Treatment: Containment through Treatment: Containment through CommunicationCommunication

Planned ResponsesPlanned Responses Behavior ModificationBehavior Modification Group TherapyGroup Therapy MedicationMedication Clonidine, Risperidal,Clonidine, Risperidal, Zyprexa, seroquelZyprexa, seroquel


ManagementManagementManagementManagement

Early interventionEarly intervention Cover as much of the child’s day as possibleCover as much of the child’s day as possible Include all caregiversInclude all caregivers Consistent over time and environmentsConsistent over time and environments Long term treatmentLong term treatment Cover all aspects of the problemCover all aspects of the problem Address all co-morbidities:Address all co-morbidities: Depression, drug abuse, ADHDDepression, drug abuse, ADHD


OTHER COMMON DISORDERS OTHER COMMON DISORDERS AMONG CLIENTSAMONG CLIENTS

OTHER COMMON DISORDERS OTHER COMMON DISORDERS AMONG CLIENTSAMONG CLIENTS


PhysicalPhysical

EducationalEducational

Sever PsychiatricSever Psychiatric


Less Common DisordersLess Common DisordersLess Common DisordersLess Common Disorders

Obsessive compulsive disorder (OCD)Obsessive compulsive disorder (OCD) Tourettes SyndromeTourettes Syndrome Seizure disordersSeizure disorders Bipolar disorderBipolar disorder Learning DisabilitiesLearning Disabilities SchizophreniaSchizophrenia


Program MilieuProgram MilieuProgram MilieuProgram Milieu

Administrative & Budgetary SupportAdministrative & Budgetary Support Staff DevelopmentStaff Development Staff AttitudesStaff Attitudes Communication and CoordinationCommunication and Coordination

Documents

11/10/02Client Psych Issues--Dan Marble1 Client Psychiatric Issues for CEOs Presented by Daniel M. Marble, LCSW Social Service Consultant And The Western