The Essentials of Mental Health
Care in CAN
Lucy Berliner
lucyb@u.washington.edu
ISPCAN
Honolulu
September 28, 2010
Colleagues
• Here:
– Tine Jensen, University of Oslo & Norwegian Centre
for Violence and Traumatic Stress Studies
– Lutz Goldbeck, University Hospital Ulm
• Not Here:
–
–
–
–
David Kolko, University of Pittsburgh
Ben Saunders, Medical University of South Carolina
Laura Murray, Johns Hopkins University
Shannon Dorsey, University of Washington
What Do We Know
• Emotional and behavioral problems for CAN
– The usual: anxiety (incl PTS), depression, behavior
problems
– Effects vary
– Not all children need formal therapy interventions
– Some interventions (lack of ) can make children
worse
• Remaining in an environment where the children are
very scared all the time
• Multiple out of home placement moves
• There are effective treatments
The Special Case of Attachment
Insecurity
• Insecure attachment rates are high
• Insecure attachment is an adaptation, not a
pathology
– Perceptions matter (e.g., labeling, reduced
expectations)
• Secure attachment can be achieved
– Many standard parent-child interventions
• Promote attachment security
+
• Reduce child behavior problems
The Essentials
1.
2.
3.
4.
5.
Identify abuse/trauma/neglect
Establish basic safety
Determine what the problem is
Engage the family and child
Systematically address current mental health
problems
 Child
 Child-parent
Identify Abuse/Trauma/Neglect
• Ask routinely
– Child welfare, mental health, health, juvenile
justice
• Why?
– Children will tell
– Demonstrates:
• Normalization (e.g., not alone)
• Validation
– Begin exposure
UCLA
Reaction
Index Trauma
Screen
Basic Safety
• Consider psychological as well as physical
• Separate when necessary (minority of cases)
– Sexual assault
– Serious and very serious physical abuse
• Reduce risk
– Explicitly address violence (don’t avoid)
– Written safety plan
– Reduced force contract
– Monitoring (formal and informal)
Assess to Determine Problem
 Identify the target problem
 Clinical interview (specific)
 Standardized measures
 Observation
 Collateral (when indicated)
 Give Feedback
 To child/family
 Achieve agreement
Approach to Clinical Interview
• Communicate interest and commitment to be
helpful; be warm
• Take open-ended, inquiring, non-judgmental
stance
• Elicit child and family perspective
• Use prompts and then listen and encourage
elaboration
• Focus more on the ***here and now***, less
on history except as critical to understanding
the clinical problem(s) now
Posttraumatic Stress Disorder (PTSD):
Child PTSD Sx Scale (CPSS)
•Kids 7/8 and older
•Add up child’s responses to
sx items 1-17
•Clinical score: 12+
•May use DSM IV algorithm
for dx
• Impairment questions
(7 at the bottom) not scored
Anxiety: SCARED
• Kids 7/8 +
• Add up responses
• Anxiety scale:
Clinical = 3+
• PTS scale:
Clinical = 6+
Depression: Moods and Feelings Q
Kids 7/8+
Add up responses
Clinical = 11+
Overall Problems: Pediatric Symptom
Checklist-17 (PSC-17)
Parent/caregiver report417 years
Total Score clinical = 15+
Internalizing clinical = 5+
Attention clinical = 7+
Externalizing clinical = 7+
Engagement in Services
• Overcoming barriers
– Beliefs about counseling
– Prior unhelpful experiences
– Problem solving concrete obstacle
• Increasing in motivation to change
– Assessing stage of change
– Moving towards change
Initial Encounter to Enhance
Treatment Engagement
• Elicit client concerns
• Communicate hope and confidence “I can help
you”
• Find out about previous counseling experiences
or attitudes toward therapy and provide
psychoed
• Proactively addressing things that could keep
people from coming back – the concrete
barriers
Stages of Change
Not ready
On the fence
Ready
(Precontemplation)
(Contemplation)
(Action)
Key Strategies
• Secure agreement to discuss topic
• Explore importance
– Goal is to increase
• Explore confidence
– Goal is to increase
• End on good terms
– Summarize
– Praise effort
Decisional Balance Scale
Reasons NOT to Change
Reasons to Change
Results of NOT Changing
Results of Changing
Change Talk
• Always attend (pay attention and respond) to
change talk
• Elicit disadvantages of status quo
– Negative aspects of not changing (elicit the
specifics)
– “What will happen if you don’t change?”
• Identify advantage of change
– Positive aspects of change (elicit the specifics)
– “What will be better if you do change?”
Addressing Identified Mental Health
Problems
• Strategies across all targets:
1. Feedback on the nature and level of the problem
2. Information about the condition (s)
•
•
•
What it is
Causes and what keeps it going
Treatment model
3. Managing negative emotions
4. Promoting accurate and helpful cognitions
Clinical Targets
• Depression
• Anxiety
– Includes PTSD
• Behavioral
– Oppositionality
– Conduct
– Conflict
– Attention
Key Ingredient: Changing Behavior
Anxiety = Exposure
 Child faces fears (real and imagined)
Depression = Activation
 Child increase activities that produce positive affect
 Child takes steps toward goals
Behavioral Problem = Interactional skills
 Parent uses positive parenting
 Parent and child learns social skills (communication,
problem solving)
Gradual Exposure Steps
• Explain mechanism
• Imaginal and in vivo
– Imaginal = imagining the feared situation
– In vivo = facing cues in environment
•
•
•
•
•
Make a plan
Gradual steps
Reinforce safety
Do SUDs ratings before, during and after
Never leave the session with high anxiety
Gradual Exposure: Fear Hierarchy
Behavioral Activation Steps
• Identify goals (“build the life you want”):
– Have friends
– Accomplish a task
– Get on team
• Break steps into small pieces
• Make a specific plan
• Anticipate obstacles
Find a Positive Action that Lifts Mood
• Listen to music, watch a funny show or smell a
flower
• Notice difference in mood
• Experience control over emotions
Behavior Problems Steps
• Working with the caregiver is KEY
• If you aren’t seeing the caregiver, in most
cases, you can’t treat the behavior (especially
with young kids)
– PCIT, Triple P, Incredible Years, Helping the
Noncompliant Child
• So…who’s buy-in do you need?
FIRST: Functional Behavior Analysis
• Define the problem behavior: What’s it look
like, sound like?
– Make it behavioral
• Define the positive opposite
• Get the details: Frequency, Duration,
Intensity
• Plan depends on the details
Key Components
• Increase positive time together
– Planned child-lead, fun, parent-child interactions
• Praise
– Attend to/praise positive behavior (positive opposite)
• Selective attention
– Actively ignore minor irritating (attention-seeking) behavior
• Giving effective instructions
– Reasonable, understandable and doable instructions
• Rewards Plan
– Always start here; make them meaningful
• Consequences for misbehavior
– Non-violent
– Consistently and immediately applied
Maximizing Effectiveness of Mental
Health Intervention
• Promote family as primary resource for child
• Take a collaborative approach with families
and children that involves them in all aspects
of the process
• Identify and reinforce natural supports and
resources
• Make formal intervention as brief as is
necessary
Summary of Essentials
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•
•
•
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Assess problems/needs for child and family
Have some form of measurement of progress
Engage and motivate child and family
Secure agreement for treatment focus
Select treatment approach matched to
identified problem (s)
• Apply interventions systematically
TF-CBT Manuals and Website
PTSD Manuals
Anxiety and Depression Manuals
• http://www.starcenter.pitt.edu/
Behavior Problem Manuals
Finding Evidence Supported
Treatments on the Web
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www.nctsn.org
www.cachildwelfareclearinghouse.org/
http://modelprograms.samhsa.gov/
www.cochrane.org
www.campbellcollaboration.org
www.colorado.edu/cspv/blueprints/model/overview.html
www.strengtheningfamilies.org/
www.ncptsd.va.gov/topics/treatment.html
http://ebmh.bmjjournals.com/