The Essentials of Mental Health Care in CAN

1. The Essentials of Mental Health Care in CAN Lucy Berliner lucyb@u.washington.edu ISPCAN Honolulu September 28, 2010

2. 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

3. 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

4. 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

5. The Essentials • Identify abuse/trauma/neglect • Establish basic safety • Determine what the problem is • Engage the family and child • Systematically address current mental health problems • Child • Child-parent

6. 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

7. UCLA Reaction Index Trauma Screen

8. 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)

9. Assess to Determine Problem • Identify the target problem • Clinical interview (specific) • Standardized measures • Observation • Collateral (when indicated) • Give Feedback • To child/family • Achieve agreement

10. 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

11. 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

12. Anxiety: SCARED • Kids 7/8 + • Add up responses • Anxiety scale: Clinical = 3+ • PTS scale: Clinical = 6+

13. Depression: Moods and Feelings Q Kids 7/8+ Add up responses Clinical = 11+

14. Overall Problems: Pediatric Symptom Checklist-17 (PSC-17) Parent/caregiver report4-17 years Total Score clinical = 15+ Internalizing clinical = 5+ Attention clinical = 7+ Externalizing clinical = 7+

15. 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

16. 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

17. Stages of Change Not ready On the fence Ready (Precontemplation) (Contemplation) (Action)

18. 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

19. Reasons NOT to Change Reasons to Change Results of NOT Changing Results of Changing Decisional Balance Scale

20. 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?”

21. Addressing Identified Mental Health Problems • Strategies across all targets: • Feedback on the nature and level of the problem • Information about the condition (s) • What it is • Causes and what keeps it going • Treatment model • Managing negative emotions • Promoting accurate and helpful cognitions

22. Clinical Targets • Depression • Anxiety • Includes PTSD • Behavioral • Oppositionality • Conduct • Conflict • Attention

23. 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)

24. 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

25. Gradual Exposure: Fear Hierarchy

26. 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

27. 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

28. 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?

29. 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

30. 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

31. 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

32. 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

33. TF-CBT Manuals and Website

34. PTSD Manuals

35. Anxiety and Depression Manuals • http://www.starcenter.pitt.edu/

36. Behavior Problem Manuals

37. 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/