**Working with youth **Working with youth who have mental who have mental health disorders**health disorders**

By: Debbie Tiger, MS, CTRSBy: Debbie Tiger, MS, CTRS

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Cunningham Children’s Cunningham Children’s HomeHome

Ages 8-18Ages 8-18 clinical disorder (DSM-5, Axis 1-3 combined now)clinical disorder (DSM-5, Axis 1-3 combined now) Mental disorder – clinically significant disturbance in an Mental disorder – clinically significant disturbance in an

individual’s cognition, emotion regulation, or behavior individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, that reflects a dysfunction in the psychological, biological, or developmental processes underlying biological, or developmental processes underlying mental functioning. (DSM-5, 2013)mental functioning. (DSM-5, 2013)

Presenting problems severely affecting most areas of Presenting problems severely affecting most areas of life: school, home, work, relationshipslife: school, home, work, relationships

Not able to be maintained in home placement Not able to be maintained in home placement (runaway, hospitalizations, suspensions from school)(runaway, hospitalizations, suspensions from school)

Common child/adolescent Common child/adolescent disorders:disorders:

Neurodevelopmental disorders (ID, Global dev. Neurodevelopmental disorders (ID, Global dev. Delay, Communication disorders, ASD, ADHD, Delay, Communication disorders, ASD, ADHD, Specific Learning Dis., Tic Disorders)Specific Learning Dis., Tic Disorders)

Schizophrenia spectrum and other psychotic Schizophrenia spectrum and other psychotic disorders (delusional disorder, schizophrenia, disorders (delusional disorder, schizophrenia, etc)etc)

Bipolar and related disorders (BP1, BP2, Bipolar and related disorders (BP1, BP2, Cyclothymic)Cyclothymic)

Depressive Disorders (Disruptive Mood Depressive Disorders (Disruptive Mood Dysregulation Disorder, Major Depressive Dysregulation Disorder, Major Depressive Disorder, Persistent Depressive Disorder)Disorder, Persistent Depressive Disorder)

Common diagnoses Common diagnoses cont’dcont’d

Anxiety disorders (separation AD, specific phobia, Anxiety disorders (separation AD, specific phobia, social AD, Panic AD, Agoraphobia, GAD)social AD, Panic AD, Agoraphobia, GAD)

OCD- and related disorders (OCD, Body Dysmorphic OCD- and related disorders (OCD, Body Dysmorphic Disorder, Hoarding)Disorder, Hoarding)

Trauma and Stressor-Related Disorders (RAD, Dis-Trauma and Stressor-Related Disorders (RAD, Dis-inhibited Social Engagement Disorder, PTSD, inhibited Social Engagement Disorder, PTSD, Adjustment Dis.)Adjustment Dis.)

Disruptive, impulse control, conduct disorders (ODD, Disruptive, impulse control, conduct disorders (ODD, Intermittent ED, conduct dis., kleptomania, pyromania)Intermittent ED, conduct dis., kleptomania, pyromania)

Substance related disorders (alcohol, caffeine, Substance related disorders (alcohol, caffeine, cannabis, opioid, stimulants, etc) cannabis, opioid, stimulants, etc)

Neurodevelopmental Neurodevelopmental DisordersDisorders

ADHD: inattentive, hyperactive, ADHD: inattentive, hyperactive, impulsive, difficulty organizing, loses impulsive, difficulty organizing, loses things, easily distracted by extraneous things, easily distracted by extraneous stimuli, “often unable to play or engage in stimuli, “often unable to play or engage in leisure activities quietly”, often talks leisure activities quietly”, often talks excessively (DSM-5 2013) **formerly part excessively (DSM-5 2013) **formerly part of disruptive disorder**of disruptive disorder**

NeuroDD cont’dNeuroDD cont’d

ASD: persistent deficits in social ASD: persistent deficits in social communication and social interaction across communication and social interaction across multiple contexts: social-emotional reciprocity multiple contexts: social-emotional reciprocity deficits, nonverbal communication deficits, deficits, nonverbal communication deficits, deficits in developing, maintaining and deficits in developing, maintaining and understanding relationships; restricted, understanding relationships; restricted, repetitive patterns of behavior, interests, repetitive patterns of behavior, interests, activities (DSM-5, 2013)-add specifiers, activities (DSM-5, 2013)-add specifiers, severity levels.severity levels.

NeuroDD cont’dNeuroDD cont’d

ID – onset during developmental period; ID – onset during developmental period; deficits in intellectual functions deficits in intellectual functions (reasoning, problem solving, abstract (reasoning, problem solving, abstract thinking, planning, judgment), deficits in thinking, planning, judgment), deficits in adaptive functioning. Specify: mild, adaptive functioning. Specify: mild, moderate, severe, profound. moderate, severe, profound.

Global DD – under age 5, clinical severity Global DD – under age 5, clinical severity level cannot be reliably assessedlevel cannot be reliably assessed

Schizophrenia SpectrumSchizophrenia Spectrum

Key features – delusions and Key features – delusions and hallucinations. hallucinations.

Generally not diagnosed as having a Generally not diagnosed as having a schizophrenia spectrum disorder until schizophrenia spectrum disorder until late adolescence or young adulthood. late adolescence or young adulthood.

Bipolar DisordersBipolar Disorders

BP1 – meets criteria for a manic episodeBP1 – meets criteria for a manic episodeCould be preceded or followed by hypomanic and depressive Could be preceded or followed by hypomanic and depressive

episodes.episodes.

BP2 – meets criteria for hypomanic and BP2 – meets criteria for hypomanic and depressive episodesdepressive episodes

Cyclothymic – for at least one year in children Cyclothymic – for at least one year in children and adolescents, there have been many and adolescents, there have been many periods of hypomanic and depressive episodes periods of hypomanic and depressive episodes – do not meet full criteria for BP2– do not meet full criteria for BP2

Specifiers – seasonal, rapid cycling etc..Specifiers – seasonal, rapid cycling etc..

Depressive DisordersDepressive Disorders

Disruptive Mood Dysreg. Disorder – Disruptive Mood Dysreg. Disorder – severe recurrent temper outbursts (verbal severe recurrent temper outbursts (verbal rages or physical aggression) that are rages or physical aggression) that are grossly out of proportion in intensity or grossly out of proportion in intensity or duration to the situation; inconsistent with duration to the situation; inconsistent with developmental level; 3 X per week; mood developmental level; 3 X per week; mood in between outbursts is irritable/angry in between outbursts is irritable/angry most of the day. most of the day.

Depressive Disorders Depressive Disorders (cont’d)(cont’d)

Major Depressive: depressed mood most of Major Depressive: depressed mood most of the day, nearly every day, irritable mood in the day, nearly every day, irritable mood in children, markedly diminished interest or children, markedly diminished interest or pleasure in all activities, weight loss/gain, pleasure in all activities, weight loss/gain, insomnia, hyper-somnia, psychomotor insomnia, hyper-somnia, psychomotor agitation/retardation, feeling worthless, agitation/retardation, feeling worthless, decreased ability to think/concentrate, thoughts decreased ability to think/concentrate, thoughts of death including suicidal thoughts, suicide of death including suicidal thoughts, suicide attempt or specific plan.attempt or specific plan.

Depressive Disorders Depressive Disorders (cont’d)(cont’d)

Persistent Depressive Disorder (formerly Persistent Depressive Disorder (formerly Dysthymia): Depressed mood most of Dysthymia): Depressed mood most of the day; presence of at least two the day; presence of at least two symptoms listed from MDD (abbreviated symptoms listed from MDD (abbreviated list – no suicidal plans). list – no suicidal plans).

Substance/medication induced Substance/medication induced depression, due to a medical condition depression, due to a medical condition

Anxiety DisordersAnxiety Disorders

Separation AD: excessive fear or anxiety Separation AD: excessive fear or anxiety concerning separatin from individual concerning separatin from individual attached to; excessive worry about losing attached to; excessive worry about losing major attachment figures (harm, illness, major attachment figures (harm, illness, disasters etc.); excessive worry about disasters etc.); excessive worry about possible events (lost, being kidnapped); possible events (lost, being kidnapped); reluctance to go out, away from home, to reluctance to go out, away from home, to school; fear of being alone, repeated school; fear of being alone, repeated nightmares about the theme of nightmares about the theme of separation.separation.

Anxiety Disorders Anxiety Disorders (cont’d)(cont’d)

Specific Phobias: marked fear or anxiety Specific Phobias: marked fear or anxiety about a specific object/situation: flying, about a specific object/situation: flying, heights, animals, blood.heights, animals, blood.

Social Anxiety Dis.(social phobia): Social Anxiety Dis.(social phobia): marked fear or anxiety related to social marked fear or anxiety related to social situations, being exposed to scrutiny situations, being exposed to scrutiny (being observed eating, giving a speech, (being observed eating, giving a speech, meeting unfamiliar people)meeting unfamiliar people)

Anxiety Disorders Anxiety Disorders (cont’d)(cont’d)

Panic Disorder – panic attacks, abrupt surge of Panic Disorder – panic attacks, abrupt surge of intense fear that reaches a peak within intense fear that reaches a peak within minutes. Symptoms: pounding heart, minutes. Symptoms: pounding heart, sweating, shaking, shortness of breath, dizzy, sweating, shaking, shortness of breath, dizzy, chills, numbness, de-realization, fear of losing chills, numbness, de-realization, fear of losing control, fear of dying. control, fear of dying.

Agoraphobia – fear/anxiety related to use of Agoraphobia – fear/anxiety related to use of public transportation, being in open spaces, public transportation, being in open spaces, enclosed spaces, being in a crowd, standing in enclosed spaces, being in a crowd, standing in line, being outside of home alone (fear escape line, being outside of home alone (fear escape might be difficult)might be difficult)

Obsessive Compulsive Obsessive Compulsive and related disordersand related disorders

OCD: intrusive, recurrent, persistent OCD: intrusive, recurrent, persistent thoughts, impulses or images (not simply thoughts, impulses or images (not simply excessive worries about real-life), excessive worries about real-life), obsessional thoughts; Compulsion - obsessional thoughts; Compulsion - repetitive bxs, aimed at preventing or repetitive bxs, aimed at preventing or reducing distress. Over-importance on reducing distress. Over-importance on thoughts – believe having a bad thought thoughts – believe having a bad thought is as bad as acting on it. is as bad as acting on it.

OCD and related (cont’d)OCD and related (cont’d)

Body Dysmorphic Disorder: preoccupation Body Dysmorphic Disorder: preoccupation with one or more defects, flaws that are not with one or more defects, flaws that are not observable or appear slight to others. Perform observable or appear slight to others. Perform repetitive mirror checking, excessive grooming, repetitive mirror checking, excessive grooming, skin picking, seeking reassurance, comparing skin picking, seeking reassurance, comparing to others. to others.

HoardingHoarding Trichotillomania Trichotillomania Excoriation Excoriation

Trauma and Stressor Trauma and Stressor related disordersrelated disorders

RAD: Disturbed and developmentally inappropriate RAD: Disturbed and developmentally inappropriate social relatedness in most contexts before age 5; social relatedness in most contexts before age 5; excessively inhibited, or highly ambivalent (resist excessively inhibited, or highly ambivalent (resist comforting, avoidance); minimal responsiveness, comforting, avoidance); minimal responsiveness, limited positive affect; Pathogenic care is part of child’s limited positive affect; Pathogenic care is part of child’s history (disregard for basic needs, emotional and history (disregard for basic needs, emotional and physical, frequent change in primary caregivers).physical, frequent change in primary caregivers).

Disinhibited Social Engagement Dis. (formerly part of Disinhibited Social Engagement Dis. (formerly part of RAD): pattern of bx, child approaches/interacts with RAD): pattern of bx, child approaches/interacts with unfamliar adults, overly familiar verbal/physical unfamliar adults, overly familiar verbal/physical interactions, willingness to go with an unfamiliar adultinteractions, willingness to go with an unfamiliar adult

Trauma/Stressor Dis. Trauma/Stressor Dis. (cont’d)(cont’d)

PTSD – exposure to actual or threatened PTSD – exposure to actual or threatened death, serious injury, or sexual violence death, serious injury, or sexual violence (directly, witnessing, learning event happened (directly, witnessing, learning event happened to close family member/friend, experiencing to close family member/friend, experiencing repeated or extreme exposure to details) repeated or extreme exposure to details) Symptoms: disorganized, agitated, intense Symptoms: disorganized, agitated, intense fear, helplessness, horror, recurrent fear, helplessness, horror, recurrent thoughts/feelings, flashbacks, distress when thoughts/feelings, flashbacks, distress when triggered, illusions, nightmares. triggered, illusions, nightmares.

Trauma/Stressor Dis. Trauma/Stressor Dis. (cont’d)(cont’d)

PTSD – persistent avoidance of stimuli PTSD – persistent avoidance of stimuli associated with trauma associated with trauma

Negative alterations in cognitions/moods Negative alterations in cognitions/moods – to manage and avoid – negative – to manage and avoid – negative coping, reactivity (exaggerated startle coping, reactivity (exaggerated startle response, hypervigilance, problems response, hypervigilance, problems concentrating, sleep disturbance, self-concentrating, sleep disturbance, self-destructive)destructive)

Tips for working with youth Tips for working with youth with ED/BD diagnoses: with ED/BD diagnoses:

Know your clienteleKnow your clientele Professional boundariesProfessional boundaries Develop a relationshipDevelop a relationship Firm, consistent limits/boundariesFirm, consistent limits/boundaries Offer choices; no power strugglesOffer choices; no power struggles Problem solve; be curiousProblem solve; be curious Empathy, caringEmpathy, caring HUMORHUMOR

Tips (cont’d):Tips (cont’d):

If you know a client has an ED or BD If you know a client has an ED or BD diagnoses:diagnoses:ask client how staff can assist themask client how staff can assist themask client what triggers themask client what triggers them

ask parent/guardian for guidanceask parent/guardian for guidancetime away to re-group; re-set time, time away to re-group; re-set time, distance, distractdistance, distractdevelop plans; be pro-activedevelop plans; be pro-active

Tips (cont’d):Tips (cont’d): SAFETYSAFETY Belonging, Independence, Generosity, Belonging, Independence, Generosity,

Mastery – Circle of Courage (Brendtro, Mastery – Circle of Courage (Brendtro, Brokenleg, Van Bockern, 1990)Brokenleg, Van Bockern, 1990)

Nurtured Hearts: Truth of the moment– Nurtured Hearts: Truth of the moment– energizing positives – low energy to energizing positives – low energy to negativesnegatives

Recreation at CCHRecreation at CCH

IIAA – residential sports associationIIAA – residential sports association Cooperative gamesCooperative games Educational groups –anti-bullying, Educational groups –anti-bullying,

relationship skills, social skills, friendship relationship skills, social skills, friendship skills, anger management, coping skillsskills, anger management, coping skills

Pet Therapy, Self Awareness, relaxation, Pet Therapy, Self Awareness, relaxation, exploring sensesexploring senses

Sports skill development, fitnessSports skill development, fitness