Common Mental Health Issues for Teens in Care

1. Common Mental Health Issues for Teens in Care Jean Vanlue, MA, LPC, LMFT www.jeanvanlue.com 503-316-9130 528 Cottage St. NE, Suite 300 Salem, OR 97301

2. Agenda • The Science: Effects of Abuse and Neglect • The Heart of the Matter: Attachment • Common Mental Health Issues in Teens • Anxiety Disorders: GAD, Panic, PTSD, OCD • Mood Disorders: Depression, Bipolar • Psychosis • Self-Injury • ADHD • Autism Spectrum Disorders • Reactive Attachment Disorder • Parenting Teens • Considering Attachment Style • Promoting Mental Health • Resources

3. Who are you? • Foster Parent • Adoptive Parent • Relative Caregiver • Staff or Community Partner

4. Advisory Notice • This training is based on the policies and procedures of the Oregon Department of Human Services Child Welfare program. If you are employed by another agency, we recommend consulting with your agency for guidance.

5. A teenager often arrives at a foster placement with: • Poor boundaries • Poor relational skills • Poor impulse control • Unresolved grief • Poor need fulfillment strategies • Feelings of guilt and shame

6. Conflicting loyalties. • Post-trauma symptoms • Trust issues. • Low self esteem. • Fears about their future. • A family history of mental health issues.

7. The Effects of Abuse and Neglectwww.childwelfare.gov/pubs/issue_briefs/brain_developmentUnderstanding the Effects of Maltreatment on Brain Development • Genetics influences us to develop in certain ways. • But our experiences with life and people make a big difference in how these predispositions play out. We are formed by Heredity + Experience

8. During the first 3-4 years of life, the anatomical brain structures that govern • personality traits, • learning processes, • coping with stress • managing emotions are established, strengthened, and made permanent. If unused, these structures atrophy.

9. Long-term effects of abuse and neglect on the developing brain: • Some areas of the brain to fail to form or fail to grow properly, with long-term consequences for abilities in • Cognition (thinking) • Language • Academics

10. Effects of abuse and neglect (cont.) • Failed attachment and multiple disrupted attachments produce neurobiological changes in the brain. • Less growth in the left hemisphere (half of the brain), increasing risk for depression • Irritability in the limbic (emotional) system, setting the stage for panic disorderand PTSD

11. Effects of abuse and neglect (cont.) • Abnormalities in the limbic system and reduced growth in the hippocampus, increasing risk for dissociative disordersand memory issues • Impairment in the connection between the two brain hemispheres, linked to ADHDsymptoms

12. Emotional and Behavioral Impact of Chronic Stress or Repeated Traumas 1. Persistent Fear Response: • Changes in attention, impulse control, sleep, hyperactivity, fine motor control, anxiety and mood. • Excess cortisol production damages neurons in critical brain areas and wears out parts of the brain involved in thinking and memory. 2. Dissociation: • “Zoning out” when stressed.

13. Emotional and Behavioral Impact of Chronic Stress or Repeated Traumas 3. Hyperarousal • Chronic activation shapes how the child sees and responds to the environment. • The fear response occurs without conscious thought. • Impedes academic and social learning. 4. Disrupted Attachment Process • When a child’s brain is focused on survival, other strategies may not develop fully. • The result may be a child who has difficulty functioning when presented with a world of kindness, nurturing and stimulation.

14. Plus… • It is likely that this teenager’s brain formation was affected by prenatal substance use.

15. Abused or neglected teens may: • Be unable to control their emotions and have frequent outbursts • Be quiet and submissive • Have difficulties learning in school • Be socially or emotionally inappropriate for their age

16. Abused or neglected teens may: • Have difficulties getting along with siblings or classmates • Attempt to provoke fights or solicit sexual experiences • Be unresponsive to affection

17. Abuse, neglect and disrupted attachment typically have these effects. Which behavior do you find the most difficult to have in your home? • A. Difficulty handling stress • B. Excessive help-seeking and dependence or • C. Excessive withdrawing • D. Difficulty regulating emotions and curbing impulses

18. The Teen Brain • Does not resemble an adult brain until the early 20s. • Full growth is reached at around age 25. • The parts of the brain responsible for controlling impulses and planning ahead are among the last to mature. • Teen brains have stronger responses to emotional images and situations than do younger children or adults.

19. The Heart of the Matter:Attachment • Mammals are hard-wired to connect. We are born helpless and seeking attachment. • Emotional connection, a felt sense of closeness, is coded as a safety cue in our brains. • Isolation and emotional separation from attachment figures are danger cues. Sue Johnson

20. Safe Haven- Secure Base (Johnson) • Everyone needs a secure bond with another person. This bond offers us a safe haven to go to with a loved one where we can find comfort and support and a secure base to go out from into the world. This need is wired in. It seems to be even more primary than aggression or sex.

21. Attachment behavior is any behavior that attains or maintains closeness or communication with a person of attachment significance. • Attachment figure = Stronger wiser other. (Furrow) • Failure to gain comfort and contact from an attachment figure leads to anxiety and anger. We now call this attachment panic.

23. Attachment styles • Children develop attachment styles or patterns as a result of how they are treated by early caregivers. • During early life, the child must answer two crucial questions: • Am I worthy of love? • Are others capable of loving me? • This produces a View of Self and a View of Others • These views result in four attachment styles.

24. Bartholomew’s Model of Self and Other

25. Secure Attachment (Orlans and Levy) • Develops when caregivers are sensitive, available and reliable. • Experience teaches that the caregivers can be expected to be dependable and protective. • Teaches socialization and reciprocity, attunement. • Is important to the development of self-regulation skills

26. Insecure Attachments • When parents cannot be counted on to be responsive and meet their children’s needs, children adapt by assuming an insecure attachment style, either: • Anxious • Avoidant or Dismissive • In the dismissive style, the child has learned to de-activate attachment behavior- to turn away as if they did not need anyone. Orlans and Levy

27. Disorganized Attachment (Orlans & Levy) • When caregivers sometimes meet the child’s needs and are sometimes unavailable, the child never knows what to expect. • Attachment behavior is over-activated. They work hard to get caregiver attention, but then pull away. • Mixed signals • “I need you but I can’t trust you.”

28. Core Beliefs Secure Attachment: • Self: “I am good, wanted, worthwhile, competent and lovable.” • Caregivers: “They are appropriately responsive to my needs, sensitive, dependable, caring, trustworthy.” • Life: “My world feels safe; life is worth living.”

29. Core Beliefs Insecure Attachment: • Self: “I am bad, unwanted, worthless, helpless and unlovable.” • Caregivers: “They are unresponsive to my needs, insensitive, hurtful and untrustworthy.” • Life: “My world feels unsafe; life is painful and burdensome.”

30. Poorly Connected Families (Furrow) • Adolescents can feel like they don’t count or matter. • Parents often feel they have little influence. • Too much independence and too little connection. • Lack of communication • Lack of control

31. Teens Need “Felt Security” (Furrow) • Felt security can occur when parents are responsive and sensitive. • Significant others in one’s life can provide corrective emotional experiences- changing the view of self and others. • Your relationship with your foster child is the pathway to change and healing.

32. Relationships are Reciprocal • The parent influences the child, the child influences the parent • In a family context, parents’ own attachment histories and insecurities are activated. • It is difficult to tolerate feeling unloved, inadequate, unworthy or have a sense of failing, therefore... • We react, become self-conscious, try to protect ourselves.

33. Mental Health Disorders • Many teens have symptoms at various times. To be clinically significant, the symptoms must • Represent a significant departure from what is expected developmentally or behaviorally • Meet diagnostic criteria • There is symptom overlap between diagnoses. • Significantly impact functioning in at least one area of life • Endure over a specified time

34. Anxiety Disorders Around 8% of teens have an anxiety disorder. Generalized Anxiety Disorder (GAD) Social anxiety disorder Panic disorder OCDTrichotillomaniaPSTD S e p a r a t i o n A n x i e t y D i s o r d e r Phobias

35. Generalized Anxiety Disorder (GAD) • Excessive worry that persists over time and is out-of-proportion. • The person finds it difficult to control or lessen the worry. • The worry may result in headaches, stomachaches, muscle tension, fatigue, being on edge, irritability, difficulty concentrating, sleep disturbances. • The worry affects the person’s ability to function at school, at home or socially.

36. Panic: Intense anxiety, fear or worry that peaks within 10 minutes and includes four or more of: • Rapid, pounding or irregular heartbeat • Sweating • Trembling or shaking • Feeling short of breath • Feeling of choking • Chest pain • Nausea or abdominal distress • Dizzy, unsteady, lightheaded • Fear of losing control or going crazy • Fear of dying • Numbness or tingling • Chills or hot flushes • Feelings of unreality or detachment from self

37. Panic Disorders… Need treatment or the person may advance to agoraphobia: anxiety about being in places or situations from which escape might be difficult or embarrassing or in which help may not be available in the event of a panic attack.

38. Post Traumatic Stress Disorder- PTSD • The person experienced exposure to a traumatic event (actual or threatened death or serious injury, or a threat to the physical integrity of self or others • The person’s response involved intense fear, helplessness or horror.

39. PTSD cont. • The traumatic event is persistently re-experienced in at least one way (recurring intrusive thoughts, dreams, sense of re-living it, reminders causing psychological and/or physical distress. • Things associated with the trauma are avoided in at least three ways and there is numbing of general emotional responsiveness • At least two symptoms of arousal: sleep, anger, difficulty concentrating, hypervigilance, exaggerated startle response

40. Obsessive Compulsive Disorder • OCD is seen in about 1 in 200 adolescents. • Obsessions are recurring, persistent unwanted thoughts, impulses or images • Compulsions are repetitive behaviors or rituals or mental acts performed in response to an obsession or rigid rules • In OCD, the o’s and c’s cause s e significant anxiety or distress, or they interfere with normal routines, school functioning or relationships.

41. About 11% of adolescents have a depressive disorder by age 18. • About 1 in 5 people will experience depression during their lifetime. Depression

42. Major Depression • More than just the ‘blues.’ • Beyond a normal grief reaction. • A cluster of both physical and emotional/mood symptoms. (There is also a chronic mild form called dysthymia.)

43. Symptoms of depression include persistent: • sad or irritable mood • decreased interest in fun • increasing social withdrawal • difficulty concentrating or making decisions • hopelessness • feeling guilty and worthless

44. Depression,cont. • fatigue, low energy • vague, unfounded physical complaints • changes in sleep (too much or too little) • changes in appetite • dark thoughts, self-destructive

45. What you can do at home: Be alert and listen to your “gut” as to whether this is serious. Find uninterrupted time to encourage the youth to talk while youlisten. Build their self-image.

46. Take the youth’s thoughts and moods seriously. If you have a concern, ask straight out if they are, or have been, thinking of harming themselves.

47. Bipolar Mood Disorders • Used to be known as manic- depressive illness. • Characterized by unusual shifts in mood and energy that are much more powerful than the normal ups and downs every teen experiences: • Some times that are very “up” and more active than usual: mania • Some times that are very sad and “down” and much less active than usual: depression. • Not due to hormones.

48. A Person Experiencing Mania May: • Feel very happy or act silly, giddy in a way that’s unusual • Have a very short temper, rude, hostile • Talk really fast about a lot of different things • Be very hard to interrupt or quiet • Be distractible and find it difficult to focus • Sleep less but not be tired

49. Mania, cont. • Be very excitable • Have inflated self-esteem and grandiosity, falsely claim to have extra skills and abilities • Show disdain for other’s skills and abilities in comparison to their own • Have racing thoughts, over-full mind • Talk and think about sex more often • Do risky things

50. Schizophrenia As with all mental illnesses, schizophrenia is a cluster of symptoms and is a departure from normal. The onset of the illness can be very insidious.