Kimberly McGrath, Psy.D . Jesus Perez, Psy.D . Gihan Omar, Psy.D .

1. Enhancing engagement by helping families understand the symptom profiles of their children vs. diagnostic categories Kimberly McGrath, Psy.D. Jesus Perez, Psy.D. Gihan Omar, Psy.D.

2. While mental disorders are widespread in the population, 26.2%, the main burden of illness is concentrated among a much smaller proportion (about 6 percent, or 1 in 17) who suffer from a seriously debilitating mental illness (NIH, 2008)

3. Just over 20 percent (or 1 in 5) children, either currently or at some point during their life, have had a seriously debilitating mental disorder(NIH, 2008).

4. Most Common Diagnoses Found in Children & Adolescents • Attention Deficit Hyperactivity Disorder (ADHD) • Bipolar Disorder (BD) • Post-Traumatic Stress Disorder (PTSD) • Disruptive Behavior Disorders (DBD)

5. Diagnostic Trends • Bipolar Disorder Blader J.C. (2011) Acute Inpatient Care for Psychiatric Disorders in the United States, 1996 through 2007. Arch Gen Psychiatric. Published online August 1, 2011

6. Diagnostic Trends % of Admissions Age Range

7. Diagnostic Trends % of Admissions Year

8. Co-Occurring Disorders • Bipolar disorder diagnosed 40 times more over the last decade (NIMH 2007) • Various studies demonstrate as much as 60% of children with BD are also diagnosed with ADHD (Scheffer, Kowatch, Carmody, Rush 2005; Dickenstein, Nelson, Mcclure, Grimley, Knopf, Brotman, Rich Pine, Leibbenluft 2007) • Children with Conduct Disorders often suffer from depression and various anxiety disorders as well as learning disorders and substance abuse disorders (Surgeon General’s Report 2001)

9. The Elements of Abnormality • Elements of abnormality include: • Suffering • Maladaptiveness • Deviancy • Violation of the Standards of Society • Social Discomfort • Irrationality and Unpredictability

10. Models of Classification • Three basic approaches include: • The categorical approach– a patient is healthy or disordered, but there is no overlap • The dimensional approach–the patient may fall along a range from superior functioning to absolutely impaired functioning • The prototypal approach–a conceptual entity depicts an idealized combination of characteristics, some of which the patient may not have

11. DSM Classification of Mental Disorders • Diagnostic and Statistical Manual of Mental Disorders (DSM) • Introduced in 1952 • Moving from a subjective to operational definition. • Diagnosis is based on signs and symptoms • DSM purports to be a categorical system, but it is in fact prototypal • Allen Frances, Chair of the DSM IV American Psychiatric association task force

12. Principal Function of Classification • Denomination • Qualification • Prediction

13. Irritability Difficulties sleeping Poor concentration/distractibility Impulsivity Disruptive Behavior Guess the Diagnosis?

14. DSM Fun Facts • DSM –IV has 295 separately named disorders but only 167 symptoms. • As such overlap and sharing of symptoms is common.

15. The Concept of Engagement • Engagement is defined as the “participation necessary to obtain optimal benefits from an intervention” (Prinz and Miller, 1991) • There are two components of engagement: • Behavioral component-Client attendance and performance • Attitudinal-Emotional investment and commitment

16. BARRIERS TO ENGAGEMENT • Exist at multiple levels including the child, family, agency and community Primary factors: • Personal and Social Stressors • Client attitude towards services and perceived relevance of the services (Mary McKay et. al, 2001) • “Perspective Divergence”-Clients who may have treatment expectations that differ from those of practitioners (Reis & Brown, 1999)

17. How do we increase engagement? • 1) Common sense language and constructs familiar to parents, teachers and peers. • 2) Avoid jargon that is stigmatizing or initiates a negative reaction in the client.

18. Terms easily understood by parents • Personality Traits • Self-Regulation • Capacity and Coping Skills • Self Related Concept (Muris, Mayer, Reinders; 2008)

19. Distress Structure of Psychopathology Internalizing Fear OCD Psychosis Alcohol Externalizing Drugs

20. Action Signs • Jenson, Goldman, Offord, et al (2011) study identified that few than 25% of children who had profiles predictive of an impairing psychiatric diagnosis received services in the previous 6 months. • They conclude symptom profiles might help increase public awareness of mental health problems.

21. Action Signs Continued • Extreme emotions that interfere with daily life (e.g. depression, anger). • Behaviors that put the child or others at risk of physical harm (suicidal plans, attempts, aggression) • Extreme inattention or hyperactive behavior that caused school failure or physical danger

22. Identification of Symptoms Effective Treatment Symptom Reduction

23. Implications • Client Level • Lack of client compliance or adherence to treatment • Multiple and/or Inappropriate Medications Possible Results: • Lack of symptom relief • Negative side effects • Adverse drug reactions

24. Implications • Client Level continued… • Self Fulfilling Prophecy • “There must be something wrong with me.” • “ I act this way because I’m Bipolar” • Negative Stigma • “I’m crazy” Possible Results: Client’s functioning and outlook continues to deteriorate

25. Implications • Caregivers, Providers and System Level • Repeated use of inappropriate treatment interventions that often lead to treatment failure • High Costs of the “Revolving Door” • Loss of credibility for the providers and the treatment system in general

26. For more information on references or about this presentation please email us: Gihano@citrushealth.com Kimberlym@citrushealth.com Jesusp@citrushealth.com