The Essentials of Mental Health Care in CAN

Lucy Berlinerlucyb@u.washington.edu

ISPCANHonolulu

September 28, 2010

Colleagues

• Here:– Tine Jensen, University of Oslo & Norwegian Centre for

Violence and Traumatic Stress Studies– Lutz Goldbeck, University Hospital Ulm

• Not Here:– David Kolko, University of Pittsburgh– Ben Saunders, Medical University of South Carolina– Laura Murray, Johns Hopkins University– Shannon Dorsey, University of Washington

What Do We Know

• Emotional and behavioral problems for CAN – The usual: anxiety (incl PTS), depression, behavior

problems– Effects vary – Not all children need formal therapy interventions– Some interventions (lack of ) can make children

worse• Remaining in an environment where the children are very

scared all the time• Multiple out of home placement moves

• There are effective treatments

The Special Case of Attachment Insecurity

• Insecure attachment rates are high • Insecure attachment is an adaptation, not a

pathology– Perceptions matter (e.g., labeling, reduced

expectations)• Secure attachment can be achieved– Many standard parent-child interventions

• Promote attachment security +• Reduce child behavior problems

The Essentials

1. Identify abuse/trauma/neglect 2. Establish basic safety 3. Determine what the problem is4. Engage the family and child 5. Systematically address current mental health

problems Child Child-parent

Identify Abuse/Trauma/Neglect

• Ask routinely– Child welfare, mental health, health, juvenile

justice • Why?– Children will tell– Demonstrates:• Normalization (e.g., not alone)• Validation

– Begin exposure

UCLA Reaction Index Trauma Screen

Basic Safety

• Consider psychological as well as physical • Separate when necessary (minority of cases)– Sexual assault– Serious and very serious physical abuse

• Reduce risk– Explicitly address violence (don’t avoid)– Written safety plan– Reduced force contract– Monitoring (formal and informal)

Assess to Determine Problem

Identify the target problem Clinical interview (specific) Standardized measures Observation Collateral (when indicated)

Give Feedback To child/family Achieve agreement

Approach to Clinical Interview

• Communicate interest and commitment to be helpful; be warm

• Take open-ended, inquiring, non-judgmental stance

• Elicit child and family perspective• Use prompts and then listen and encourage

elaboration • Focus more on the ***here and now***, less

on history except as critical to understanding the clinical problem(s) now

Posttraumatic Stress Disorder (PTSD):

Child PTSD Sx Scale (CPSS)

•Kids 7/8 and older

•Add up child’s responses to sx items 1-17

•Clinical score: 12+

•May use DSM IV algorithm for dx

• Impairment questions (7 at the bottom) not scored

Anxiety: SCARED

• Kids 7/8 +• Add up responses• Anxiety scale:

Clinical = 3+

• PTS scale: Clinical = 6+

Kids 7/8+Add up responsesClinical = 11+

Depression: Moods and Feelings Q

Overall Problems: Pediatric Symptom Checklist-17 (PSC-17)

Parent/caregiver report4-17 yearsTotal Score clinical = 15+Internalizing clinical = 5+Attention clinical = 7+Externalizing clinical = 7+

Engagement in Services

• Overcoming barriers– Beliefs about counseling– Prior unhelpful experiences– Problem solving concrete obstacle

• Increasing in motivation to change– Assessing stage of change– Moving towards change

Initial Encounter to Enhance Treatment Engagement

• Elicit client concerns• Communicate hope and confidence “I can help

you”• Find out about previous counseling experiences or

attitudes toward therapy and provide psychoed• Proactively addressing things that could keep

people from coming back – the concrete barriers

Stages of Change

Not ready On the fence Ready(Precontemplation) (Contemplation) (Action)

Key Strategies

• Secure agreement to discuss topic• Explore importance– Goal is to increase

• Explore confidence– Goal is to increase

• End on good terms– Summarize– Praise effort

Reasons to ChangeReasons NOT to Change

Results of NOT Changing Results of Changing

Decisional Balance Scale

Change Talk

• Always attend (pay attention and respond) to change talk

• Elicit disadvantages of status quo– Negative aspects of not changing (elicit the

specifics)– “What will happen if you don’t change?”

• Identify advantage of change– Positive aspects of change (elicit the specifics)– “What will be better if you do change?”

Addressing Identified Mental Health Problems

• Strategies across all targets:1. Feedback on the nature and level of the problem2. Information about the condition (s)• What it is• Causes and what keeps it going• Treatment model

3. Managing negative emotions4. Promoting accurate and helpful cognitions

Clinical Targets

• Depression• Anxiety– Includes PTSD

• Behavioral– Oppositionality– Conduct– Conflict– Attention

Key Ingredient: Changing Behavior

Anxiety = Exposure Child faces fears (real and imagined)

Depression = Activation Child increase activities that produce positive affect Child takes steps toward goals

Behavioral Problem = Interactional skills Parent uses positive parenting Parent and child learns social skills (communication,

problem solving)

Gradual Exposure Steps

• Explain mechanism• Imaginal and in vivo– Imaginal = imagining the feared situation– In vivo = facing cues in environment

• Make a plan• Gradual steps• Reinforce safety • Do SUDs ratings before, during and after• Never leave the session with high anxiety

Gradual Exposure: Fear Hierarchy

Behavioral Activation Steps

• Identify goals (“build the life you want”):– Have friends– Accomplish a task– Get on team

• Break steps into small pieces• Make a specific plan• Anticipate obstacles

Find a Positive Action that Lifts Mood

• Listen to music, watch a funny show or smell a flower

• Notice difference in mood• Experience control over emotions

Behavior Problems Steps

• Working with the caregiver is KEY• If you aren’t seeing the caregiver, in most

cases, you can’t treat the behavior (especially with young kids)– PCIT, Triple P, Incredible Years, Helping the

Noncompliant Child

• So…who’s buy-in do you need?

FIRST: Functional Behavior Analysis

• Define the problem behavior: What’s it look like, sound like?– Make it behavioral

• Define the positive opposite• Get the details: Frequency, Duration,

Intensity• Plan depends on the details

Key Components• Increase positive time together

– Planned child-lead, fun, parent-child interactions• Praise

– Attend to/praise positive behavior (positive opposite)• Selective attention

– Actively ignore minor irritating (attention-seeking) behavior• Giving effective instructions

– Reasonable, understandable and doable instructions• Rewards Plan

– Always start here; make them meaningful• Consequences for misbehavior

– Non-violent– Consistently and immediately applied

Maximizing Effectiveness of Mental Health Intervention

• Promote family as primary resource for child• Take a collaborative approach with families

and children that involves them in all aspects of the process

• Identify and reinforce natural supports and resources

• Make formal intervention as brief as is necessary

Summary of Essentials

• Assess problems/needs for child and family• Have some form of measurement of progress• Engage and motivate child and family• Secure agreement for treatment focus• Select treatment approach matched to

identified problem (s)• Apply interventions systematically

TF-CBT Manuals and Website

PTSD Manuals

Anxiety and Depression Manuals

• http://www.starcenter.pitt.edu/

Behavior Problem Manuals

Finding Evidence Supported Treatments on the Web• www.nctsn.org• www.cachildwelfareclearinghouse.org/• http://modelprograms.samhsa.gov/• www.cochrane.org• www.campbellcollaboration.org• www.colorado.edu/cspv/blueprints/model/overview.html• www.strengtheningfamilies.org/• www.ncptsd.va.gov/topics/treatment.html• http://ebmh.bmjjournals.com/