Download Impact of Parental Mental Illness on Children

Basic Core
Participant Manual
Mental Health
Version 3.0
Developed by the Southwest Institute for Family and Child Advocacy
Developed by the Southwest Institute for Family & Child Advocacy at NMSU
In collaboration with CYFD Protective Services
Acknowledgments
Many individuals have contributed their expertise, vision, creative abilities, and support to the
development of the revised CORE curriculum. All contributors have enriched the curriculum.
We thank the following people for their assistance in identifying curriculum content and
methodologies:
CORE Revision Committee:
Andrea Poole, CYFD, Training Bureau Chief
Camille Hancock, CYFD Protective Custody
Don Stage CYFD Protective Custody
Denise Montoya CYFD Protective Custody
Monica Montoya, NMSU
Traci Tippett, NMSU
Shelly Bucher, NMSU
Delphine Trujillo, CYFD Protective Custody
Brenda Manus CYFD Protective Custody
Deb Gray CYFD Attorney
Nora Buchanan, CYFD
Pam Brown, CYFD Professional Development Bureau
Lynette Carlson, CYFD
Grace Nailor CYFD Protective Custody
Kerri Pattison CYFD Protective Custody
Vince Beatty CYFD Professional Development Bureau
Elizabeth Alarid CYFD Professional Development Bureau
Linda McNall, CYFD
Jared Rounsville CYFD Protective Custody
Ed Schissel, CYFD Attorney
Mary Garrison, Facilitator and Curriculum Development
Peter Dahlin, Curriculum Development
Traci Tippett, Curriculum Development
Charmaine Britton, Curriculum Development
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Central Themes in the CORE Curriculum
The CORE curriculum has been developed as a comprehensive pre-service curriculum for child
welfare worker. This curriculum provides opportunities for participants to assess their knowledge,
strengths and resources and apply knowledge and critical thinking skills to real case scenarios.
The participant exercises are designed to be relevant and applicable to child welfare workers, new to
the field, and to those persons coming to child welfare from other professions.
This curriculum underscores the importance of different adult learning styles and provides information
in a number of ways to help trainees integrate the information they are learning. The CORE
curriculum, which includes participant activities is designed to integrate the knowledge and
experiences of the participants and encourages them to share that knowledge and those experiences
with others during the course of the training.
The following themes are recognized as central concepts and are present in each module:

Cultural Issues

Fairness, Equity, and Bias

Engagement

Documentation

CFSR Outcomes

Stress Management

Evidenced Based Practice

Collaboration
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This course includes material adapted from the following sources:
Butler Institute for Families at the
University of Denver
California Social Work Education Center at the
University of California at Berkeley
Institute for Human Services at the
North American Resource Center for Child Welfare
Columbus, OH
Family and Child Welfare Training and Research Project
School of Social Work
New Mexico State University
Pennsylvania Child Welfare
Training Program at the
University of Pittsburgh
State of New Mexico Children, Youth & Families Department
Professional Development Bureau
State of Texas Department of Family and Protective Services
Professional Development Division
Tennessee Center for Child Welfare at
Middle Tennessee State University
Peter Dahlin
Dahlin and Associates
Mary Garrison, Consultant
Garrision and Associates
Traci Tippett
New Mexico State University
Nora Gerber, Consultant
Rose Marie Wentz, Consultant
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Learning Objectives
As a result of this training, participants will:
1) Identify signs, symptoms, and treatment options including medications
associated with common mental illnesses such as:
a. Mood Disorders
b. Behavior Disorders
c. Anxiety Disorders
d. Psychotic Disorders
e. Personality Disorders.
2) Describe the relationship between mental illness and neglect and abuse, and
the prevalence of mental illness among caregivers of children in the child
welfare system.
3) Identify common dynamics of families with a member who is mentally ill and
its impact on meeting the basic needs of a family and on safety, and risk.
4) Recognize the need for safety and risk assessments and planning with a
family with mental illness as an issue identifying red flag issues as related to
mental illness.
5) Explore the relationship between the culture and mental illness distinguishing
between cultural practices and symptoms or signs of mental illness.
6) Recognize the safety issues for children and workers in working with volatile
situations such as mental illness.
7) Identify and plan strategies for dealing effectively with personal and systemic
biases around cases involving mental illness.
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8) Identify the minimum standard of care when dealing with clients and
caregivers who are mentally ill.
9) Incorporate practice of documentation using FACTS including:
a. Medical icon
b. TCM
c. Treatment Planning
10) Appreciate the role of the case worker as advocate for the mentally ill client or
caregiver.
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CFSR Outcomes
1.Well Being Outcome 1: Item 17: Needs/services of child, parents, and foster parents
2.Well Being Outcome3: Item23: Mental Health
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Agenda
 Introduction
 Facts and Stats
 Labeling and Stigma
 Culture & Mental Health
 Definitions
 Strength Based Perspective: Understanding Mental Health from a Lifespan
Perspective
 Overview of Common Diagnoses and Implications for Child Welfare
Anxiety Disorders
Mood Disorders
Psychosis
Personality Disorders
Case Planning implications for each of the above
 FACTS Applications
 Evaluation
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National Alliance on Mental Illness
Facts and Stats
 23% percent of American adults (ages 18 and older) suffer from a
diagnosable mental disorder in a given year, but only half report impairment
of their daily functioning due to the mental disorder.
 Six percent of adults have addictive disorders alone, and three percent
have both mental and addictive disorders.
 An estimated 1 in 4 adults in this country have a diagnosable mental
disorder in a given year.
 5-7 percent have a serious mental illness, such as schizophrenia major
depression or bipolar disorder.
 Adults with serious mental illness die 25 years younger than other
Americans.
 Mental disorders are the leading cause of disability in the US for ages 1544.
 Four of the ten leading causes of disability in the United States and other
developed countries are mental disorders, which include major depression,
bipolar disorder, schizophrenia, and obsessive-compulsive disorder.
 Less than one-third of adults with a diagnosable mental disorder, and an
even smaller proportion of children, receive any mental health services in a
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given year.7 Racial and ethnic minorities have even less access to mental
health services and often receive a poorer quality of care.
 People with mental illness report a delay of nearly a decade from the onset
of symptoms until the first contact with the treatment system, and that delay
increases the likelihood of disability and negative social outcomes.
 In 2003, the California Mental Health Planning Council estimated that
approximately 300,000 adults with serious mental illnesses did not have
access to needed services.
 One in 20 persons with a severe mental illness is homeless.
 Approximately one-third of the estimated homeless people in the US have
a severe mental illness.
 Only 5-7% of homeless persons with a mental illness need to be
institutionalized; most can live in the community with appropriate,
supportive housing.
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Labeling and Stigmas*
Throughout history, misperception, misunderstanding, and confusion about
mental illness, and why people behave and act differently has lead to
discrimination, oppression, and abuse. This has seriously affected those
suffering with mental illness and has also impeded their access to resources
(such as employment, housing, and health care) and opportunities to fully
participate in society. Consider how the mentally ill were talked about in your
childhood. Consider the comments you hear from neighbors and friends who are
not in the field of social services (and maybe some who are) that are based on
biased views and ignorance about mental illness.
Dispelling the myths about mental illness continues to be a challenge. While
some progress has been made in the general public’s understanding of mental
illness (i.e. anxiety, depression, bipolar, psychosis), misperceptions continue. In
a survey taken by researchers in 1996, the stigma of mental illness, especially
related to the general public’s fear of violence and the misperception of people
with psychosis as being “very violent” continues to fuel negative beliefs. Further
it appears that these misperceptions are growing as more than twice as many
people associate psychosis with violent behavior than those surveyed in the
1950’s. Further when there is a publicized act of violence by someone who is
psychotic, there are increases in stigma for all. However, violence is not the only
common misperception about people who suffer from a mental illness.
Many times parents who have a mental illness are assumed to be less capable of
protecting and providing adequate care for their children. While this can
sometimes be an issue, it should not be assumed that a parent with a mental
illness is incapable of acting in a safe and protective manner on behalf of their
children. Additionally, families are sometimes guilty of biased thinking about
loved ones who have a mental illness. Families may infantilize the loved one and
enable dependence rather than independence. This enabling can prevent a
person with a mental illness from accessing needed treatment and resources and
works to inhibit progress.
Some people who suffer from mental illness will tell you that the stigma that their
condition carries in the US culture is far worse than the symptoms of their
disorder. Stigma, as a form of oppression, leads to further isolation, depreciation
of self-esteem and self-worth, increased shame and hopelessness, and mistrust
of others. The stigma of mental illness greatly impacts those who are suffering
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from diagnosable mental disorders in seeking help. It is estimated that 2/3 of
people who have diagnosable mental disorders do not seek treatment. This
number is even higher for people-of-color.
Now link this to the problem of disproportionality. Consider how a mentally ill
parent, who is a person of color, might experience stigma and bias. Consider
how this fear might keep them from accessing treatment. Consider how this lack
of treatment can be perceived by the child welfare system. Consider how the
stigma and oppression has affected other resources that are an important part of
parenting and family success such as housing, employment, and education.
When considering all of the above, the opportunity for systemic bias seems
present within the system of child welfare.
Child Welfare Workers have a two fold obligation regarding disproportionality and
the link to the stigma of mental illness. First, the CWW must be aware of his/her
own biases and be constantly vigilant of how these biases might impact his/her
decision making and practice and seek to prevent biased practice. Second, the
CWW must act as advocate for the mentally ill family member remembering that
child welfare has a duty to the family as a whole to increase independence and
functionality in the service safety, permanence, and well-being.
Add any others that come up in your small group discussions.
Stigmas/Labels:
 Crazy
 Helpless
 Hopeless
 Bad parents
 Unintelligent
 Immoral
 Retarded
 Don’t want help
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 Resistant
 Non-compliant
 Violent


What are some of the biases you have with regards to the mentally ill?
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Cultural Implications in Mental Health
Child welfare workers are in a unique position to help assess how cultural
influences might be affecting their clients’ behavior. In some instances, they may
even be able to show that the behavior that others see as indicative of mental
illness in mainstream culture is not considered a sign of mental illness in certain
individual’s culture. And in other instances, workers will be able to help clients
manage and overcome symptoms of mental illness by calling upon some of their
client’s unique cultural resources and systems of supports.
The CWW must always evaluate mental health issues in their cultural context.
For example, certain minority groups may evidence paranoia, which in fact is
based upon real experiences of prejudice, discrimination, or even persecution.
Do not jump to conclusions that someone is mentally ill because they express
some suspiciousness. If the person expresses distrust, it is important to be
empathic and to endeavor to understand the situation from their point of view.
Similarly, in families of domestic violence, a culture of distrust develops and is
nourished by the abuser who isolates the family and often plays on insecurities to
keep members of the family in a distrusting mode. This type of paranoia is not
based in delusion but in learned behavior. Understanding the origins of the
behaviors and the purpose it serves within the culture can make the work with
the family more effective.
There are some cultural rituals that involve seemingly psychotic behaviors such
as hallucinations, talking in tongues, and/or altered states of consciousness.
Examples of this in various cultures come in a variety of forms. For instance,
Native American cultures which employ a vision quest in their spiritual practices,
fundamentalist religions that believe the spirit of God speaks through them in
only a language God can understand, hearing the voices of the dead as a
guardian angel or visitor from the other side, are all common practices in different
cultures represented in the US. Taken in isolation, any of these examples could
appear to be delusions or hallucinations.
As reported in the Surgeon General’s Mental Health Report in 1999, cultural
variations must be considered when interpreting signs and symptoms such as
hallucinations, delusions, or bizarre behaviors. As the Surgeon General notes,
“among members of some cultural groups, ‘visions’ or ‘voices’ of religious figures
are part of normal religious experience. In many communities, ‘seeing’ and being
‘visited’ by a recently deceased person are not unusual among family members.”
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Finally, in examining cultural implications the CWW must understand the culture
of mental illness. The attendance of regular appointments and possible periodic
hospitalizations of a mental health nature are an integral part of this culture.
Medication regimens, prescriptions and pharmacies become a commonplace.
Caretaking family members, case managers, therapists, physicians,
transportation technicians, day treatment/partial hospitalization technicians and
more become regular figures in the culture of mental illness.
The stigma and discrimination associated with the mentally ill are also part of the
culture. It is not dissimilar to the culture of the medically fragile or the chronically
ill medical patient. However, the one major difference is the stigma associated
with the belief that somehow the mentally ill person is not as “good” in some way
as everyone else. Whether “good” refers to ability to contribute in employment
setting or to ability to parent or to ability to manage his/her own affairs, the stigma
is greater for mental health concerns than for most medical concerns.
It is imperative that CWW view all signs and symptoms through the cultural lens
of the family or individual. Just as crucial is the need to examine one’s own
biases about mental illness and how these biases may affect practice with
family’s suffering with mental illness.
Identify Aspects of the Culture of the Mentally Ill:
1)
2)
3)
4)
Identify Practices from your Family’s Culture that could be misunderstood as
mental illness:
1)
2)
3)
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4)
Advocacy Worksheet
Develop a list of ways a child welfare worker can advocate for mentally ill clients:
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Definitions
 Acute: severe and of short duration: describes a disease that is brief, severe,
and quickly comes to a crisis
 Attunement: refers to a parent’s ability to pick up on the needs of a child and
attend to them
 Chronic: with long-term illness: having a particular long-term illness or condition
 Delusion: a false belief that is fixed as truth
 DSM-IV: Diagnostic Statistical Manual Fourth Edition is the manual which
provides the criteria for making mental health and developmental diagnoses
o Axis I: used for reporting all the various mental disorders or conditions
except for personality disorders and developmental disorders
o Axis II: used for reporting personality and developmental disorders and
can also be used for noting prominent maladaptive personality features
that do not meet the threshold for a personality disorder. Defense
mechanisms can also be noted here.
o Axis III: note current general medical conditions that are potentially
relevant to the understanding and management of the individual’s
mental disorder. Some clinicians also use this axis to note significant
physical signs and symptoms that need further evaluation. The purpose
of notice medical conditions is to encourage thoroughness in evaluation
communication among health care providers.
o Axis IV: used for reporting psychosocial and environmental probably
affect the diagnosis, treatment, and prognosis of mental disorders
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o Axis V: provides the clinician’s judgment of the individual’s overall or
global level of functioning at the time of evaluation
 Hallucination: a false perception or false experience of the senses
 Mental Disorder: health conditions that are characterized by alterations of
thinking, mood, or behavior or some combination associated with distress
and/or impaired functioning
 Mental Health: refers to successful performance of mental functions resulting
in productive activities, fulfilling relationships with other people, and the ability
to adapt to change and to cope with adversity.
 Mental Illness: health conditions characterized by alterations in thinking,
mood, or behavior (or some combination) associated with distress and/or
impaired functioning. Refers to all diagnosable mental disorders.
 Prognosis: opinion on course of disease: a medical opinion as to the likely
course and outcome of a disease; prediction: a prediction about how a given
situation will develop
 Sign: an objective manifestation of a pathological condition seen by an
observer rather than reported by the affected individual
 Symptom: a subjective manifestation of a pathological condition reported by
the affected individual rather than seen by an observer
 Syndrome: a grouping of signs and symptoms, based on their frequent cooccurrence, that may suggest a common underlying pathogenesis, course,
familial pattern, or treatment selection
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Strengths and Protective Influences
Mental disorders also express themselves very differently from person-to-person.
Two individuals suffering from the same condition, for example, can vary
enormously in terms of their ability to handle day-to-day demands. Some mental
disorders are also more commonly found among children and youth while others
are first identified during the adult years. And some conditions identified early in
life persist throughout the lifespan, while others identified early might wax and
wane.
An individual’s symptoms and signs, regardless of age and developmental stage,
will be influenced by ecological factors. Existing social supports, socioeconomic
conditions, and a host of other ecological factors can influence the degrees to
which some disorders impede an individual’s day-to-day functioning.
Researchers have found time and time again that there seems to be identifiable
patterns around advantage and in disadvantage and that these patterns can
influence how mental disorders are expressed throughout the lifespan. In other
words, individuals who suffer from a mental illness who have some advantages
in life will express symptoms differently from individuals without the same
patterns of advantages.
Researchers are identifying important protective processes in the lives of
individuals, who, despite enduring a life long mental disorder, have still been able
to carve out meaningful lives. Their research underlies the importance of
keeping a watchful eye on individual strengths, coping resources, sources of
social support, and doing all that can be done to insure that these strengths,
resources, and support are highlighted. This is particularly important when
considering how mental illness impacts parenting and the ability of a caregiver to
act in a protective manner on behalf of a child. It is imperative that CWW’s strive
to identify strengths, coping resources, sources of support, and signs of
resiliency in the mentally ill. It is these things that will mitigate risk and help in
assessing a family’s ability to safely parent their children.
A useful tool for assessing resources is the Eco Map. By completing an Eco Map
with a mentally ill person, a CWW may be able to identify resources working with
the client that might not be seen as strengths but can be important in creating a
safety plan and in mitigating risk. For instance, a mentally ill parent who lives in
supported housing will have resources who could be helped to provide support to
the parent.
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Remember the stats, many people who have been suffering with signs of a
mental illness do not get treatment for many years. Often they have learned to
cope and some even exhibit incredible strengths in dealing with their symptoms
and managing to move their lives along. It is crucial that CWW look for these
developed coping strategies as identified strengths. It is through some of these
strategies that workers will be able to create effective plans with the mentally ill
caregiver.
Can you think of some strengths that many families coping with mental
illness develop?
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Strengths and Mitigating Factors
 Resources
 Family/friends network
 Financial supports
 Other professional providers
 Rituals and routines
 Resiliency
 Intelligence
 Permanency
 Bonding
 Intact characterological structure
 Compliance



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When a Parent Has a Mental Illness
From Risk to Resiliency: Protective Factors for Children
The effect of parental mental illness on children is varied and unpredictable.
Although parental mental illness presents biological, psychosocial and
environmental risks for children, not all children will be negatively affected, or in
the same way. The parental diagnosis of mental illness alone is not sufficient to
cause problems for the child and family. Rather, it is how the diagnosis affects
the parent’s behavior as well as familial relationships that may cause risk to a
child. The age of onset, severity and duration of the parents’ mental illness, the
degree of stress in the family resulting from the parents’ illness, and most
importantly, the extent to which parents’ symptoms interfere with positive
parenting, such as their ability to show interest in their children, will determine the
level of risk to a child.
The Prevention Perspective
Whether or not children of parents with mental illness will develop social,
emotional, or behavioral problems depends on a number of factors. These
include the child’s genetic vulnerability, the parent’s behavior, the child’s
understanding of the parent’s illness, and the degree of family stability (e.g.,
number of parent-child separations). Preventive interventions aimed at
addressing these risk factors and increasing children’s protective factors increase
the likelihood that they will be resilient, and grow and develop in positive ways.
Effective prevention strategies help increase family stability, strengthen parents’
ability to meet their children’s needs, and minimize children’s exposure to
negative manifestations of their parent’s illness.
Risk Factors
Children whose parents have a mental illness are at risk for developing social,
emotional and/or behavioral problems. An inconsistent and unpredictable family
environment, often found in families in which a parent has mental illness,
contributes to a child’s risk. Other factors that place all children at risk, but
particularly increase the vulnerability of children whose parents have a mental
illness, include:
Poverty
 Occupational or marital difficulties
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



Poor parent-child communication
Parent’s co-occurring substance abuse disorder
Openly aggressive or hostile behavior by a parent
Single-parent families
Source: Excerpted from “Strengthening Families Fact Sheet,” National Mental Health Association .
Families at greatest risk are those in which mental illness, a child with a difficult
temperament, and chronically stressful family environments are all present. Many
of these factors, however, can be reduced through preventive interventions. For
example, poor parent-child communication can be improved through skills
training, and marital conflict can be reduced through couples therapy.
Protective Factors
Increasing a child’s protective factors helps develop his or her resiliency.
Resilient children understand that they are not responsible for their parent’s
difficulties, and are able to move forward in the face of life’s challenges.
Protective factors for children include:
 A sense of being loved by their parent
 Positive self-esteem
 Good coping skills
 Positive peer relationships
 Interest in and success at school
 Healthy engagement with adults outside the home
 An ability to articulate their feelings
 Parents who are functioning well at home, at work, and in their social
relationships
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 Parental employment
 A parent’s warm and supportive relationship with his/her children
 Help and support from immediate and extended family members
Impact of Mental Illness on Parenting Capacity
Mothers and fathers with mental illness experience all of the challenges of other
adults attempting to balance their roles as workers, spouses and parents. The
symptoms of mental illness, however, may inhibit these parents’ ability to
maintain a good balance at home and may impair their parenting capacity. When
parents are depressed, for example, they may become less emotionally involved
and invested in their children’s daily lives. Consequently, parent-child
communication may be impaired. The severity of a parent’s serious mental
illness and extent of the symptoms may be a more important predictor of
parenting success than diagnosis.
To be effective, intervention programs and supports for families need to be
comprehensive, addressing the needs of the whole family. Services should also
be long-term, supporting the family until their primary needs are addressed.
Impact of Parental Mental Illness on Children
The impact of parental mental illness on family life and children’s well-being can
be significant. Children whose parents have a mental illness are at risk of
developing social, emotional and/or behavioral problems. The environment in
which children grow affects their development and emotional well-being as much
as their genetic makeup does.
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Service providers and advocates working with families, in which a parent has a
mental illness have identified a number of challenges faced by their children. For
example, children may take on inappropriate levels of responsibility in caring for
themselves and managing the household. Children sometimes blame themselves
for their parents’ difficulties, and experience anger, anxiety or guilt. Feeling
embarrassed or ashamed as a result of the stigma associated with their parents’
mental illness, they may become isolated from their peers and other community
members. They may be at increased risk for problems at school, drug use and
poor social relationships. Children of parents with any mental illness are at risk
for a range of mental health problems, including mood disorders, alcoholism, and
personality disorders.
Despite these challenges, many children of parents with mental illness are
resilient and are able to thrive in spite of genetic and environmental vulnerability.
Resiliency is directly proportionate to the number of risk and protective factors
present within the family: the greater number of protective factors and smaller
number of risk factors, the greater the likelihood of a child being resilient.
Therefore, services for families and children should include opportunities to
reduce risk and enhance resiliency.
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Warning Signs of Mental Illness
In an adult
A person with one or more of the following symptoms should be evaluated by a
psychiatrist or other physician as soon as possible:
1. Marked personality change
2. Inability to cope with problems and daily activities
3. Strange or grandiose ideas.
4. Excessive anxieties.
5. Prolonged depression and apathy.
6. Marked changes in eating or sleeping patterns.
7. Extreme highs and lows.
8. Abuse of alcohol or drugs.
9. Excessive anger, hostility, or violent behavior.
A person who is thinking or talking about suicide or homicide should seek help
immediately.
In a child
Having only one or two of the problems listed below is not necessarily cause for
alarm. They may simply indicate that a practical solution is called for, such as
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more consistent discipline or a visit with the child's teachers or guidance
counselor to see whether there is anything out of the ordinary going on at school.
A combination of symptoms, however, is a signal for professional intervention.
 The child seems overwhelmed and troubled by his or her feelings, unable
to cope with them.
 The child cries a lot.
 The child frequently asks or hints for help.
 The child seems constantly preoccupied, worried, anxious, and intense.
Some children develop a fear of a variety of things--rain, barking dogs,
burglars, their parents' getting killed when out of sight, and so on--while
other children simply wear their anxiety on their faces.
 The child has fears or phobias that are unreasonable or interfere with
normal activities.
 The child can't seem to concentrate on schoolwork and other ageappropriate tasks.
 The child's school performance declines and doesn't pick up again.
 The child's teachers, school administrators, or other authority figures in the
child's life ask the parent what might be troubling the child.
 The child is having difficulty mastering schoolwork.
 Teachers suggest that the child may have a learning disability or other type
of school-related problem.
 The child loses interest in playing.
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 The child tries to stimulate him or herself in various ways. Examples of this
kind of behavior include excessive thumb sucking or hair pulling, rocking of
the body, head banging to the point of hurting himself, and masturbating
often or in public.
 The child has no friends and gets into fights with other youngsters.
Teachers or others may report, "This is a very angry or disruptive kid."
 The child isolates himself or herself from other people.
 The child regularly talks about death and dying.
 The child appears to have low self-esteem and little self-confidence. Over
and over the child may make such comments as: "I can't do anything right."
"I'm so stupid." "I don't see why anyone would love me." "I know you [or
someone else] hates me." "Nobody likes me." "I'm ugly . . . too big . . . too
small. . . too fat. . . too skinny. . . too tall. . . too short, etc."
 Sleep difficulties don't appear to be resolving. They include refusing to be
separated from one or both parents at bedtime, inability to sleep, sleeping
too much, sleeping on the parents or parents' bed, nightmares, and night
terrors.
 The child begins to act in a provocatively sexual manner. This is more
common in girls as they approach puberty and thereafter, but even much
younger girls may flirt with men in sexually suggestive ways.
 The child sets fires.
Some symptoms or reactions are so serious that a pediatrician or a psychiatrist
should be consulted immediately:
 The child talks about suicide. Children don't talk idly about suicide to get
attention. Once they have begun to talk about it, they also may have begun
to plan a way to do it.
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 The child appears to be accident-prone. In younger children a succession
of accidents can become the equivalent of suicide attempts.
 The child mutilates himself in some way – cutting or scarring himself,
pulling out his hair, or biting fingernails until nail beds bleed.
 The child mutilates or kills animals.
 The child's eating habits change to the point that his weight is affected.
This can be caused by either overeating or under eating.
 The child adopts ritualistic behaviors. This is indicative of obsessivecompulsive disorder. A child may have to line up her toys in a certain way
every night, for example, or get ready for bed following a routine that never
varies. If she forgets one item in the routine, she must start all over again.
 The child beats up others – another child, a parent, or other adult.
 The child is using alcohol or other drugs.
 The child is sexually active or on the verge of becoming so. Again, this is
rare in children 12 and under but certainly not unheard of, especially since
there is great pressure on kids today to become sexually active at
progressively earlier ages. When children are depressed or their selfesteem is low, they may be more vulnerable to that pressure. Also, if they
are still hurting from feelings of rejection and loneliness related to the
divorce, they may be searching for love and affection and have a need to
prove their lovability.
Core Version 3
Page 28
Anxiety Disorders
Type of
Disorder
Signs/Symptoms
Panic Disorder
With or
without
Agoraphobia
A discrete period of intense fear or
discomfort, in which four (or more) of the
following symptoms developed abruptly
and reached a peak within 10 minutes:
1. palpitations, pounding heart, or
accelerated heart rate
2. sweating
3. trembling or shaking
4. sensations of shortness of breath or
smothering
5. feeling of choking
6. chest pain or discomfort
7. nausea or abdominal distress
8. feeling dizzy, unsteady, lightheaded, or
faint
9. derealization (feelings of unreality) or
depersonalization (being detached from
oneself)
10. fear of losing control or going crazy
11. fear of dying
12. paresthesias (numbness or tingling
sensations)
13. chills or hot flushes
Warning Signs of
Escalation
 Wide eyes
 Rapid or
shallow
breathing
 Rapid speech
 More frequent
attacks
 Diminishing
comfort zone
outside of the
home
Risk Factors which
may be present
Parents who are in the
midst of panic:
 may not use the
best judgment
regarding parenting
issues
 may not interpret
things the same as
when not in a panic
 may ask
unreasonable things
of children in order
to meet needs of
parent or family
 may not be attuned
to their children
Parents with
agoraphobia:
 May become more
limited in their
ability to be mobile
and move outside
of the home
therefore not taking
children to school
and/or other
necessary
appointments
Implications for Case Planning







MH assessment
Medication assessment
Coordination with MH
provider to ascertain abilities
for parenting
Family counseling
May need transportation for
children
Additional family and
community supports to be
identified as part of safety
plan when caregiver is in
crisis
Pharmacotherapy:
benzodiazepines, selective
serotonin reuptakes (Prozac,
Zoloft, etc), Buspar
Type of
Disorder
Obsessive
Compulsive
Disorder
Signs/Symptoms
Warning Signs of
Escalation
Obsessions as defined by 1,2,3, and 4:
 obsessive
1. recurrent and persistent thoughts,
thoughts
impulses, or images that are
occupying so
experienced, at some time during the
much thought
disturbance, as intrusive and
that can’t
inappropriate and that cause marked
concentrate on
anxiety or distress
tasks
2. the thoughts, impulses, or images are

compulsions
not simple excessive worries about realpreventing
life problems
3. the person attempts to ignore or
productive
suppress such thoughts, impulses, or
functioning
images, or to neutralize them with some  compulsions
other thought or action
beginning to
4. the person recognizes that the obsessive
become self
thoughts, impulses, or images are a
injurious
product of his or her own mind (not
imposes from without as in thought
insertion
Compulsions as defined by 1 and 2:
1. repetitive behaviors (e.g., hand
washing, ordering, checking) or mental
acts (e.g., praying, counting, repeating
words silently) that the person feels
driven to perform in response to an
obsession, or according to rules that
must be applied rigidly
2. the behaviors or mental acts are aimed
at preventing or reducing distress or
preventing some dreaded event or
situation; however, these behaviors or
mental acts either are not connected in a
realistic way with what they are
designed to neutralize or prevent or are
clearly excessive
Core Version 3
Risk Factors which
may be present
 inappropriate
demands on
members of house
to comply with
specific
compulsions
 inappropriate
expectations around
cleanliness
 may become
incapacitated by
symptoms
 may be extremely
rigid in parenting
style which can
stifle the natural
developmental
process
Implications for Case Planning







Page 30
MH assessment
Medication assessment
Coordination with MH
provider
Individual/Family counseling
Parenting classes on how to
parent teens
Family supports to help
maintain perspective for
OCD caregiver: i.e. someone
to provide a normalizing
perspective
Pharmacotherapy: Anafranil,
selective serotonin reuptakes
(Prozac, Zoloft, etc)
Type of
Disorder
Signs/Symptoms
Warning Signs of
Escalation
Generalized
Anxiety
A.


B.
C.
1.
2.
3.
4.
5.
6.
Core Version 3
Excessive anxiety and worry
(apprehensive expectation), occurring
more days than not for at least 6
months, about a number of events or
activities (such as work or school
performance).
The person finds it difficult to control
the worry.
The anxiety and worry are associated
with three (or more) of the following
six symptoms (with at least some
symptoms present for more days than
not for the past 6 months). Note:
Only one item is required in children.
Restlessness or feeling keyed up or
on edge
being easily fatigued
difficulty concentrating or mind
going blank
irritability
muscle tension
sleep disturbance (difficulty falling
or staying asleep, or restless
unsatisfying sleep)


Risk Factors which
may be present
not sleeping

becoming
physically ill
with symptoms
of anxiety such as
stomach distress,
tension
headaches,

unable to
concentrate on
daily functioning
due to worry

increase in
number of things
to worry about

can be overly fearful
about unrealistic
threats and therefore
become overly
restrictive of
children’s
movements and
freedoms
can miss signals of
child’s needs because
so caught up in fears
and worries
may not tolerate age
appropriate
independence in
children
difficulty focusing on
child’s needs
Implications for Case Planning







Page 31
MH assessment
Medication assessment
Coordination with MH
provider
Individual/Family counseling
Family supports to help
maintain perspective for
caregiver: i.e. someone to
provide a normalizing
perspective around
appropriate expectations for
children and independence
Safety supports for parenting
infants
Pharmacotherapy:
benzodiazepines, selective
serotonin reuptakes (Prozac,
Zoloft, etc), Buspar
Type of
Disorder
Signs/Symptoms
Warning Signs of
Escalation
Risk Factors which
may be present
Implications for Case Planning
Post-Traumatic
Stress Disorder
A.









B.
C.
D.
The person has been exposed to a
traumatic event
The traumatic event is persistently reexperienced
Persistent avoidance of stimuli
associated with the trauma and
numbing of general responsiveness
(not present before the trauma),
Persistent symptoms of increased
arousal (not present before the
trauma),
Explosive rage
Agitation
Erratic behavior
Lack of sleep
Use of substances
to self medicate




Core Version 3
Become enraged with
children
May have flashbacks
in which children
could be victimized
Use of substances can
lead to
unpredictability and
lack of safety in the
home
In recreating event
may choose
perpetrators to bring
into the home
Loud noises
exacerbate stress of
the hypervigilant
person such as in
chaotic children’s
play resulting in
stress reactions and
temper outbursts






Page 32
MH assessment
Medication assessment
Coordination with MH
provider
Individual/Family counseling
Anger Management
Support Groups
Non-offending parent group
Stress reduction practices
Pharmacotherapy:
benzodiazepines, selective
serotonin reuptakes (Prozac,
Zoloft, etc), Buspar, Antidepressants
Mood Disorders
Type of
Disorder
Major
Depression
Signs/Symptoms
Warning Signs of
Escalation
Risk Factors which may
be present
Implications for Case Planning
















Dysthymia


Core Version 3
Persistent sad or irritable
mood
Loss of interest in activities
once enjoyed
Significant change in
appetite or body weight
Difficulty sleeping or
oversleeping
Psychomotor agitation or
retardation
Loss of energy
Feelings of worthlessness or
inappropriate guilt
Difficulty concentrating
Recurrent thoughts of death
or suicide
Five or more of these
symptoms must persist for 2
or more weeks before a
diagnosis of major
depression is indicated
Symptoms of depression
listed above without
vegetative symptoms
Symptoms are low grade
and chronic







Suicidal behavior
Psychotic
symptoms
Paranoia
Lack of interest in
anything
Over reliance on
sleep
Irritability
Lack of attention
to hygiene
Vegetative
symptoms
Escalating into
major depressive
episode





May feel the need to
put end to the misery
in the family
May not take care of
children’s needs due
to diminished interest
in anything
General lack of
attunement to children
Stress of parenting
may be more than
depressed person can
handle which can
escalate danger of
taking violent action
Same as above if
escalates into major
depressive episode
May struggle to
maintain employment
due to low grade
depression












Page 33
MH assessment
Medication assessment
Coordination with MH
provider
Individual/Family counseling
Support Groups
Family/community support to
assure more resources for
supervising children and
monitoring family situation
Monitoring of bonding and
attachment with children under
age 3
Safety plan
Pharmacotherapy: selective
serotonin reuptakes
(Prozac, Zoloft, etc), Antidepressants
MH assessment
Medication assessment
Coordination with MH
provider
Individual/Family counseling
Support Groups
Family management strategies
such as shopping for family,
banking and paying bills, food
preparation, etc.
Type of
Disorder
Bipolar
Signs/Symptoms
Warning Signs of
Escalation
Risk Factors which may
be present
Implications for Case Planning






Dramatic mood swings from
mania to depression with
periods of normal mood in
between
 Mania is characterized by:
o
an unusually and
persistently elevated,
expansive or irritable
mood, inflated selfesteem or grandiosity
o Decreased need for sleep
o Excessive talking
o Flight of ideas
o Distractability
o Psychomotor agitation or
increased goal-directed
activity
o Risk taking behavior
Core Version 3






Increased
spending and
impulsive
behavior
Diminishing social
boundaries that
appear as a
change in
behavior
Lack of sleep
Pressured speech
Agitation
Raging outbursts
Delusions




Delusions can lead to
violence in the family
Impulsive spending
can lead to financial
ruin and the added
stressors of
homelessness, lack of
ability to meet the
basic needs of family
Sexually explicit
behaviors in the home
due to loss of
boundaries
Behavior can appear
erratic and bizarre to
children and may be
frightening
Rage can be directed
at anyone in the home




MH assessment
Medication assessment
Coordination with MH
provider
Individual/Family counseling
Support Groups: such as
gambling, sex addicts,
substance abuse,
overspending
Anger management
Family/community support to
assure more resources for
supervising children and
monitoring family situation
 Monitoring of bonding and
attachment with children under
age 3
 Safety plan
 Consumer Credit Counseling
 Pharmacotherapy:
Mood stabilizers
Page 34
Psychotic Disorders
Type of
Disorder
Signs/Symptoms
Warning Signs of
Escalation
Risk Factors which may
be present
Implications for Case Planning
Schizophrenia















Core Version 3
Psychotic symptoms such as
hallucinations and delusions
Disorganized speech
Loss of ego boundaries
Grossly disorganized or
catatonic behavior
Negative symptoms:
o Flat affect
o Poverty of speech
o Poverty of content of
speech
o Lack of energy or
drive/apathy
Disorganization in personal
care in social and
professional performance
Profound disruption in
cognition and emotions
Perceptions of reality
strikingly different from the
reality seen and shared by
others around them




Agitation
Increase in
paranoia
Increase in
disorganization
Catatonia
Increase in
hallucinations
Delusional
behaviors



Potential for violence
Lack of attunement to
children’s needs
Lack of attention to
children’s needs
Lack of safe
supervision of children
Lack of sound
judgment in acting to
protect children from
potential threats









Page 35
MH assessment
Medication assessment
Coordination with MH
provider
Day Treatment
Support Groups
Family/community support to
assure more resources for
supervising children and
monitoring family situation
Monitoring of bonding and
attachment with children under
age 3
Safety plan
Supervised housing
Parenting classes
Medication support group
Pharmacotherapy:
neuroleptics
Type of
Disorder
Signs/Symptoms
Warning Signs of
Escalation
Risk Factors which may
be present
Implications for Case Planning
Mood disorder
with psychotic
features








Hallucinations and/or
delusions in the presence of
a mood disorder



Agitation
Increase in
paranoia
Increase in
disorganization
Increase in
hallucinations
Delusional
behaviors



Potential for violence
Lack of attunement to
children’s needs
Lack of attention to
children’s needs
Lack of safe
supervision of children
Lack of sound
judgment in acting to
protect children from
potential threats








Core Version 3
Page 36
MH assessment
Medication assessment
Coordination with MH
provider
Support Groups
Family/community support to
assure more resources for
supervising children and
monitoring family situation
Monitoring of bonding and
attachment with children under
age 3
Safety plan
Supervised housing
Parenting classes
Medication support group
Pharmacotherapy:
neuroleptics, mood stabilizers,
anti-depressants, SSRI
Personality Disorders
Type of
Disorder
Borderline
Signs/Symptoms







Core Version 3
Warning Signs of
Escalation
Characterized by
 Agitation
impulsivity, instability of
 Increase in
mood, self-image, and
intensity
personal relationships
 Suicidal
Marked mood swings with
gesture
periods of intense
 Threats
depression, irritability,
toward others
and/or anxiety
 Stalking types
Inappropriate, intense, or
of behaviors
uncontrolled anger
 Increase in
Recurring suicidal threats
obsession with
or self injurious behavior
another
Unstable, intense personal
person
relationships with extreme
black-and-white views of
people
Sensitive to environmental
circumstances
Frantic efforts to avoid
abandonment
Risk Factors which may
be present
 Impulsivity can lead to
very poor decision
making with regards to
safety and children’s
supervision
 Intensity of mood and
mood swings can be
very confusing to a
developing child and
can lead to very
maladaptive patterns in
the child
 Intensity of anger
coupled with
impulsivity can be very
volatile and frightening
as well as pose a real
threat to safety
 If afraid of
abandonment can go
to great lengths to
keep children
dependent on them to
the significant
detriment to the child
Implications for Case Planning








Page 37
MH assessment
Coordination with MH
provider
Support Groups
Family/community support to
assure more resources for
supervising children and
monitoring family situation
Monitoring of bonding and
attachment with children under
age 3
Safety plan
Parenting classes
Anger Management
Type of
Disorder
Narcissistic
Signs/Symptoms




Dependent


Core Version 3
Pervasive pattern of
grandiosity (in fantasy or
behavior)
Self-centeredness
Need for admiration
Lack of empathy
pattern of submissive and
clinging behavior
a persistent need to be
taken care of by others
Warning Signs of
Escalation
 when made to
feel less than
will escalate
 when
humiliated
may react in
very volatile
ways
 when
confronted
with needing
to put others
needs first will
act
unpredictably
Risk Factors which may
be present
 little or no regard for
children’s welfare
except as far as it
furthers their image of
themselves
 see children as only an
extension of
themselves and when
children rebel against
wishes may reject child
and/or become
abusive especially in
adolescence
 risk of ongoing
emotional abuse due
to any mistakes made
by children can be
seen as embarrassing
and humiliating
Implications for Case Planning




during
transitions in
relationships
may escalate

may align with abusive
partners due to need to
be taken care of
may parentify children
(requiring them to take
on role of caregiver)


MH assessment
Coordination with MH
provider

Family/community support to
assure more resources for
supervising children and
monitoring family situation
Monitoring of bonding and
attachment with children under
age 3
Safety plan
Parenting classes






Page 38
MH assessment
Coordination with MH
provider
Support Groups
Safety plan if DV present
Domestic Violence
Education/Support
Type of
Disorder
Antisocial
Signs/Symptoms


Core Version 3
pattern of disregard for
and violation of the basic
rights of others or society
central features include:
o deceitfulness
o aggressiveness
o disregards for the
safety of self or others
o lack of remorse
Warning Signs of
Escalation
 when
threatened by
law
enforcement
or some other
authority may
escalate to
violence or
criminal
activity
Risk Factors which may
be present
 May use children in
criminal activities
 Will have no remorse if
cause injury to children
 may not hesitate to
hurt children if children
anger them or thwart
them in some way
 may encourage
children in aggressive
or criminal activity
 may endanger children
due to complete lack of
regard self and
children’s safety
Implications for Case Planning









Page 39
MH assessment
Coordination with MH
provider
Support Groups
Family/community support to
assure more resources for
supervising children and
monitoring family situation
Monitoring of bonding and
attachment with children under
age 3
Safety plan
Parenting classes
Anger Management
Accountability for criminal
activity
Fictitious Disorders
Type of
Disorder
Fictitious
Disorder
Signs/Symptoms

attempts to assume the role
of a sick person who is in
need of help by intentionally
producing physical and/or
psychological symptoms
 Motivation is a psychological
need to assume the sick role
 Symptom presentation may
include:
o Fabrication of subjective
complaints (e.g. acute
abdominal pain)
o Self-inflicted conditions
o Exaggeration or
exacerbation of pre-existing
general medical conditions
(simulating a grand mal
seizure)
Core Version 3
Warning Signs of
Escalation
 Confronting
the lies may
escalate
behavior
 Any attempts
to dispel the
fiction may
lead to
increased
distress
Risk Factors which may
be present
 May put children or
themselves in
vulnerable or
dangerous situations
in order to make
themselves look
more heroic and/or
to gain sympathy
and attention
 May ignore or be out
of attunement with
children’s needs due
to requiring the focus
to be on their
ongoing drama
 May leave children
unsupervised in an
attempt to further
their fiction
Implications for Case Planning


MH assessment
Coordination with MH
provider

Family/community support to
assure more resources for
supervising children and
monitoring family situation
Monitoring of bonding and
attachment with children under
age 3
Safety plan
Parenting classes




Page 40
Accountability for criminal
activity
Type of
Signs/Symptoms
Disorder
Fictitious
 Motivation is a psychological
Disorder by
need to assume the role of
Proxy
hero or martyr
(Munchausen  Symptom presentation may
by Proxy)
include:
o Fabrication of subjective
complaints (e.g. acute
abdominal pain)
o Inflicted conditions
 Exaggeration or exacerbation
of pre-existing general
medical conditions
(simulating a grand mal
seizure)
 Individual (such as a parent)
is deliberately faking or
producing illness in another
person (such as a child) who
is under the care of the
individual
 Individual is satisfying his or
her needs at the expense of
another person
Core Version 3
Warning Signs of
Escalation
 Confronting
the lies may
escalate
behavior
 Any attempts
to dispel the
fiction may
lead to
increased
distress
Risk Factors which may
be present
 May make children
sick or in constant
danger or crisis in
order to play out the
fiction
 May ignore or be out
of attunement with
children’s needs due
to requiring the
focus to be on their
ongoing drama
 May bring children to
the brink of death in
order to rescue them
Implications for Case Planning


MH assessment
Coordination with MH
provider

Family/community support to
assure more resources for
supervising children and
monitoring family situation
Monitoring of bonding and
attachment with children under
age 3
Safety plan
Parenting classes




Page 41
Accountability for criminal
activity
Case Collaboration with Mentally Ill Clients
Helpful Hints:
 Work in tandem with other professionals: many times the mental health
practitioner is only aware of what his/her client tells them unless another
professional in the case has assured a release of information is active and
has provided information to inform the process.
 Know and understand the various systems with which you are working
(know what their primary functions are and understand their limitations).
 Develop relationships with agency representatives (you will always have a
better response if you’ve already taken the time to identify relationships
with agency representatives) Cultivate and nurture relationships so that if
you are stuck and can’t get a call returned, you can call your colleague who
can make things happen.
 Take an active role in putting the family’s situation in a contextual
framework.
 Become comfortable utilizing your own authority to delegate tasks:
remember you are a specialist too with specialized information necessary
in assisting the client and his/her family. Don’t let MH intimidate you!
 Assure that someone is assigned the case manager role.
 Work with clearly written contracts between yourself and families and
between yourself and agency personnel.
 Set up realistic goals that you are able to measure through observation
making sure that the goals are clear, measurable, and observable to the
client as well.
 Create a list of community resources to pull from and refer to for your
clients.
Version 2
42
 Use the system’s resources to your advantage. More professionals working
with a family can mean more eyes to watch for deterioration, risk, strengths,
and resources.
 When making a referral:
o Inform mental health about the reason for the referral: without this the
mental health workers must ask parents and children why they have
come to the clinic. If the person doesn’t know (or claims not to know)
beyond “I’m here because CPS sent me”, MH will be hampered during
the intake screening. Make sure you send a letter or better still a
phone call to be documented for the record as a part of the evaluation.
This insures that MH will evaluate the signs you saw rather than just
the symptoms the client reports.
o Always get a client-information release form. If you can get blank
release forms from MH to have on hand, you could fill the form out with
the client and send the original to MH. Most of the time MH requires
the use of their own form. Make sure you include the specific
information you want to share with MH and the information you will
want MH to share with you such as: all information pertaining to
evaluation and treatment interventions”.
o Include appropriate client contact information: if a work number is
obtained, what times are suitable to call the workplace. If a client does
not have a phone, list an alternate number of a friend, or when the
client might be in your office and could be reached there.
o List other professionals involved in the case.
o Clearly state your agency’s expectations for the referral outcome as
well as what your continuing role will be in the case; include any
relevant timelines.
o Set up the work together as a team collaboration.
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Systems of Care Working with MH
 Specialized Mental Health Sector: consists of health care professionals
(psychiatrists, psychologists, clinical social workers, marriage & family
therapists, psychiatric nurses) who have specialized training in treating people
with mental disorders. Services are provided in outpatient settings, psychiatric
hospitals/psychiatric units in a general hospital, residential treatment centers,
group homes, day treatment and other intensive settings.
 General Medical/Primary Care Sector: consists of health care professionals
(internists, general practitioner, neurologists, and nurse practitioners) who
specialize in physical health care. The general medical sector has been
identified as the initial point of contact for many adults with mental disorders.
 Human Services Sector: consists of school and community based programs,
social service systems, and religious professional counselors.
 Voluntary Support Network Sector: consists of self-help groups (12 step,
peer counseling, support groups); it is important for CWW to have an
understanding of the mental health services that are available through the
Human Care and Volunteer Support Network Sectors. These include a wide
array of self help groups in the community targeting both general and specific
mental health conditions. Use of informal or adjunctive services, such as
community support systems, self-help groups, and especially culturally
relevant social support networks provide a valuable safety net for clients.
 Wraparound: many communities have wraparound services which represent
a new paradigm in the mental health delivery system where services are
tailored to individual client and family needs. These wraparound services are
also forging new collaborative partnerships between the different sectors of
care.
 Psychiatrist: a physician who has a medical degree and at least four
additional years of study and training in psychiatry. Among the services that
psychiatrists provide are medical/psychiatric evaluations, treatment for
emotional and behavioral problems, and medication management. Most
insurances relegate psychiatrist’s roles to evaluation and med management.
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 Clinical Psychologist: a doctoral level mental health provider who is trained
to conduct psychological evaluations and to treat mental health problems.
Psychologists can prescribe medications in the state of New Mexico. Some
psychologists specialize in forensics and will complete competency
evaluations for the court to determine if a person is competent to assist in the
own defense.
 Clinical Social Worker: a master’s degree in social work with a specialization
in clinical practice. A licensed clinical social worker has obtained a license in
California and can offer services in both private and public practice settings.
 Licensed Marriage, Family Therapist: a master’s degree with a license to
provide therapy services to families struggling with a wide range of emotional
crises.
 Primary Care Physician: physicians who provide wide-ranging services to
patients, and who often assist patients in locating more specialized services
and who can and do prescribe medications including in treatment of many
mental illnesses
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REFERENCES
MENTAL HEALTH & MENTAL DISORDERS
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