Client Psychiatric Issues for
CEOs
Presented by
Daniel M. Marble, LCSW
Social Service Consultant
And
The Western Child Welfare Law
Center
11/10/02
Client Psych Issues--Dan Marble
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Introduction
Today you will gain a functional understanding
regarding the establishment and support of the
agency’s treatment philosophy and milieu.
Allow you to better recognize the pathology of your
client population so that you can establish better
risk management procedures.
Allow you to employ policy and budgetary
decisions which support treatment priorities.
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Client Psych Issues--Dan Marble
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Overview and Objectives
Examine major pathology types.
 Program Milieu
 Course Objectives
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Client Psych Issues--Dan Marble
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Major Pathology Types Among
Foster Children
Attachment Disorder
 ADD/ADHD
 Depression/loss/morning
 Others
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Client Psych Issues--Dan Marble
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ATTACHMENT
“The Tie that Binds”
An Overview of Attachment Disorder
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Client Psych Issues--Dan Marble
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Attachment
A lasting psychological connection between
human beings.
 The emotional bond that grows between
child and caretaker.
 Begins in utero and develops over time.
 Infants are predisposed to attach.
 It exists in a continuum-no perfect
attachment or total lack of attachment.

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Attachment Disorder Causes
Abuse: physical/emotional/sexual
 Neglect
 Sudden separation-primary caregiver
 Inadequate or changing daycare
 Undiagnosed or painful illness

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Symptoms of Attachment
Disorder in Older Children
Act superficial and phony-(strangers and those they
feel they can manipulate)
 Avoid eye contact unless lying or conning
 Indiscriminate affection with strangers
 Lack of ability to feel\empathize/care
 Extreme control problems/sneaky
 Leave a trail of destruction-pets and all possessions

Constant lying Client Psych Issues--Dan Marble
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More Symptoms-Older Children
Highly impulsive
 Learning disorders-my way or the highway
 No cause and effect thinking
 Little or no conscience
 Abnormal eating patterns
 Other kids avoid them (3Cs) conscience,
control, cruelty
 Speech (Interrupt,
noise and control)
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Client Psych Issues--Dan Marble
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Still More Symptoms
Inappropriately demanding
 Abnormal speech patterns
 Lie (False allegations, believed =power)
 Divide and conquer (Mom vs. Dad)
 Abuse their caregivers
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Techniques to Enhance
Attachment
Holding and touching
 Reciprocal games and activities
 Teaching emotions
 Assessing/discussing attachment
 Looking for opportunities to nurture
 Clarification of life events
 Promoting family identification
discipline
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Client Psych
Issues--Dan Marble
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Holding and Touching
As much physical contact as the child can tolerate
 Snuggling while reading or watching TV
 Parents should wear soft clothing and short sleeves
for as much skin to skin contact as possible
 At meals the child can sit between two nurturing
parents
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Reciprocal Games and Activities
Hide and seek
 Feeding each other
 Singing together
 Dancing and moving together in unison
 Use movies and stories to describe
attachment, such as Dumbo
 Face painting
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Teaching Emotions
Look for opportunities to comment on the
child’s feelings
 Point out congruent facial expressions
 Stand in front of a mirror and make faces
representing various feelings
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Assessing/Discussing Attachment
Discussions about how it feels to belong or
not to belong to a family
 Talk about closeness and trusting
 When the child lies, talk about how this
represents their inability to trust you
 Represent trusting as feeling strong enough
to trust
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Looking for Opportunities to
nurture
Notice times when the child is hurt or sick
or frightened and come to their aid
 Make a big deal out of bandaging and
kissing a skinned knee
 Rock, hold and comfort

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Clarification of Life Events
Make sure the child knows about its history
 Help the child build a photo album about
their past life
 Gather and tell stories about past events in
the child’s life
 Help put together a Life History Book

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Promoting Family Identification
Develop and talk about family rituals
around holidays, birthdays
 Make family rituals out of everyday events
such as bed time or meals
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Firm, Consistent Discipline
This is one of the primary attachment techniques
 Keep the environment as stable and organized as
possible
 Do not use physical or separation or isolation types
of punishment
 Time outs should be in a chair in the same room as
the adult
 The “one minute scolding”
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Treatment Approach
AREAS OF
REEDUCATION
Adult-child
relationships
AD CHILD’S
CURRENT
VIEW
GOAL OF
TREATMENT
Relationships are Will be able to form
adversarial
trusting relationships
with adults
The acceptability Powerless over
Learn acceptable
their feelings
ways to express
of feelings and
feelings
certain behaviors
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Treatment Approach
The worth of an
individual
See self as
defective and
worthless
Internalize
feelings of self
worth
Working together Defiant because
as part of a family they feel that if
or group
they obey, they
have “lost.”
Will learn that
relationships
require working
together
Ways to care for
and about oneself
Learn
independence &
how provide for
own needs
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Focus on self as a
helpless victim.
Work against self
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Treatment Approach
Ways to care for
and about others
Ways to have fun
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Others are
competition rather
then people to
honor & respect
Explore
relationships based
on cooperation
rather then
competition
Feel that fun is
Expand view of fun
about being
to include art,
entertained, getting reading & activity,
something or
etc.
winning
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Patience Pays Off
Be prepared for the process to take longer
then you thought
 Be prepared for setbacks
 Be prepared for the many breakthroughs
that will make your staff feel like it was all
worth it
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ADD/ADHD
An Overview of Types
And Treatment
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Definitions
Attention Deficit Hyperactivity Disorder: A
diagnostic label given children and adults
who have significant problems in four main
areas of their lives:
 Inattention
 Impulsivity
 Hyperactivity
 Boredom
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More Definitions
ADD is not the result of “bad parenting” or
obnoxious willful defiance on the part of the
child.
 It is a medical condition caused by genetic
factors that result in neurological
differences.
 It affects one or two areas of the brain.
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Important Characteristics
It is pervasive across all areas of life.
 The problems are apparent before age 7.
 Anti-social behaviors are common.
 60% also have oppositional defiant disorder
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Dr. Daniel Amen’s Six
Types
1. Classic Type
 2. Inattentive ADD
 3. Over focused or Cingulate Function
ADD
 Limbic Systems Functions ADD
 5.Temporal Lobe ADD
 6. Ring of Fire Add
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1. Classic ADD
Symptoms
Restlessness
 Hyperactivity
 Inability to focus
 Lack of planning
 Excessively Talkative
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Classic ADD Treatment
Medications
Antidepressants
 Tofranil
 Effexor
 Stimulants
 Adderall
 Dexadrine
 Ritalin

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2. Inattentive ADD
Symptoms
Short attention span for routine matters.
 Distractible
 Poor follow-through
 Spacey
 Internally Preoccupied
 Sluggish
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Inattentive ADD
Treatment
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Same as Type 1
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3. Over focused ADD
Symptoms
Difficulty shifting attention
 Stuck on thoughts
 Stuck on behaviors
 Can become oppositional-wanting to
continue repetitive behavior.
 Holds grudges
 Ritualistic
 May mimic OCD

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Over focused ADD
Treatment
Paxil
 Zoloft
 Prozac
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Limbic Systems Add
Treatment
Imipramine
 Wellbutrin
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5. Temporal Lobe ADD
Symptoms
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Memory Problems
Spaciness/confusion
Emotional Instability
Difficulty reading social cues
Difficulty with use of language plus auditory
and visual processing
Physical symptoms
Mild paranoia/anxiety
Aggressive
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Temporal Lobe ADD
Treatment
Usual Stimulants
 Anticonvulsants
 Depakote
 Dilantin
 Must have close physical monitoring
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6. Ring of Fire ADD
Symptoms
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Overly Aggressive
Overly focused
Violent behavior
Social problems
Very verbal
May appear bipolar
Hyperactive

Hypersensitive to:
light, sound, taste, and/or
touch.

Impulsivity
Distractible
Addictive and criminal
behavior
Oppositional

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Ring of Fire ADD
Treatment
Anticonvulsants
 Antipsychotics
 Risperdal
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Additional Helpful
Considerations
Attention to diet
 Attention to education
 Alternative natural medications
 Summer drug holidays
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Diet/Health
Plenty of protein
 Cut simple carbohydrates and caffeine
 Plenty of exercise

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Educational Changes
Address learning disabilities
 IEP and 504 Accommodations
Less homework
More time on tests
Tests given verbally
Work closely with teachers
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Medication Adjustments
In mild cases there is some success with
Attend and Extress
 Summer drug holidays
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Counseling
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ADD/ADHD clients have usually gone
undiagnosed for some time. The results are
residual feelings of being dumb, bad and
rejected. They often dislike school as it
represents failure. It is improper to treat
with medication alone. Counseling is
needed to address these residual issues.
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DEPRESION
An Overview
Types
And Treatment
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Causes
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Chemical/Biological
An imbalance of serotonin and receptors
Genetic
Depressed parent=child is 3X the risk
Environmental
Traumatic events
Peer or family conflict
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Symptoms in Children
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Irritability
Anxiety Symptoms
Temper Tantrums
Unexplained aches
and pains
Difficulty thinking
Sleep Problems
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Low self esteem
Feelings of guilt and
hopelessness
Constant
Fatigue/Lacks Energy
Hearing voices
Feeling Suicidal
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Symptoms in Adolescence
Sleeping too much
 Weight gain or loss
 Difficulty thinking and making decisions
 School failure
 Feeling friendless
 Suicidal thoughts/Attempts
 Delusions

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Types of Depression
Endogenous
Internally produced
 Exogenous
Externally produced
 Major Depression
 Manic Depressive Disorder
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Treatment
Psychotherapy
 Medication
 Milieu
 Environmental Manipulation
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CONDUCT DISORDERS
An Overview
Types
and
Treatment
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Definition

Repetitive Persistent Behavior Pattern
Impairment in:
 Social
 Academic
 Family Functioning
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Types
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Conduct Disorder
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Oppositional-Defiant Disorder

With Co-morbid Disorders
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Symptoms of Conduct Disorder
Aggressive behavior
Bullying, Intimidation, Threats
 Non-Aggressive behavior
Deliberate destruction of property
 Deceitfulness or Theft
Lying, conning, breaking and entering
 Serious Rule Violations
Run away, truancy

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Symptoms of
Oppositional Defiant Disorder
Often loses temper
 Often argues with adults
 Defies or refuses to comply
 Deliberately annoys
 Blames others for mistakes
 Touchy/easily annoyed by others
 Angry resentful
 Spiteful and vindictive

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Treatment: Containment through
Communication
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Planned Responses
Behavior Modification
Group Therapy
Medication
Clonidine, Risperidal,
Zyprexa, seroquel
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Management
Early intervention
 Cover as much of the child’s day as possible
 Include all caregivers
 Consistent over time and environments
 Long term treatment
 Cover all aspects of the problem
 Address all co-morbidities:
Depression, drug abuse, ADHD

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OTHER COMMON DISORDERS
AMONG CLIENTS
An Overview
Physical
Educational
Sever Psychiatric
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Less Common Disorders
Obsessive compulsive disorder (OCD)
 Tourettes Syndrome
 Seizure disorders
 Bipolar disorder
 Learning Disabilities
 Schizophrenia

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Program Milieu
Administrative & Budgetary Support
 Staff Development
 Staff Attitudes
 Communication and Coordination

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