Clients ’ Children: How Can We Support Them? Clinical Considerations

1. Clients’ Children: How Can We Support Them?Clinical Considerations Presenter: Arthur Krzyzanowski, Psy.D. Children’s Research Triangle akrzyzanowski@cr-triangle.org

2. Risk Factors for Children of Substance Abusing Women • Prenatal Alcohol and/or Drug Exposure • Inadequate Prenatal Care • Genetic Predisposition to: - Substance abuse - Mood Disorders - More severe mental illness • Environmental Stress (ex: poverty, crime) • Greater risk for neglect and sexual, physical and psychological harm

3. Prenatal Substance Exposure According to a recent study:* • 40,000 children/year are diagnosed with FAS • Still, 95% of children with FAS go undiagnosed NOTE: A negative toxicology screening at birth does not mean there was no prenatal alcohol/drug exposure. * Lupton, C., Burd, L., & Harwood, R. (2004). Cost of Fetal Alcohol Spectrum Disorders. American Journal of Medical Genetics, 127C (1), 42-50.

4. Diagnostic Considerations • Attention Deficit/Hyperactivity Disorder • Mood Disorders • Behavior Disorders • Post Traumatic Stress Disorder • Anxiety Disorders • Attachment Disorders • Language Based Disorders • Learning Disabilities • Pervasive Developmental Disorders

5. Diagnostic Considerations • Attention Deficit/Hyperactivity Disorder (Cluster 1) • Mood Disorders (Cluster 2) • Behavior Disorders (Cluster 3) • Post Traumatic Stress Disorder (Clusters 4 & 5) • Anxiety Disorders (Cluster 7) • Attachment Disorders (Cluster 8) • Language Based Disorders (Cluster 8) • Learning Disabilities (Cluster 8) • Pervasive Developmental Disorders (Cluster 8)

6. Co-morbidity/Dual Diagnoses Often there is significant overlap between clusters, with the manifest symptoms often secondary to some other underlying concern. • DX: Conduct Disorder ► Learning Disability • DX: ADHD ► Sensory Integration Disorder • DX: ODD ► Executive dysfunction • DX: Intermittent Explosive Disorder ► PTSD • DX: Substance Abuse ► Any of the above

7. Treating the Whole Child The emergence of behavioral, emotional, physical and/or social problems in the children we serve is over-determined! The child’s development and functioning are influenced by risk factors stemming from: • The Child • The Parent/Family System • Society/Environment

8. Child Risk Factors • Exposure to Toxins In Utero • Inadequate Prenatal Care • Pre-maturity • Birth Anomalies/Defects • Chronic or Serious Illness • Temperament • Mental Retardation/Low Cognitive Abilities • Childhood Trauma • Insecure Attachments • Anti-Social Peer Group

9. Parental Risk Factors • Active Substance Abuse • Maltreatment and Trauma • Parent’s Own History of Loss and Trauma • Insecure Attachment • Single Parenthood (With Lack of Support) • Harsh, Inconsistent or Inadequate Parenting • Family Disorganization • Social Isolation

10. Parent Risk Factors (Cont.) • High Parental Conflict • Domestic Violence • Separation/Divorce • Parental Psychopathology • Illness • Death of Family Member • Foster Care Placement

11. Poverty Lack of Access to Medical Care/Social Services Parental Unemployment Homelessness Inadequate Childcare Exposure to racism Poor Schools Frequent Residence Change Environmental Toxins Dangerous Neighborhood Community Violence Social/Environmental Risk Factors

12. Child Protective Factors • Good Health • Personality Factors • Above Average Intelligence • History of Adequate Development • Hobbies/Interests • Good Peer Relationships

13. Parental/Family Protective Factors • Secure Attachments • Parents Supportive of Child • Household Structure, Monitoring, Rules • Support/Involvement of Extended Family • Stable Parental Relationship • Parents Model Competence/Coping Skills • Family Expectations of Pro-social Behavior • High Parental Education Level

14. Social/Environmental Protective Factors • Middle Class or Above SES • Access to Health Care/Social Services • Consistent Parental Employment • Adequate Housing • Family Religious Participation • Good Schools • Supportive Adults Outside of Family

15. Identifying Needs and Accessing Appropriate Services • Appropriate Interventions start with accurate and comprehensive assessments • Medical and Psychological Assessment • Academic Achievement • Occupational Therapy • Physical Therapy • Developmental Therapy (Ages 0-3) • Speech/Language Therapy

16. Supporting the Children Trans-Disciplinary Approach • A child’s problems are over-determined, so their treatment needs to be multi-faceted, with risk factors from several directions simultaneously. • Providers work collaboratively, each bringing their expertise to bear in addressing the child’s needs • Contrasting the traditional medical model with its reliance on hierarchy (M.D., Ph.D., MSW, OT/PT…) • No one provider has all the answers. We each hold a piece of the puzzle.

17. Possible Treatment Providers • Addiction Counselor(s) • Court System • Occupational Therapist • Pediatrician • Physical Therapist • Psychiatrist(s)/Neurologist(s) • Psychologist(s)/Neuropsychologist(s) • Social Worker(s) • Speech/Language Therapist • Teachers/Educational Specialists

18. Intervention Strategies “An ounce of prevention is worth a pound of cure.” • Parent’s Recovery (Pregnancy & Post-partum) • Parent Education, Training and Support • Prenatal and Perinatal Care • Early Intervention Services for the infant

19. Maximizing the Impact of Interventions Intervention strategies that: • address multiple risk factors rather than focusing on only one factor; • Provide the child and family support in a variety of settings; • Work with the family and child over time (2-5 years); and • Are initiated as early as possible in the infant’s life have the greatest potential for positively affecting the outcome of an at-risk child’s development.

20. O-3/Early Intervention Services • Medical • Developmental Therapy • Occupational Therapy • Physical Therapy • Speech/Language Therapy • Social/Emotional Development

21. Sensory Integration (SI) Disorder • Deficits in processing and modulating incoming sensory information • FAS/FASD students are more or less sensitive to stimuli • Lower threshold = Easily overwhelmed • Higher threshold = Under-responsive • Treated through Occupational Therapy with a SI focus • Classroom accommodations available to facilitate attention and on task behavior within the classroom

22. Impact of Sensory Processing Problems • May result in considerable agitation and discomfort (both physical & emotional) • May increase distractibility and irritability • Disruptions often lead to impairments in social, emotional and cognitive functioning

23. Treatment Techniques Picking the right therapy for my child: • Attachment Therapies - Theraplay® - Dyadic Developmental Psychotherapy • Experiential Therapies • Family/Parent-Child Therapy • Behavior Modification Therapy • Parent Psycho-education

24. Playful, joyful, empathic, attuned responsiveness Creation of a more positive relationship between children & their parents is possible! Roots of development of self esteem lie in the early years, thus returning to the derailed developmental stage is essential Basic Assumptions of Theraplay®www.theraplay.org

25. Treatment is directive and client-centered Parent is present during sessions Playful interactions focused on positive affective experiences Nonverbal as well as verbal communication Exploration of shame with empathy Co-regulation of affect Therapist and parent maintain attitude: PACE (Playful, Accepting, Curious, Empathic) Dyadic Developmental PsychotherapyDaniel A. Hughes PhD www.danielahughes@homestead.com

26. Experiential Therapies • Self-regulation – Combining Sensory Integration into Psychotherapy www.alertprogram.com • Narrative therapy – Creating a coherent autobiographical narrative for the child www.familyattachment.com

27. Parent Psycho-education • Effects of mother’s substance abuse (prenatal and post-partum) on their child’s development • Age-Appropriate developmental expectations • Parenting skills for the behavioral and/or emotional disturbed child • Advocating for services from the larger community

29. Behavioral Consultation • Identify the problem behaviors • Frequency • Duration • Latency • Intensity • Context (Precipitating & Sustaining factors) • Identify the student’s strengths

30. Behavioral Consultation (Cont.) • Concretely define targeted behavior(s) to be eliminated • Identify substitute behavior or required level of performance • Always state behavioral goals in the positive (“Johnny will do…”) rather than the negative (“Johnny will not…”). Be explicit with the student as to the behavior expected.

31. Behavioral Consultation (Cont.) • Develop Preventative and ReactiveStrategies to deal with the behavior(s) • Develop a means of assessing behavior change • Assessing consultant effectiveness

32. School-Based Assessments • Parent meeting with teachers, administration and associated services • Multi-disciplinary team meetings; IFSP and IEP Development and Reviews • Academic Assessment • Psychological Assessment (including IQ) • Speech/Language Therapy • Occupational Therapy • Physical Therapy • Social Work

33. A Parable about Problem-Solving A person standing near a river hears a call for help and sees someone drowning. He jumps in and pulls the struggling swimmer out of the water and resuscitates him. As he finishes resuscitating the first swimmer, a second cries out. Again, he enters the water and with great effort hauls the second drowning person ashore. A third person calls out for help and he jumps to the rescue and nearly drowns in the effort, but manages to pull the third person out of the river. An admiring crowd has gathered when a fourth person calls for help and our hero walks away. “Where are you going? What about this person who is drowning?” He turns and says, “I’m tired of rescuing people from the river. I’m going upstream to find out who’s pushing them in!” Quoted from McGourty & Chasnoff (2003). Power Beyond Measure. Chicago, IL: NTI Publishing.