Coping with the Crisis in Child Mental Health W. Douglas Tynan, Ph.D., ABPP Nemours Health & Prevention Services Newark, DE

The Need for Mental Health Promotion & Services An estimated 9 to 13% of American children and adolescents between ages 9 and 17 have serious diagnosable emotional or behavioral health disorders (Friedman, 2002) An estimated 9 to 13% of American children and adolescents between ages 9 and 17 have serious diagnosable emotional or behavioral health disorders (Friedman, 2002) Strong need for early intervention programs: Strong need for early intervention programs: –Children who are identified as hard to manage at ages 3 and 4 have a high probability (50:50) of continued behavioral difficulties in adolescence (Campbell & Ewing, 1990; Egeland et al., 1990; Fischer, Rolf, Hasazi, & Cummings, 1984) –When aggressive and antisocial behavior has persisted to age 9, further intervention has a poor chance of 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 Problem Up to 20% of children have diagnosable problems Only about 20% of those having a problem receive services The situation has not changed in 25 years.

There are evidence based practices that are effective in changing this developmental trajectory…the problem is not what to do, but rests in where and how we can support children and help families access services 5

Behavior Disorders of Childhood Discriminating between “difficult” children and those with a formal diagnosis is hard Discriminating between “difficult” children and those with a formal diagnosis is hard Behavior problems are on a continuum Behavior problems are on a continuum There are a number of common behaviors across disorders There are a number of common behaviors across disorders In a number of studies, more than 50% of children receiving special education services are identified as having a diagnosable behavioral disorder. In a number of studies, more than 50% of children receiving special education services are identified as having a diagnosable behavioral disorder.

Differences Between Psychiatric Diagnosis and Educational Classification Some children meet criteria for a psychiatric diagnosis, but do not qualify for school classification Some children meet criteria for a psychiatric diagnosis, but do not qualify for school classification –Disorder is not severely impairing to school functioning Other children do not meet criteria for a psychiatric diagnosis, but do qualify for school classification Other children do not meet criteria for a psychiatric diagnosis, but do qualify for school classification –Problem does not meet criteria for disorder but is impeding school progress Can be confusing that psychiatric diagnoses and educational classifications under IDEA often apply different labels to overlapping behaviors Can be confusing that psychiatric diagnoses and educational classifications under IDEA often apply different labels to overlapping behaviors

Common Disruptive Behavior Disorders of Childhood Adjustment Disorders Adjustment Disorders Attention Deficit Hyperactivity Disorder Attention Deficit Hyperactivity Disorder Oppositional Defiant Disorder Oppositional Defiant Disorder Conduct Disorder Conduct Disorder Bipolar Disorder Bipolar Disorder Considerable overlap between these disorders, rarely is there a definitive diagnosis Considerable overlap between these disorders, rarely is there a definitive diagnosis Interventions are very much the same. Interventions are very much the same.

Symptoms Common to ADHD, ODD, and Bipolar Disorder ADHD - Bipolar:  Distractibility  Hyperactivity  Impulsivity  Restlessness/ Fidgetiness  Silliness, Goofiness, Giddiness  Learning Disabilities  Poor Short-Term Memory  Lack of Organization ODD - Bipolar:  Bossiness  Lying  Oppositional behavior  Deliberately annoys people  Defies rules  Blames other for mistakes

Causes of Disruptive Behavior Problems in Childhood All disorders are on a continuum ranging from normal variation in behavior to a clinically significant problem All disorders are on a continuum ranging from normal variation in behavior to a clinically significant problem No single cause for any disorder No single cause for any disorder No single treatment for any disorder No single treatment for any disorder Next, we will discuss variations that can lead to disorder Next, we will discuss variations that can lead to disorder

Risk Factors Within-child factors Within-child factors Family environment Family environment Community influences Community influences There is never a single ‘cause’ There is never a single ‘cause’

Within Child Risk Factors temperament temperament health health gender gender cognitive status, learning difficulties cognitive status, learning difficulties sociability sociability reaction to stress reaction to stress

Temperament Temperament is behavioral individuality in infants, children and adults Temperament is behavioral individuality in infants, children and adults In the same way that babies are born with their own combination of physical characteristics such as hair and eye color, skin tone, and physique, each one has patterns of behavior, or temperament, that are also part of their uniqueness In the same way that babies are born with their own combination of physical characteristics such as hair and eye color, skin tone, and physique, each one has patterns of behavior, or temperament, that are also part of their uniqueness

Temperament: Short Form Consider the child’s behavior in these major areas: Consider the child’s behavior in these major areas: –Activity & Attention Span –Sociability –Emotionality

Family Environment Risk Factors Stress Stress Parental conflict Parental conflict Parental health Parental health Unhelpful beliefs Unhelpful beliefs Emotional escalation Emotional escalation Physical escalation Physical escalation Safety & stability of environment Safety & stability of environment Harsh parenting Harsh parenting Unrealistic expectations Unrealistic expectations Accidental rewards Accidental rewards Ignoring desirable behavior Ignoring desirable behavior Ineffective commands Ineffective commands Ineffective punishment Ineffective punishment Inconsistent management Inconsistent management Inappropriate models of behavior Inappropriate models of behavior

Community Risk Factors Neighborhood Neighborhood Peer group Peer group Media Media School School

Protective Family and Community Factors Social support: Social support: –Neighbors –Religious community –School –Other community organizations Positive parental mental health Positive parental mental health Safety at home, at play Safety at home, at play Stable economic resources Stable economic resources

Effective Evidence Based Services Services that have some research to show that they work Services that have some research to show that they work Services that are implemented faithfully to the model Services that are implemented faithfully to the model Outcome data are routinely collected Outcome data are routinely collected These are rare. These are rare.

Services that are effective: Evidence Based Positive Behavior Support in School Positive Behavior Support in School **Child Emotion Recognition, Problem Solving and Social Skills Training** **Child Emotion Recognition, Problem Solving and Social Skills Training** Some Medication – mostly stimulants Some Medication – mostly stimulants Parent Management Training Parent Management Training –Improving parenting skills

School PBS Services: Disruptive Behaviors in the Classroom Assessment of behavior Assessment of behavior –Frequency counts, comparison to peers Functional analysis of behavior Functional analysis of behavior –Antecedent, behavior, consequence –What is the function of the behavior? –Proceed cautiously if you do not know Intervention Intervention –Seek help if the child does not respond to intervention or if severity of problem increases

Interventions for Disruptive Behaviors Attention/distractibility & starting and stopping work Attention/distractibility & starting and stopping work –Preferential seating in the front, middle of classroom –Rewards for on-task behavior –Daily report card –Nonverbal – – Organizational skills Organizational skills –Give clear instructions one at a time –Homework folder –Rewards for writing down assignments, having agenda book signed, bringing assignments to home/school –Daily report card – –

Interventions for Disruptive Behaviors Overactivity Overactivity –Preferential seating on edge of room so child can move around without distracting others –Permission for frequent breaks –Rewards for staying in seat –Daily report card – – Blurting out/ butting in Blurting out/ butting in –Rewards for raising hand, waiting turn –Writing down instead of blurting out –Daily report card – –

Reward Systems Rewards are not bribes Rewards are not bribes We reward what is difficult to do consistently We reward what is difficult to do consistently Use rewards to increase rates of desired behavior Use rewards to increase rates of desired behavior –do not punish to increase performance Social rewards work best Social rewards work best Use your reward points or chips to buy typical reward activities Use your reward points or chips to buy typical reward activities Develop a reward menu Develop a reward menu –What is rewarding for this particular child? Use rewards to increase behavior, never threat of punishment Use rewards to increase behavior, never threat of punishment

Daily Report Card Set up a daily index card, Set up a daily index card, 3 or 4 behaviors 3 or 4 behaviors Rate the child 2 to 5 times per day Rate the child 2 to 5 times per day Use an understandable rating system Use an understandable rating system Total points at end of the day Total points at end of the day Use school or home based reward Use school or home based reward Behaviors: Completes task, plays or speaks politely with others, follows directions Behaviors: Completes task, plays or speaks politely with others, follows directions Rate each behavior on a 1 to 5 scale twice per day Rate each behavior on a 1 to 5 scale twice per day Send card home and have parent sign Send card home and have parent sign

Emotion Recognition Training Complements existing PBS work Complements existing PBS work Teach children to recognize, manage and work with their own emotions Teach children to recognize, manage and work with their own emotions Do it within the context of teaching other materials. Do it within the context of teaching other materials.