kimberly mcgrath, psy.d . jesus perez, psy.d . gihan omar, psy.d

Enhancing engagement by helping families understand the symptom

profiles of their children vs. diagnostic categories

Kimberly McGrath, Psy.D.Jesus Perez, Psy.D.

Gihan Omar, Psy.D.

While mental disorders are widespread in the population, 26.2%, the main burden of illness is concentrated among a much smaller proportion (about 6 percent, or 1 in 17) who suffer from a seriously debilitating mental illness (NIH, 2008)

Just over 20 percent (or 1 in 5) children, either currently or at some point during

their life, have had a seriously debilitating mental disorder(NIH, 2008).

Attention Deficit Hyperactivity Disorder (ADHD)

Bipolar Disorder (BD) Post-Traumatic Stress Disorder (PTSD) Disruptive Behavior Disorders (DBD)

Most Common Diagnoses Found in Children &

Adolescents

Bipolar Disorder

Diagnostic Trends

Blader J.C. (2011) Acute Inpatient Care for Psychiatric Disorders in the United States, 1996 through

2007. Arch Gen Psychiatric. Published online August 1, 2011

Diagnosis

96-97 98-99 00-01 02-03 04-05 06-07

8.90% 9.38% 21.5% 28.3% 28.3% 33.4% 29.8%

4-12yrs 13-17yrs 18-25yrs 26-40yrs 40+05

101520253035404550

4.4

35.2

14.3 16.2

29.3

Diagnostic Trends

Age Range

% o

f Ad

mis

sion

s

2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

5

10

15

20

25

30

6.1 7.4 7.3 8.5 9.1 9.712

1013.6

16.4

Diagnostic Trends

Year

% o

f Ad

mis

sion

s

Bipolar disorder diagnosed 40 times more over the last decade (NIMH 2007)

Various studies demonstrate as much as 60% of children with BD are also diagnosed with ADHD (Scheffer, Kowatch, Carmody, Rush 2005; Dickenstein, Nelson, Mcclure, Grimley, Knopf, Brotman, Rich Pine, Leibbenluft 2007)

Children with Conduct Disorders often suffer from depression and various anxiety disorders as well as learning disorders and substance abuse disorders (Surgeon General’s Report 2001)

Co-Occurring Disorders

Elements of abnormality include:◦ Suffering◦ Maladaptiveness◦ Deviancy◦ Violation of the Standards of Society◦ Social Discomfort◦ Irrationality and Unpredictability

The Elements of Abnormality

Three basic approaches include:◦ The categorical approach–

a patient is healthy or disordered, but there is no overlap

◦ The dimensional approach–the patient may fall along a range from superior functioning to absolutely impaired functioning

◦ The prototypal approach–a conceptual entity depicts an idealized combination of characteristics, some of which the patient may not have

Models of Classification

Diagnostic and Statistical Manual of Mental Disorders (DSM)◦ Introduced in 1952 ◦ Moving from a subjective to operational definition.◦ Diagnosis is based on signs and symptoms

DSM purports to be a categorical system, but it is in fact prototypal

Allen Frances, Chair of the DSM IV American Psychiatric association task force

DSM Classification of Mental Disorders

Denomination Qualification Prediction

Principal Function of Classification

Irritability Difficulties sleeping Poor concentration/distractibility Impulsivity Disruptive Behavior

Guess the Diagnosis?

DSM –IV has 295 separately named disorders but only 167 symptoms.

As such overlap and sharing of symptoms is common.

DSM Fun Facts

Engagement is defined as the “participation necessary to obtain optimal benefits from an intervention” (Prinz and Miller, 1991)

There are two components of engagement: Behavioral component-Client attendance and performance Attitudinal-Emotional investment and commitment

The Concept of Engagement

Exist at multiple levels including the child, family, agency and community

Primary factors: Personal and Social Stressors Client attitude towards services and perceived

relevance of the services (Mary McKay et. al, 2001) “Perspective Divergence”-Clients who may have

treatment expectations that differ from those of practitioners (Reis & Brown, 1999)

BARRIERS TO ENGAGEMENT

1) Common sense language and constructs familiar to parents, teachers and peers.

2) Avoid jargon that is stigmatizing or initiates a negative reaction in the client.

How do we increase engagement?

Personality Traits Self-Regulation Capacity and Coping Skills Self Related Concept

(Muris, Mayer, Reinders; 2008)

Terms easily understood by parents

Structure of Psychopathology

Fear

OCD

Distress

Alcohol

Drugs

Internalizing

Externalizing

Psychosis

Jenson, Goldman, Offord, et al (2011) study identified that few than 25% of children who had profiles predictive of an impairing psychiatric diagnosis received services in the previous 6 months.

They conclude symptom profiles might help increase public awareness of mental health problems.

Action Signs

Extreme emotions that interfere with daily life (e.g. depression, anger).

Behaviors that put the child or others at risk of physical harm (suicidal plans, attempts, aggression)

Extreme inattention or hyperactive behavior that caused school failure or physical danger

Action Signs Continued

Identification of Symptoms

Effective Treatment

Symptom Reduction

Client Level

◦ Lack of client compliance or adherence to treatment

◦ Multiple and/or Inappropriate MedicationsPossible Results:

Lack of symptom relief Negative side effects Adverse drug reactions

Implications

Client Level continued…◦ Self Fulfilling Prophecy

“There must be something wrong with me.” “ I act this way because I’m Bipolar”

◦ Negative Stigma “I’m crazy”

Possible Results: Client’s functioning and outlook continues to deteriorate

Implications

Caregivers, Providers and System Level◦ Repeated use of inappropriate treatment

interventions that often lead to treatment failure

◦ High Costs of the “Revolving Door”

◦ Loss of credibility for the providers and the treatment system in general

Implications

For more information on references or about this presentation please email us:Gihano@citrushealth.comKimberlym@citrushealth.comJesusp@citrushealth.com