Coping with the Crisis in Child Coping with the Crisis in Child Mental HealthMental Health

W. Douglas Tynan, Ph.D., ABPPW. Douglas Tynan, Ph.D., ABPP

DTYNAN@NEMOURS.ORGDTYNAN@NEMOURS.ORG

Nemours Health & Prevention ServicesNemours Health & Prevention Services

Newark, DENewark, DE

The Need for Mental Health The Need for Mental Health Promotion & ServicesPromotion & Services

An estimated 9 to 13% of American An estimated 9 to 13% of American children and adolescents between children and adolescents between ages 9 and 17 have serious ages 9 and 17 have serious diagnosable emotional or behavioral diagnosable emotional or behavioral health disorders (Friedman, 2002) health disorders (Friedman, 2002)

Strong need for early intervention Strong need for early intervention programs:programs:– Children who are identified as hard to Children who are identified as hard to

manage at ages 3 and 4 have a high manage at ages 3 and 4 have a high probability (50:50) of continued probability (50:50) of continued behavioral difficulties in adolescence behavioral difficulties in adolescence (Campbell & Ewing, 1990; Egeland et al., (Campbell & Ewing, 1990; Egeland et al., 1990; Fischer, Rolf, Hasazi, & 1990; Fischer, Rolf, Hasazi, & Cummings, 1984)Cummings, 1984)

– When aggressive and antisocial behavior When aggressive and antisocial behavior has persisted to age 9, further has persisted to age 9, further intervention has a poor chance of intervention has a poor chance of success (Dodge, 1993)success (Dodge, 1993)

Low Rates of Treatment Delivery• Of the young children who show early signs of challenging behavior, fewer than 10% receive services for these difficulties (Kazdin & Kendall, 1998)

• Of the children and adolescents with a diagnosable condition, less than a third actually receive any type of treatment (Leaf et al., 1996)

The 20/20 ProblemThe 20/20 Problem

Up to 20% of children have diagnosable Up to 20% of children have diagnosable problemsproblems

Only about 20% of those having a problem Only about 20% of those having a problem receive servicesreceive services

The situation has not changed in 25 years.The situation has not changed in 25 years.

There are evidence There are evidence based practices that are based practices that are

effective in changing effective in changing this developmental this developmental

trajectory…the problem trajectory…the problem is not what to do, but is not what to do, but

rests in where and how rests in where and how we can support children we can support children and help families access and help families access

servicesservices

5

Behavior Disorders of ChildhoodBehavior Disorders of Childhood

Discriminating between “difficult” children and Discriminating between “difficult” children and those with a formal diagnosis is hardthose with a formal diagnosis is hard

Behavior problems are on a continuumBehavior problems are on a continuum

There are a number of common behaviors There are a number of common behaviors across disordersacross disorders

In a number of studies, more than 50% of In a number of studies, more than 50% of children receiving special education services are children receiving special education services are identified as having a diagnosable behavioral identified as having a diagnosable behavioral disorder.disorder.

Differences Between Psychiatric Diagnosis Differences Between Psychiatric Diagnosis and Educational Classificationand Educational Classification

Some children meet criteria for a psychiatric Some children meet criteria for a psychiatric diagnosis, but do not qualify for school classificationdiagnosis, but do not qualify for school classification– Disorder is not severely impairing to school functioningDisorder is not severely impairing to school functioning

Other children do not meet criteria for a psychiatric Other children do not meet criteria for a psychiatric diagnosis, but do qualify for school classificationdiagnosis, but do qualify for school classification– Problem does not meet criteria for disorder but is impeding Problem does not meet criteria for disorder but is impeding

school progressschool progress

Can be confusing that psychiatric diagnoses and Can be confusing that psychiatric diagnoses and educational classifications under IDEA often apply educational classifications under IDEA often apply different labels to overlapping behaviorsdifferent labels to overlapping behaviors

Common Disruptive Behavior Common Disruptive Behavior Disorders of ChildhoodDisorders of Childhood

Adjustment Disorders Adjustment Disorders Attention Deficit Hyperactivity DisorderAttention Deficit Hyperactivity Disorder Oppositional Defiant DisorderOppositional Defiant Disorder Conduct DisorderConduct Disorder Bipolar DisorderBipolar Disorder

Considerable overlap between these Considerable overlap between these disorders, rarely is there a definitive disorders, rarely is there a definitive diagnosisdiagnosis

Interventions are very much the same.Interventions are very much the same.

Symptoms Common to ADHD, Symptoms Common to ADHD, ODD, and Bipolar DisorderODD, and Bipolar Disorder

ADHD - Bipolar:ADHD - Bipolar: DistractibilityDistractibility HyperactivityHyperactivity ImpulsivityImpulsivity Restlessness/ Restlessness/

FidgetinessFidgetiness Silliness, Goofiness, Silliness, Goofiness,

GiddinessGiddiness Learning DisabilitiesLearning Disabilities Poor Short-Term MemoryPoor Short-Term Memory Lack of OrganizationLack of Organization

ODD - Bipolar:ODD - Bipolar: BossinessBossiness LyingLying Oppositional behaviorOppositional behavior Deliberately annoys Deliberately annoys

peoplepeople Defies rulesDefies rules Blames other for Blames other for

mistakesmistakes

Causes of Disruptive Behavior Causes of Disruptive Behavior Problems in ChildhoodProblems in Childhood

All disorders are on a continuum ranging from normal All disorders are on a continuum ranging from normal variation in behavior to a clinically significant problemvariation in behavior to a clinically significant problem

No single causeNo single cause for any disorder for any disorder No single treatmentNo single treatment for any disorder for any disorder

Next, we will discuss variations that can lead to Next, we will discuss variations that can lead to disorderdisorder

Risk FactorsRisk Factors

Within-child factorsWithin-child factors

Family environmentFamily environment

Community influencesCommunity influences

There is never a single ‘cause’There is never a single ‘cause’

Within Child Risk FactorsWithin Child Risk Factors

temperament temperament healthhealth gendergender cognitive status, learning difficultiescognitive status, learning difficulties sociabilitysociability reaction to stressreaction to stress

TemperamentTemperament

Temperament is behavioral individuality in Temperament is behavioral individuality in infants, children and adultsinfants, children and adults

In the same way that babies are born with their In the same way that babies are born with their own combination of physical characteristics such own combination of physical characteristics such as hair and eye color, skin tone, and physique, as hair and eye color, skin tone, and physique, each one has patterns of behavior, or each one has patterns of behavior, or temperament, that are also part of their temperament, that are also part of their uniquenessuniqueness

Temperament: Short FormTemperament: Short Form

Consider the child’s behavior in these Consider the child’s behavior in these major areas:major areas:– Activity & Attention SpanActivity & Attention Span– SociabilitySociability– EmotionalityEmotionality

Family Environment Risk FactorsFamily Environment Risk Factors

StressStress Parental conflictParental conflict Parental healthParental health Unhelpful beliefs Unhelpful beliefs Emotional escalationEmotional escalation Physical escalationPhysical escalation Safety & stability of Safety & stability of

environmentenvironment Harsh parentingHarsh parenting

Unrealistic expectationsUnrealistic expectations Accidental rewardsAccidental rewards Ignoring desirable Ignoring desirable

behaviorbehavior Ineffective commandsIneffective commands Ineffective punishmentIneffective punishment Inconsistent management Inconsistent management Inappropriate models of Inappropriate models of

behaviorbehavior

Community Risk FactorsCommunity Risk Factors

NeighborhoodNeighborhood Peer groupPeer group MediaMedia SchoolSchool

Protective Family and Protective Family and Community FactorsCommunity Factors

Social support:Social support:– NeighborsNeighbors– Religious communityReligious community– SchoolSchool– Other community organizationsOther community organizations

Positive parental mental healthPositive parental mental health Safety at home, at playSafety at home, at play Stable economic resourcesStable economic resources

Effective Evidence Based ServicesEffective Evidence Based Services

Services that have some research to show Services that have some research to show that they workthat they work

Services that are implemented faithfully to Services that are implemented faithfully to the modelthe model

Outcome data are routinely collectedOutcome data are routinely collected These are rare.These are rare.

Services that are effective: Services that are effective: Evidence BasedEvidence Based

Positive Behavior Support in SchoolPositive Behavior Support in School **Child Emotion Recognition, Problem **Child Emotion Recognition, Problem

Solving and Social Skills Training**Solving and Social Skills Training** Some Medication – mostly stimulantsSome Medication – mostly stimulants Parent Management TrainingParent Management Training

– Improving parenting skillsImproving parenting skills

School PBS Services: Disruptive School PBS Services: Disruptive Behaviors in the ClassroomBehaviors in the Classroom

Assessment of behaviorAssessment of behavior– Frequency counts, comparison to peersFrequency counts, comparison to peers

Functional analysis of behaviorFunctional analysis of behavior– Antecedent, behavior, consequenceAntecedent, behavior, consequence– What is the function of the behavior?What is the function of the behavior?– Proceed cautiously if you do not knowProceed cautiously if you do not know

InterventionIntervention– Seek help if the child does not respond to intervention Seek help if the child does not respond to intervention

or if severity of problem increasesor if severity of problem increases

Interventions for Disruptive BehaviorsInterventions for Disruptive Behaviors

Attention/distractibility & starting and stopping workAttention/distractibility & starting and stopping work– Preferential seating in the front, middle of classroom Preferential seating in the front, middle of classroom – Rewards for on-task behaviorRewards for on-task behavior– Daily report cardDaily report card– Nonverbal Nonverbal – –

Organizational skillsOrganizational skills– Give clear instructions one at a timeGive clear instructions one at a time– Homework folder Homework folder – Rewards for writing down assignments, having agenda book Rewards for writing down assignments, having agenda book

signed, bringing assignments to home/schoolsigned, bringing assignments to home/school– Daily report cardDaily report card– –

Interventions for Disruptive BehaviorsInterventions for Disruptive Behaviors

OveractivityOveractivity– Preferential seating on edge of room so child can move around Preferential seating on edge of room so child can move around

without distracting otherswithout distracting others– Permission for frequent breaksPermission for frequent breaks– Rewards for staying in seatRewards for staying in seat– Daily report cardDaily report card– –

Blurting out/ butting inBlurting out/ butting in– Rewards for raising hand, waiting turnRewards for raising hand, waiting turn– Writing down instead of blurting outWriting down instead of blurting out– Daily report cardDaily report card– –

Reward SystemsReward Systems

Rewards are not bribesRewards are not bribes We reward what is difficult to do consistentlyWe reward what is difficult to do consistently Use rewards to increase rates of desired behaviorUse rewards to increase rates of desired behavior

– do not punish to increase performancedo not punish to increase performance Social rewards work bestSocial rewards work best Use your reward points or chips to buy typical reward Use your reward points or chips to buy typical reward

activitiesactivities Develop a reward menuDevelop a reward menu

– What is rewarding for this particular child?What is rewarding for this particular child? Use rewards to increase behavior, never threat of Use rewards to increase behavior, never threat of

punishmentpunishment

Daily Report CardDaily Report Card

Set up a daily index card, Set up a daily index card, 3 or 4 behaviors3 or 4 behaviors Rate the child 2 to 5 times per dayRate the child 2 to 5 times per day Use an understandable rating systemUse an understandable rating system Total points at end of the dayTotal points at end of the day Use school or home based rewardUse school or home based reward Behaviors: Completes task, plays or speaks politely Behaviors: Completes task, plays or speaks politely

with others, follows directionswith others, follows directions Rate each behavior on a 1 to 5 scale twice per dayRate each behavior on a 1 to 5 scale twice per day Send card home and have parent signSend card home and have parent sign

Emotion Recognition TrainingEmotion Recognition Training

Complements existing PBS workComplements existing PBS work Teach children to recognize, manage and Teach children to recognize, manage and

work with their own emotionswork with their own emotions Do it within the context of teaching other Do it within the context of teaching other

materials.materials.