special needs children a risk assessment model … › portals › 0 › afcc oct 2019...

10/16/2019

1

1

Special Needs Children: A Risk Assessment Model for Developing

Parenting Plans

Daniel Pickar, PhD, ABPP

AFCC Webinar PresentationOctober 16, 2019

Sponsored by OurFamilyWizard

Contact Information for Presenter

Daniel Pickar, PhD, ABPP Email: [email protected]

Website: www.danielpickarphd.com

Special Needs Children: Risk Assessment and Parenting Plans

2

Recent Publications by Daniel Pickar, Ph.D. on Special Needs Children

Pickar, D.B., & Kaufman, R.L. (2015). Parenting plans for special needs children: Applying a risk-assessment model. Family Court Review, 52(1), 113-133.

Kaufman, R.L., & Pickar, D.B. (2017). Understanding Parental Gatekeeping in Families with a Special Needs Child. Family Court Review, 55(2), 195-212.

Pickar, D.B., & Kaufman, R.L. (2019). The Special Needs Child After Separation or Divorce: Involving Both Parents in Treatment and Intervention Planning(book chapter). In Greenberg, Saini, & Fidler (Eds.). Evidence-Informed Interventions for Court Involved Families, Oxford University Press.


3

10/16/2019

2

Definition of Special Needs Children (SNC)

SNC is an umbrella designation encompassing a staggering array of children with various disorders

“Special Needs” can include children with: Autistic spectrum disorders/Down

Syndrome/Cerebral Palsy ADHD and learning disabilities Serious psychiatric disorders Serious medical illnesses, chronic developmental

disorders, physical disabilities Profound cognitive impairment/Intellectual Disability Sensory impairment


4

Specialized Parenting Approaches Most Often Required

For many SNC, “ordinary” parenting skills are insufficient, as they may require extraordinary parenting

These children often place phenomenal demands upon the adults who care for them

SNC children require a very high level of supervision and time-consuming interface with medical, educational, and mental health personnel

If parents disagree on treatment/educational approaches while married, separation/divorce usually magnifies these differences


5

“Developmentally-Based” Parenting Plans and SNC

Use “developmentally – based” parenting plans (PP) with caution with SNC

Developmentally based PP’s may be inappropriate, as many SNC function significantly below their developmental age and pose extreme behavioral challenges

In many instances, the need for consistent routine and stability in residential placement and/or the primary need for safety/supervision may outweigh a PP schedule that provides significant time with both parents


6

10/16/2019

3

Dramatic Rise In Children/Teens With Special Needs In Last 15

Years

Prevalence of Autistic Spectrum Disorders (ASD) CDC (2006) – 1 in 110 (.9 %) children dx with ASD

CDC (2012) - 1 in 88 (1.2 %) children dx with ASD

CDC (2015) – 1 in 59 children dx with ASD (1.5 %; 4.5x more prevalent in boys)

Prevalence of ADHD DSM V (2013) – 5 % of children dx with ADHD

CDC (2013) – 1 in 5 (20%) high school boys dx with ADHD

Prevalence of Depressive Disorders 3 % in children

8% in teenagers (1 in 5 teens dx with depression by age 18)

Teen suicide is 2nd leading cause of adolescent death in U.S.

Non-suicidal self-injury (12 to 14 % in teens)


7

Challenges For Family Law Professionals With SNC

Increasing % of cases in Family Courts have a SNC No professional can be expert on every type of SNC However – Judges, mediators, attorneys, custody

evaluators, and parenting coordinators need specialized knowledge about the most commonly seen SNC in family court

Specialized knowledge is required to facilitate development of appropriate parenting plans for these families


8

Impact of Special Needs Children on Marriage

Several research studies have found higher rates of separation and divorce in families with autistic spectrum disorders and ADHD

Autistic Spectrum Disorders – 5 years after diagnosis – 23% ended in divorce compared to 13.8% for controls (Hartley, Barker, 2010)

ADHD- by age 8, 22.7% ended in divorce compared to 12.6 % for controls (Wymbs et al, 2008)

A higher percentage of parents in these studies had: greater sleep disturbance, burn-out, anxiety, and depression (than controls)


9

10/16/2019

4

Impact of Separation/Divorce on Special Needs Children

Stresses of parental separation/divorce exacerbates the symptoms of many SNC, especially those with psychiatric disorders, ADHD, autistic spectrum disorders, asthma

Due to separation or divorce, there are often fewer financial resources for these children

If parents disagree on treatment/educational approaches while married, separation/divorce usually magnifies these differences


10

Determining “Best Interests” Parenting Plans with SNC

Must consider more than common statutory factors (i.e., parental stability, parenting skills, attachment relationships)

Multiple health, safety, and educational issues must be weighed with SNC

Like all children, SNC are at risk for poor outcomes when their families go through separation/divorce.

However, many SNC may be at risk for a host of greater harmful short and long-term consequences based upon the presence and severity of their disorder


11

Importance of Risk Assessment with SNC

Risk assessment already being utilized in family court cases with DV (Jaffe, Johnston, Crooks, and Bala, 2012; Austin and Drozd, 2012) and relocation (Austin, 2008)

Decision Trees (Drozd, Olesen, Saini, 2013) also highly useful for risk-assessment

Risk assessment can be useful for family law professionals who must weight multiple factors in SNC cases

The important question in risk assessment is, “how can harm be reduced and positive adjustment enhanced”

Risk factors should be based on empirical research


12

10/16/2019

5

Development of a Risk-Assessment Model with SNC -1

Important to provide a systematic analysis of multiple factors related to SNC

Domains/variables in our model are drawn from several sources, including: Child psychiatry, pediatric medicine (i.e., DSM V),

other risk assessment models used in family law Diagnostic and treatment research - symptom

profiles and developmental courses of specific disorders that can lead to physical, social, or emotional compromises for child

Educational and medical risks associated with a range of childhood disorders


13

Development of a Risk-Assessment Model with SNC - 2

Empirically-based educational, psychotherapeutic, and medical treatment interventions that can benefit specific childhood disorders

The risk to a special needs child if such interventions are not provided

Emphasis is placed on the demands on parents to support and participate in intervention plans

The model incorporates previous literature focused on SNC in divorce (i.e, Jennings, 2005; Saposnek et al, 2005)


14

Risk-Protection factors

Domains & sub-variables exist on a continuum of risk versus protection.

Examine domains in the context of other global variables:

Child factors: including basic temperament; the nature and severity of the disorder; the nature and demands of the treatment plan.

Parent factors: including each parent’s capacity to address the special circumstances and behaviors that arise from the child’s disorder; parent availability; parent participation in the treatment plan.

Parent–child factors: including parent insightfulness and empathy for the child; the temperamental match between each parent and the child.


15

10/16/2019

6

Risk-Protection Continuum for Use with Special Needs Children

Domain More likely risk for harm

More likely to provide protection

Implications

Safety Serious safety concerns for child, caretakers, siblings and environment may trump all other factors in custody determinations.

Physical safety/ supervision

Lack of or inconsistent supervision

Vigilant supervision consistent with child’s functional capacities

Environmental safety

Parent has not implemented appropriate home safety modifications as needed

Parent has or is willing to implement recommended home safety modifications


16




Implications

Nature/severity of specific syndromes

Impact on child’s day-to-day functioning

More severe disorder with compromises in self-care and other adaptive behavior

Disorder is relatively mild in severity and does not significantly impact adaptive behavior

More compromised children are less adaptable and may have more difficulty with “age-typical” physical custody schedules.

Overall treatment and intervention plan

More complex and/or controversial and difficult to implement and sustain

Relatively straightforward and easy to implement.

The more complex the plan, the more agreement is needed between parents. In these cases, consider carefully if joint decision-making can be done in a timely fashion with limited conflict.


17



More likely to provide

protection

Implications

Intervention plan: Medical; Educational; Therapeutic Awareness and

acceptance of intervention plan

Parent denies need for and/or refuses to pursue needed services.

Parent pursues and implements appropriate services.

Consider primary decision-maker and/or custodial parent if one parent is not cooperative with services

Time availability Parent is not available to take child to needed appointments and is not in contact with treatment providers.

Parent has good availability for appointments and prioritizes availability for child’s treatment.

If parents are not similarly available, consider a primary custodial parent (for physical custody), especially if demands for appointments are high.

Parent participation in services

Parent refuses to participate in parent component of therapeutic services.

Parent is available and willing to participate in parent component of therapeutic services.

Consider primary decision-maker and/or custodial parent if one parent is not cooperative services


18

10/16/2019

7


Domain:

Parenting skills

Implications:

In general, when one parent is far more skilled and attuned than the other, consider a primary custodial parent, especially when disorder is moderate to severe.If a parent’s skill and attunement are so faulty as to impact judgment, consider sole decision-making to the other parent.


19


Domain: More likely risk for harm More likely to provide protection

Parenting Skills

Parent/child temperament match

Poor match between parent and child temperaments, which interferes with parent’s ability to tolerate and manage child’s behavior.

Positive match between parent and child temperaments which enables parent to tolerate and manage child behaviors.

Structure; routine; discipline Parent unable to implement consistent and appropriate structures and routines (i.e., meals, bedtime, hygiene, chores), and follow-thorough with in-home behavioral plan.

Parent able to implement consistent structures and routines (i.e., meals, bedtime, hygiene, chores) and follow-through with in-home behavioral plan.

Time availability at home Parent does not have adequate time to manage special needs of child at home.

Parent has time available to manage the special needs of the child at home.

Emotional attunement Parent misses or misreads cues and is unable to implement effective and timely interventions.

Parent is able to fashion and implement effective and timely interventions.


20



More likely to provide

protection

Implications

Co-parenting and level of conflict Co-parenting

relationshipPoor communication; lack of collaboration; lack of coordination between homes

Reasonably effective and timely communication; able to coordinate child’s life in both homes.

With poor communication and lack of coordination, consider both sole legal decision-making and a primary custodial parent.

Conflict level Relatively high and persistent. Child exposed to parents’ disagreements and acrimony

Relatively low; conflict limited to discrete infrequent episodes. Child buffered from whatever conflict arises.

The higher the conflict, the less likely that shared parenting and joint decision-making are feasible.


21

10/16/2019

8




Parenting plan – schedule considerations Transitions between

homesSchedule with multiple transitions, especially when parents are in conflict.

Schedule that minimizes transitions and has low-key and effective transitions.

Predictability of schedule Schedule that has many changes week-to-week or has too much unpredictability.

Schedule that is stable, predictable and one that the child can learn.

Parenting plan schedule consistent with child’s developmental level (not just chronological age)

Parenting plan is not consistent with child’s developmental level.

Parenting plan is consistent with child’s developmental level.


22


23IS JOINT LEGAL-DECISION-MAKING POSSIBLE?

Do the parents agree on:

Diagnosis?

Intervention Plan?

Co-parenting?

23

Re: Legal Custody andDecision-Making

Consider…


24

Agreement re:Diagnosis?

Agreement re:Treatment Plan?

Co-Parenting Consider

Yes Yes Reasonably sound and functional

Joint Legal Custody

Yes or No No Poor &/or high conflict

Sole legal custody

Yes Yes– Apart from discrete areas

Reasonably sound and functional

Joint Legal Custody

Yes or No Yes Poor &/or high conflict

Joint Legal with PC

10/16/2019

9

AD/HD Deficits & Difficulties

ADHD Seen in 11% of U.S. Children as Diagnoses Rise

New York Times, March 31, 2013 – CDC Study

Behavioral disinhibition (a disorder of “too much behavior”)

Poor sustained attention/resistance to distraction

Deficits in self-regulation of activity level in a given situation (including emotional regulation)

Difficulty remembering (poor “working memory”)

Poor sense of time

Difficulty initiating work

Lack of flexibility in thinking and planning

Greater variability in task performance


25

Treating the Family with an ADHD Child

Pillars of treatment: Parent-based education and

behavioral management Behavioral counseling with parents has

been shown to be more effective than individual counseling with the child

Carefully managed medication Proper school planning and

accommodations, when indicated


26

USING THE RISK ASSESSMENT MODEL TO INFORM INTERVENTIONS WITH

ADHD CHILDREN

ADHD – these children benefit from environmental consistency between homes and school

ADHD children thrive with clear structure and rules, and consistency in behavioral interventions and consequences

Requires a high level of parental coordination and cooperation to meet ADHD child’s needs

Parents need to agree on expected behaviors, reinforce such behaviors, and provide consistent punishment or consequences when behavior not met


27

10/16/2019

10

Specific Challenges for Divorced Parents – ADHD

Level of acceptance vs. denial that the child suffers from ADHD

Use of medication

Agreement on treatment providers and treatment modalities

High conflict: the challenge of collaboration

Parallel parenting: viable solution?


28

Parenting Plan Considerations ADHD

Good assessment(s) of the child Defining treatment needs and providers

Coordination between homes and caregivers Parenting plan considerations:

Transitions between homes Need for stable routines How to keep both parents involved if there is a

“school-week” parent

All parents involved with school and the treatment team


29

Depression (Especially in Adolescents)

Major Depressive Episode, Persistent Depressive Disorder (Dysthymia), Disruptive Mood Dysregulation Disorder

Characteristics and Symptoms of Major Depressive Disorder and Persistent Depressive Disorder

Depressed mood/diminished interest in activities

Insomnia/weight loss/fatigue/low energy

Poor concentration or difficulty making decisions

Low self-esteem/feelings of hopelessness

Suicidal thinking – high risk of suicide attempts in teens who are impulsive

Self-harm behavior – cutting, burning, substance abuse


30

10/16/2019

11

Prevalence of Depression in Adolescents

In any given year, about 8% of female adolescents and 4% of males experience a serious episode of depression

Around 1 in 5 adolescents will experience at least one depressive episode before adulthood

Around 80% of teen suicide attempters and 60% of teen suicide completers have a mood disorder

Teen suicide – 2nd leading cause of death in teens (teen girls attempt 5x more than boys; more completed suicides by boys though, due to lethality of means (i.e., gunshot vs. overdose of pills)

1 in 5 teens think about suicide:/1 in 12 teen made suicide attempt


31

Evidence-Based Treatments for Depression in Teens

Cognitive Behavioral Therapy (CBT) – typically conducted in individual or group therapy

Medication – typically SSRI’s and mood stabilizers (should never be used as a “stand alone” treatment)

Dialectical Behavior Therapy (best research support) Combines skill-based multi-family groups with

individual therapy (high level of parental involvement)

Teaching of skills for emotion regulation, distress tolerance, mindfulness, and interpersonal effectiveness

DBT skills are most often taught in multi-family group skills classes


32

Physical Safety Considerations with Depressed/Suicidal Teens

Co-parenting interventions are crucial with suicidal teens, to arrive at joint safety plans

Therapists working with parents must insure that each parent has acceptance of the seriousness of their teen’s condition (as opposed to being “in denial”)

Preservation of life and and participation in mental health treatment may take priority over child sharing

Safety - If teen is suicidal and engages in self-harm behavior, can both parents supervise/lock-up sharps

Are there disagreements about medication for the depressed teen

Is the teen using alcohol and/or drugs, as drug or alcohol use greatly increases the risk of suicidal or self-harm behavior.

Need for parental monitoring of drug or alcohol use, such as drug test, periodic room checks, being awake at night when teen comes home from a social event to check if teen has been using alcohol or drugs (“hug and sniff test”)


33

10/16/2019

12

Autistic Spectrum Disorder: Defining Characteristics

ASD – A group of neurodevelopmental conditions whose primary features are (DSM V): Significant difficulties with reciprocal interaction Deficits in verbal and nonverbal communication (not making

eye contact, not reading social cues) The presence of repetitive or ritualistic behavior/hyper-

reactivity to sensory input Insistence on sameness and inflexible adherence to routine

Continuum/Spectrum Diagnosis – 3 severity levels 1. Level 1 – Requiring Support (i.e., in DSM IV – Asperger’s) 2. Level 2 – Requiring Substantial Support 3. Level 3 – Requiring very substantial support (these children

often have significant intellectual and language impairment)


34

Prognosis for ASD

For most children, ASD symptoms on the severe end of the spectrum (level 2 and 3) are chronic and require lifelong management.

Higher functioning ASD children (level 1) have better prognosis for independent and successful adult functioning, but with limitations in types of employment, quality of social relationships, and continued social skill deficits


35

Key Considerations for Parenting Plan Development

Interventions such as Applied Behavioral Analysis require significant parent training (20-40 hrs. week for 2 years)

ASD child thrives with schedules and predictability ASD children have excessive need for environmental

consistency ASD children may become highly stressed and self-

injurious when routines are disrupted or with too many transitions

Physical dangers due to self absorption – severe ASD children require 24 hour supervision


36

10/16/2019

13

Autistic Spectrum Disorder Case for Child Custody Evaluation

Mother and Father separated after 10 years of marriage

2 female children, ages 12 and 9 12 year old child has severe ASD (level 3) Custody evaluation is taking place one year after

separation Parents have joint legal and physical custody 9 year old child in 50/50 custody arrangement – no

dispute between parents about her parenting plan ASD child engages in self-injurious behavior when

stressed or with changes in routine


37

Custody Dispute Over ASD Child

Father has had primary physical custody since separation, and he has remained in the marital home

ASD child is with mother

Sundays from 1 pm to 7 pm

Wednesday and Friday from 2:30 to 7 pm

Mother has had 3 to 4 overnights in total over last 3 months

It took ASD child 6 months to even get out of the car to go into mother’s home

Mother wants to begin having 3 overnights a week (i.e., Friday to Saturday; Sunday to Monday; Wednesday to Thursday)

Father believes ASD child should be overnight in his home on every school night “for consistency and sameness”


38

Risk-Protection Factors: 1. Safety/Home Environment

Both parents supervise ASD child well

Both parents have safe physical home environments

Key difference between homes

ASD child has her own bedroom at Father’s Home

ASD child does not have her own bedroom at Mother’s home, but sleeps in mother’s bed and mother sleeps on the couch if child spends an overnight; Therefore, ASD child cannot have “sameness” and consistency in bedroom environments in Mother’s home


39

10/16/2019

14

2. Nature/Severity of Specific Syndrome

Child has “severe” ASD (level 3 – requiring very substantial support)

ASD child is impulsive, has limited frustration tolerance; she is very rigid and inflexible about changes in her routine

Therefore, child does not adapt well to changes in her environment and gets highly anxious and sometimes self-injurious with transitions

Two home environments with frequent transitions between homes is not ideal for severe ASD child

Given severity, one primary home may be best for child


40

3. Intervention Plan: Medical, educational, & Therapeutic

Child in excellent school for SNC Children Father has especially good relationship with school

staff, although Mother’s is improving Both parents accepting of dx of ASD Father works from home and is far more available

than Mother to take to school and to various medical and occupational therapy appointments

Both parents are willing to participate with child in sessions with the behavioral specialist, who will come to either home


41

4. Parenting skills

Father has features of high functioning ASD, which has led to some past problems interfacing with professionals

Conversely, Father’s ASD features have led him to have a good empathic attunement to daughter

Both parents generally have good attunement to child’s needs (but better temperament match for Father and child)

Both parents able to maintain consistent routine for child Discipline – Mother is more effective than Father in dealing with

“meltdowns” and self-injurious behavior While Mother is considerably more effective than Father in pushing ASD

child to try new behaviors and activities, Father is more patient and mother more prone to lose her temper

Mother models better interpersonal skills than father Mother more attentive to personal hygiene of child


42

10/16/2019

15

5. Co-Parenting and Level of Conflict

Father is very rigid and perseverative in thinking Father can be inattentive to social cues, making

communication with Mother difficult However, Father’s incredible dedication to his child ultimately

leads him to be inclusive of mother and he values her role Mother more flexible than Father Mother has mild substance abuse problem (2-3 glasses of wine

per day; nightly cannabis for sleep), but has recently reduced use

Parents can cooperate and support ASD child’s relationship with other parent, but joint decision-making is difficult


43

6. Parenting Plans Schedule Considerations

ASD Child needs schedule which minimizes transitions between homes

PP must must be consistent with child’s developmental level, which is similar to a 4 year old

There have been 3 to 4 instances of Mother having ASD child on school week overnight, and school staff noted child had difficulty getting out of Mother’s car, and was highly anxious at school on these days, with more behavioral tantrums and self-injurious behavior than usual

School staff requested that ASD child only come to school from Father’s home


44

Parenting Plan Recommendations -1

Joint Legal Custody of children, but Father to have decision-making authority if there is a dispute related to education, therapeutic, or medical treatment (he must first seek mother’s input)

9 year old child to remain on 50/50 schedule (2-2-5-5-); she also benefits from respite from sister

ASD Child - Primary physical custody with Father; Maternal Custody as follows: 1. Mother must provide residence whereby ASD child has

her own bedroom 2. Friday pick-up at school until Sunday at 4 pm 3. Wednesday (no overnight) from pick-up at school til 7pm


45

10/16/2019

16

Parenting Plan Recommendations - 2

Mother be required to not smoke marijuana and not consume alcohol on her custodial days

Mother required to attend one AA or NA meeting per week for 6 months

Co-parent counseling for minimum 12 sessions to address: 1. Consistency in diet to reduce ASD child’s weight in

conjunction with nutritionist 2. Consistency in hygiene standards (daily showers at father’s

home) 3. Hostile phone conversations should not happen in front of

children 4. Assist with the transition of ASD child beginning regular

overnights with mother


46

Conclusions (1)

Family law professionals should develop fundamental knowledge of commonly seen SNC and be familiar with evidence-based treatments;

Be cautious about automatically using “developmentally appropriate” parenting plans;

Parenting plans should be informed by assessment of the range of variables, with emphasis on parent availability, acceptance of diagnosis & treatment plan and ability to work with other parent;


47

Conclusions (2)

Risk for poor outcomes is multi-determined & depend on the nature/severity of disorder as well as parenting factors;

Consider safety first; Custodial plans may need to be

reviewed more frequently than is typical;

Consider the entire family system


48

special needs children a risk assessment model … › portals › 0 › afcc oct 2019...

Documents