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Introduction to Mental Health in Child Welfare Presented by: Dr. Jayme Jones Adult Major Mental Illnesses • Anxiety Disorders – Excessive anxiety & worry about multiple events or activities – Psychological manifestations • • • • • • Worry Fearfulness Apprehension Anxious anticipation Avoidance Obsessions Adult Major Mental Illnesses • Anxiety Disorders • Physical manifestations – Racing heart/Heart Palpitations – Shortness of breath – Trembling/Shaking – Dizziness – Muscle tension – Agitation – Compulsions Adult Major Mental Illnesses • Anxiety Disorders – Common profiles • • • • • Generalized Anxiety Panic Attacks Agoraphobia Phobia Obsessive Compulsive Disorder (OCD) Adult Major Mental Illnesses • Anxiety Disorders – Post-Traumatic Stress Disorder (PTSD) • Profile – Traumatic Event – Re-experiencing • Flashbacks/Recurrent Thematic Dreams – Avoidance • Thoughts • Activities – Arousal • Sleep disturbance • Irritability • Poor Concentration • Hypervigilance/Increased Startle Response Adult Major Mental Illnesses • Anxiety Disorders – Prevalence • • • • • 1 – 2% Panic 1 – 3% OCD 7 – 11% Specific Phobia 3 – 13% Social Phobia 8% PTSD Adult Major Mental Illnesses • Anxiety Disorders – Familial/genetic components • Increased incidence of all anxiety disorders among first degree relatives – Environmental components • Negative experience • “Transmission” of Anxiety Adult Major Mental Illnesses • Anxiety Disorders – Gender factors • 2 to 3 times more common among women • OCD the same – Cultural factors • Focus of anxiety • Presentation of symptoms – Impact on family • Restriction of behaviors • “Transmission” of Anxiety Adult Major Mental Illnesses • Mood Disorders – Depression • Psychological manifestations – Depressed mood (or irritability) – Frequent crying – Loss of interest – Poor concentration – Feelings of guilt and worthlessness – Thoughts of death and/or suicide Adult Major Mental Illnesses • Mood Disorders – Depression • Physical manifestations – Weight change – Sleep disturbance – Motor Slowness – Fatigue Adult Major Mental Illnesses • Mood Disorders – Mania • Psychological manifestations – Expansive or elated mood – Inflated self-esteem/grandiosity – Talkative/flight of ideas – Distractible – Increase in goal directed activity – Excessive involvement in pleasurable activities Adult Major Mental Illnesses • Mood Disorders – Mania • Physical Manifestations – Decreased need for sleep – Appetite Changes Adult Major Mental Illness • Mood Disorders – Prevalence • Depression – 10-25% women – 5 to 12% men • Bipolar .4 to 1.6% Adult Major Mental Illness • Mood Disorders – Familial/genetic components • Depression - 1.5 to 3 times more common among 1st degree relative • Bipolar - 10 to 15 times more common – Environmental components • Situational stressors Adult Major Mental Illness • Mood disorders – Gender factors • More women than men especially in US and Europe – Cultural factors • • • • Somatic concerns “Nerves” – Latino and Mediterranean cultures “Imbalance” weakness, tiredness - Asian cultures “Heart” - Middle Eastern Adult Major Mental Illnesses • Mood disorders – Impact on Family • Difficulty with self and other care • Neglect • Possible suicide Adult Major Mental Illnesses • Psychotic Disorders – Symptoms • Impaired Reality – Delusions – not culturally acceptable – Hallucinations • Affect Impairment • Thought Impairment Adult Major Mental Illnesses • Psychotic Disorders – Prevalence • .5 to 1.5 – Familial/genetic components • First degree relatives 10 times higher – Environmental components • Stressors • Family Communication Patterns Adult Major Mental Illnesses • Psychotic Disorders – Gender factors • Men develop earlier (18 to 25 v. 25 to 35) – 3-10% of women after 40 • Women better pre-morbid functioning, more affective symptoms, paranoid delusions and hallucinations • Men more negative symptoms • Women have better prognosis (fewer hospitalizations, shorter durations, more improved with medication) Adult Major Mental Illnesses • Psychotic Disorders – Cultural Factors • Catatonic behavior more common in nonWestern countries – Impact on family • Delusions and hallucinations re: family • Impaired self and other care • Neglect • Abuse Childhood Major Mental Illnesses • Attention Deficit Hyperactivity Disorder – Symptom Profile • Inattention • Hyperactivity and Impulsivity – Familial/genetic components • Higher likelihood among first degree relatives – Environmental components • Differences in reporting Childhood Major Mental Illnesses • Attention Deficit Hyperactivity Disorder – Prevalence • 3 to 5 % of school age children – Gender differences • 4:1 to 9:1 – Impact on family • Increased interaction with schools • Increased need for behavioral management • Increased risk for abuse Childhood Major Mental Illnesses • Anxiety Disorders – Differences in symptom profiles • More physical symptoms • Crying, tantrums, freezing, or clinging • Increase in activity level • Washing, checking and ordering Childhood Major Mental Illnesses • Anxiety Disorders – Separation Anxiety Disorder • 4% of children • Frequent in children whose mother’s have panic disorder – Post-Traumatic Stress Disorder • Distressing events change to generalized nightmares of monsters, rescuing others, or threats to self • Repetitive play Childhood Major Mental Illnesses • Anxiety Disorders – Gender factors • OCD more common in boys – Impact on family • Increased need for emotional support • Increased risk for emotional abuse Childhood Major Mental Illnesses • Mood Disorders – Differences in symptom profiles • • • • • • • More irritability Increase in physical complaints Friends “dropped” or ignored Increase is risk-taking behavior Constant search for distractions and new activities Aggressive behavior Mania - adolescents often have psychotic symptoms Childhood Major Mental Illnesses • Mood Disorders – Prevalence • Depression – 2-5% of pre-pubescent children – 1.5% adolescent males – 7% adolescent females • Mania – rare in childhood – .5% of adolescents Childhood Major Mental Illnesses • Mood Disorders – Gender factors • Equal numbers in childhood – Impact on family • Often ignored in childhood • Attributed to personality traits in adolescents • Risk of suicide often ignores Childhood Major Mental Illnesses • Psychotic Disorders – Differences in symptom profiles • Delusions and hallucinations less elaborate • More visual hallucinations – Prevalence • Less than .5% – Gender factors – none noted – Impact on family Application Exercise • A 24 year-old man tells you he recently consulted his physician because of dizziness and difficulty falling asleep. During your interview, he is visibly distressed, gulping before he speaks, sweating, and continually fidgeting in his chair. He reports that he always feels tense, and worries about anything and everything. Application Exercise • A 38 year old single mother of four children reports feelings of intense sadness for the past two months. Seven months ago she was laid-off from her job, the family’s sole source of income. About six weeks ago, she began having difficulty sleeping and lost her appetite, resulting in weight loss. She has little energy and no interest in activities that she normally enjoyed. She reported that household chores seemed overwhelming and were impossible to do. Her children have missed several days of school during the past three weeks because she is unable to get them ready. Application Exercise • Mr. W., a thirty-two-year-old factory worker, has been married for eight years. He and his wife have two children. One morning, Mr. W. told his wife that he was bursting with energy and ideas, that his job was unfulfilling, and that he was just wasting his talent. That night he slept very little, spending most of the time at a desk, writing furiously. The next morning he left for work at the usual time, but returned at 11:00am, his car overflowing with aquariums and other equipment for tropical fish. He had quit his job and withdrawn all the money from the family’s savings account and spent it on the equipment. He told his wife that the night before he had worked out a way to modify existing equipment so that fish “won’t die anymore. We’ll be millionaires.” Application Exercise • Eight months ago, a 27 year old female’s boyfriend had been stabbed to death during a mugging from which she escaped unharmed. After a period of mourning she appeared to return to her usual self. Shortly after the arrest of the man accused of the murder, she began to have nightmares and vivid memories of the night of the stabbing. Her friends noted that she startled easily and seemed to be pre-occupied. She began to sleep restlessly, and her work suffered because of her poor concentration. Application Exercise • A 6 year old girl was referred to DCFS by her teacher who suspected child abuse. During your interview, the girl sits calmly while you ask her about her friends and school, and answers all of your questions. When you begin to ask questions related to the referral question, she begins to run around the room and speak very quickly about non-related topics. She does not respond to your questions. She then climbs on a desk, from which you have to remove her for her safety. Impact of culture, language and social context • Perceptions of mental illness and the causes vary by culture • Beliefs about health, healing and wellness also vary by culture • Culture influences attitudes toward health care providers – Latinos are more likely to terminate treatment prematurely - (60-75%) after one session Source: Sergio A. Aguilar-Gaxiolo, MD, PhD Impact of culture, language and social context • Disparity in access to and quality of mental health services – African-American and Latino youth identified and referred at the same rate, but less likely to receive specialized mental health services – Asian-American and Latino children have highest rates of depression • Under-representation of providers from culturally and linguistically diverse groups Source: Sergio A. Aguilar-Gaxiolo, MD, PhD Intervention and Planning • Identification vs. Assessment and Treatment – The role of the CSW – Referral sources • Documentation (Strength Based) – Needed information • Objective Observations (Behaviorally-specific) Intervention and Planning • Documentation (Strength Based) – Needed information • Consultation with Collaterals – – – – SCSW Psychiatrist School Staff Therapist • Interventions Provided – Specific – Examples Intervention and Planning • Documentation concerns – Confidentiality – Impact on Case Planning – How would you integrate information about mental health into the case plan? • Referral for therapy • Referral for medication evaluation • Follow-up Youth Suicide • 3rd leading cause of death among adolescents • Approximately 5 to 8% of adolescents attempt suicide • Approximately 1 in 5 Latinas make a suicide attempt Crisis Intervention • Types – Suicide – Homicide – Danger to Child • Response of the CSW Crisis Intervention • Three levels of intervention – 1st = “Informal” (Nuclear & Extended Family) – 2nd = Community & Faith Based Organizations – 3rd = “Formal” (DCFS) • Assistance – When to get it – Where to get it Vignette Application Exercise