Client Psychiatric Issues for CEOs
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Transcript Client Psychiatric Issues for CEOs
Client Psychiatric Issues for
CEOs
Presented by
Daniel M. Marble, LCSW
Social Service Consultant
And
The Western Child Welfare Law
Center
11/10/02
Client Psych Issues--Dan Marble
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Introduction
Today you will gain a functional understanding
regarding the establishment and support of the
agency’s treatment philosophy and milieu.
Allow you to better recognize the pathology of your
client population so that you can establish better
risk management procedures.
Allow you to employ policy and budgetary
decisions which support treatment priorities.
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Overview and Objectives
Examine major pathology types.
Program Milieu
Course Objectives
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Major Pathology Types Among
Foster Children
Attachment Disorder
ADD/ADHD
Depression/loss/morning
Others
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ATTACHMENT
“The Tie that Binds”
An Overview of Attachment Disorder
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Attachment
A lasting psychological connection between
human beings.
The emotional bond that grows between
child and caretaker.
Begins in utero and develops over time.
Infants are predisposed to attach.
It exists in a continuum-no perfect
attachment or total lack of attachment.
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Attachment Disorder Causes
Abuse: physical/emotional/sexual
Neglect
Sudden separation-primary caregiver
Inadequate or changing daycare
Undiagnosed or painful illness
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Symptoms of Attachment
Disorder in Older Children
Act superficial and phony-(strangers and those they
feel they can manipulate)
Avoid eye contact unless lying or conning
Indiscriminate affection with strangers
Lack of ability to feel\empathize/care
Extreme control problems/sneaky
Leave a trail of destruction-pets and all possessions
Constant lying Client Psych Issues--Dan Marble
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More Symptoms-Older Children
Highly impulsive
Learning disorders-my way or the highway
No cause and effect thinking
Little or no conscience
Abnormal eating patterns
Other kids avoid them (3Cs) conscience,
control, cruelty
Speech (Interrupt,
noise and control)
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Still More Symptoms
Inappropriately demanding
Abnormal speech patterns
Lie (False allegations, believed =power)
Divide and conquer (Mom vs. Dad)
Abuse their caregivers
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Techniques to Enhance
Attachment
Holding and touching
Reciprocal games and activities
Teaching emotions
Assessing/discussing attachment
Looking for opportunities to nurture
Clarification of life events
Promoting family identification
discipline
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Issues--Dan Marble
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Holding and Touching
As much physical contact as the child can tolerate
Snuggling while reading or watching TV
Parents should wear soft clothing and short sleeves
for as much skin to skin contact as possible
At meals the child can sit between two nurturing
parents
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Reciprocal Games and Activities
Hide and seek
Feeding each other
Singing together
Dancing and moving together in unison
Use movies and stories to describe
attachment, such as Dumbo
Face painting
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Teaching Emotions
Look for opportunities to comment on the
child’s feelings
Point out congruent facial expressions
Stand in front of a mirror and make faces
representing various feelings
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Assessing/Discussing Attachment
Discussions about how it feels to belong or
not to belong to a family
Talk about closeness and trusting
When the child lies, talk about how this
represents their inability to trust you
Represent trusting as feeling strong enough
to trust
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Looking for Opportunities to
nurture
Notice times when the child is hurt or sick
or frightened and come to their aid
Make a big deal out of bandaging and
kissing a skinned knee
Rock, hold and comfort
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Clarification of Life Events
Make sure the child knows about its history
Help the child build a photo album about
their past life
Gather and tell stories about past events in
the child’s life
Help put together a Life History Book
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Promoting Family Identification
Develop and talk about family rituals
around holidays, birthdays
Make family rituals out of everyday events
such as bed time or meals
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Firm, Consistent Discipline
This is one of the primary attachment techniques
Keep the environment as stable and organized as
possible
Do not use physical or separation or isolation types
of punishment
Time outs should be in a chair in the same room as
the adult
The “one minute scolding”
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Treatment Approach
AREAS OF
REEDUCATION
Adult-child
relationships
AD CHILD’S
CURRENT
VIEW
GOAL OF
TREATMENT
Relationships are Will be able to form
adversarial
trusting relationships
with adults
The acceptability Powerless over
Learn acceptable
their feelings
ways to express
of feelings and
feelings
certain behaviors
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Treatment Approach
The worth of an
individual
See self as
defective and
worthless
Internalize
feelings of self
worth
Working together Defiant because
as part of a family they feel that if
or group
they obey, they
have “lost.”
Will learn that
relationships
require working
together
Ways to care for
and about oneself
Learn
independence &
how provide for
own needs
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Focus on self as a
helpless victim.
Work against self
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Treatment Approach
Ways to care for
and about others
Ways to have fun
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Others are
competition rather
then people to
honor & respect
Explore
relationships based
on cooperation
rather then
competition
Feel that fun is
Expand view of fun
about being
to include art,
entertained, getting reading & activity,
something or
etc.
winning
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Patience Pays Off
Be prepared for the process to take longer
then you thought
Be prepared for setbacks
Be prepared for the many breakthroughs
that will make your staff feel like it was all
worth it
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ADD/ADHD
An Overview of Types
And Treatment
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Definitions
Attention Deficit Hyperactivity Disorder: A
diagnostic label given children and adults
who have significant problems in four main
areas of their lives:
Inattention
Impulsivity
Hyperactivity
Boredom
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More Definitions
ADD is not the result of “bad parenting” or
obnoxious willful defiance on the part of the
child.
It is a medical condition caused by genetic
factors that result in neurological
differences.
It affects one or two areas of the brain.
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Important Characteristics
It is pervasive across all areas of life.
The problems are apparent before age 7.
Anti-social behaviors are common.
60% also have oppositional defiant disorder
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Dr. Daniel Amen’s Six
Types
1. Classic Type
2. Inattentive ADD
3. Over focused or Cingulate Function
ADD
Limbic Systems Functions ADD
5.Temporal Lobe ADD
6. Ring of Fire Add
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1. Classic ADD
Symptoms
Restlessness
Hyperactivity
Inability to focus
Lack of planning
Excessively Talkative
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Classic ADD Treatment
Medications
Antidepressants
Tofranil
Effexor
Stimulants
Adderall
Dexadrine
Ritalin
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2. Inattentive ADD
Symptoms
Short attention span for routine matters.
Distractible
Poor follow-through
Spacey
Internally Preoccupied
Sluggish
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Inattentive ADD
Treatment
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Same as Type 1
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3. Over focused ADD
Symptoms
Difficulty shifting attention
Stuck on thoughts
Stuck on behaviors
Can become oppositional-wanting to
continue repetitive behavior.
Holds grudges
Ritualistic
May mimic OCD
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Over focused ADD
Treatment
Paxil
Zoloft
Prozac
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Limbic Systems Add
Treatment
Imipramine
Wellbutrin
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5. Temporal Lobe ADD
Symptoms
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Memory Problems
Spaciness/confusion
Emotional Instability
Difficulty reading social cues
Difficulty with use of language plus auditory
and visual processing
Physical symptoms
Mild paranoia/anxiety
Aggressive
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Temporal Lobe ADD
Treatment
Usual Stimulants
Anticonvulsants
Depakote
Dilantin
Must have close physical monitoring
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6. Ring of Fire ADD
Symptoms
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Overly Aggressive
Overly focused
Violent behavior
Social problems
Very verbal
May appear bipolar
Hyperactive
Hypersensitive to:
light, sound, taste, and/or
touch.
Impulsivity
Distractible
Addictive and criminal
behavior
Oppositional
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Ring of Fire ADD
Treatment
Anticonvulsants
Antipsychotics
Risperdal
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Additional Helpful
Considerations
Attention to diet
Attention to education
Alternative natural medications
Summer drug holidays
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Diet/Health
Plenty of protein
Cut simple carbohydrates and caffeine
Plenty of exercise
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Educational Changes
Address learning disabilities
IEP and 504 Accommodations
Less homework
More time on tests
Tests given verbally
Work closely with teachers
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Medication Adjustments
In mild cases there is some success with
Attend and Extress
Summer drug holidays
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Counseling
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ADD/ADHD clients have usually gone
undiagnosed for some time. The results are
residual feelings of being dumb, bad and
rejected. They often dislike school as it
represents failure. It is improper to treat
with medication alone. Counseling is
needed to address these residual issues.
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DEPRESION
An Overview
Types
And Treatment
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Causes
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Chemical/Biological
An imbalance of serotonin and receptors
Genetic
Depressed parent=child is 3X the risk
Environmental
Traumatic events
Peer or family conflict
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Symptoms in Children
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Irritability
Anxiety Symptoms
Temper Tantrums
Unexplained aches
and pains
Difficulty thinking
Sleep Problems
Low self esteem
Feelings of guilt and
hopelessness
Constant
Fatigue/Lacks Energy
Hearing voices
Feeling Suicidal
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Symptoms in Adolescence
Sleeping too much
Weight gain or loss
Difficulty thinking and making decisions
School failure
Feeling friendless
Suicidal thoughts/Attempts
Delusions
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Types of Depression
Endogenous
Internally produced
Exogenous
Externally produced
Major Depression
Manic Depressive Disorder
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Treatment
Psychotherapy
Medication
Milieu
Environmental Manipulation
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CONDUCT DISORDERS
An Overview
Types
and
Treatment
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Definition
Repetitive Persistent Behavior Pattern
Impairment in:
Social
Academic
Family Functioning
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Types
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Conduct Disorder
Oppositional-Defiant Disorder
With Co-morbid Disorders
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Symptoms of Conduct Disorder
Aggressive behavior
Bullying, Intimidation, Threats
Non-Aggressive behavior
Deliberate destruction of property
Deceitfulness or Theft
Lying, conning, breaking and entering
Serious Rule Violations
Run away, truancy
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Symptoms of
Oppositional Defiant Disorder
Often loses temper
Often argues with adults
Defies or refuses to comply
Deliberately annoys
Blames others for mistakes
Touchy/easily annoyed by others
Angry resentful
Spiteful and vindictive
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Treatment: Containment through
Communication
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Planned Responses
Behavior Modification
Group Therapy
Medication
Clonidine, Risperidal,
Zyprexa, seroquel
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Management
Early intervention
Cover as much of the child’s day as possible
Include all caregivers
Consistent over time and environments
Long term treatment
Cover all aspects of the problem
Address all co-morbidities:
Depression, drug abuse, ADHD
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OTHER COMMON DISORDERS
AMONG CLIENTS
An Overview
Physical
Educational
Sever Psychiatric
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Less Common Disorders
Obsessive compulsive disorder (OCD)
Tourettes Syndrome
Seizure disorders
Bipolar disorder
Learning Disabilities
Schizophrenia
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Program Milieu
Administrative & Budgetary Support
Staff Development
Staff Attitudes
Communication and Coordination
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