Psychiatry and Speech Language P h l Pathology As many as 48% of children who have speech-language disabilities may later be diagnosed with a psychiatric disorder (Beitchman et al. 1986). Those with speech and language problems may develop co-morbid psychiatric disorders, i e depression/ anxiety (Johnson et al i.e. al. 1998).

Psychiatry and Speech Language P h l Pathology • Mental illness may manifest itself as a speech or language problem, i.e. selective mutism (Johnson et al al. 1998) • Disorders of speech may point to a psychiatric etiology of a disease disease, i.e., ie pressured speech as a manifestation of mania (Johnson (J h ett al. l 1998)

Psychiatry and Speech Language P h l Pathology • According g to Beitchman et al. 1986, as many y as 48.7% of children with speech/language disorders were later diagnosed as having a psychiatric disorder. • According to Cohen et al., 1989, out of 37 children aged 5-12, that were referred for psychiatric assessments, 28% had a moderate or severe language deficit that had not been previously suspected or diagnosed diagnosed. • Disorders of grammar, semantics, and pragmatics, but not phonology, overlap significantly with childhood psychiatric disorders disorders, according to Toppelberg et al al., 2000. • According to McDonald et al., 1998, 12 out of 53 psychiatrically hi t i ll di disturbed t b d children hild h had d no speech h and d language impairment (77% impaired)

Working with Children with Emotional/ Behavioral Disorders

Dawn R. Girten, M.A., CCC-SLP Chris Lackey Lackey, M.S., M S CCC-SLP CCC SLP

Objectives • Participants will be able to identify the relationship between mental health disorders and communication deficits. • Participants will be able to list common g and common mental health diagnosis characteristics associated with each diagnosis. • Participants will be able to list different strategies to use in therapy for children with ith emotional/ ti l/ b behavioral h i l di disorders. d

Psychiatry and Speech Language P h l Pathology The prevalence of language disorders among children with mental health issues is variable and ranges from 28% with moderate to severe language deficits that were never previously suspected (Cohen et al., 1989) to 77% language impairment among children with inpatient psychiatric admissions (McDonald et al., 1998).

Cincinnati Children’s Hospital Medical Center College Hill Program A psychiatric program consisting of Inpatient Residential Inpatient, Residential, Day Treatment Treatment, and Outpatient programs.

Reasons? Complex trauma associated with mental health disorders – Complex trauma refers to children’s experience of multiple traumatic events that occur within the care giving system and the social environment that is supposed to be the source of safety and stability in a child’s life. Physical abuse, sexual abuse, neglect, traumatic grief, d domestic ti violence, i l community it and d school h l violence, i l complex trauma, medical trauma, refugee, war, and terrorism

College Hill – 5 Inpatient Units – 3 Residential Units – Outpatient Program

Trauma According to the Department of Health and Human Services, neglect continues to be the most common form of abuse. abuse

– 2 Day Hospital Programs • Partial Hospitalization • Therapeutic Interagency Preschool Program

Cortisol eliminates neurons and cortisol i caused is db by stress. t

Treatment Team

Implications

• Psychiatrist Psychiatrist, Care Manager Manager, Social Worker, Nurse, Behavioral therapist, Occupational Therapist Therapist, SpeechSpeech Language Pathologist, Recreational Therapist Spiritual Leader Therapist,

• Comprehensive assessments are necessary for evaluating the whole child • Implementing individual strategies to aid in the child’s success and with education for the family upon discharge • Connecting the families to appropriate outpatient t ti t services i to t address dd underlying d l i deficits

Speech pathologists provide: • Screenings • Evaluations • Individual Treatment • Group treatment

Screenings Screenings are provided because research shows that the system of waiting for referrals from an inpatient psychiatric unit for a speech-language evaluation is about 21 days. The evaluation reports gave specific recommendations for the child’s treatment plan in 95% of the cases. (Scahill, 1989.) The Fluharty-2 Fluharty 2 Preschool and Language Screening Test OR • Clinical Evaluation of Language Fundamentals- 4th edition (CELF (CELF-4) 4) Screening Test OR • Adolescent Language Screening Test (ALST) AND • Social-Emotional Rating Scale OR • CELF- Observational Scale •

Evaluations A comprehensive evaluation consists of: • Receptive Language • Expressive E i L Language • Articulation Skills • Pragmatic Language Skills • Reading/ Writing Skills • Problem Solving Skills

Therapeutic Program Goal of Flow of Care: • Day 1: Initiate Assessment • Day D 2 2: C Complete l t A Assessmentt • Day 3: Develop treatment plan • Day 4: Specific individual treatment g implemented p strategies • Day 5: Education with parents • Day 6: Discharge

Program • Impacting the length of stay/ flow of hospital services • Decreasing recidivism/ decreasing readmissions • Upholding U h ldi JJoint i tC Commission i i standards t d d with developmental disabilities; Language d fi it how deficitsh tto supportt patient ti t from f going i into a crisis

Speech Language Pathology at C ll College Hill Patients with psychiatric diagnosis often have difficulty with communication or social language use use. There are potential barriers to effective treatment if the speech or language problem is not detected during the hospital stay. Language is central to group therapy therapy, individual therapy, family therapy, and milieu therapy. therapy

DSM-IV DSM IV Continued • Axis III: Acute medical conditions and physical disorders (brain injury) • Axis IV: Psychosocial stressors and environmental i t l ffactors t • Axis V: Global Assessment of Functioning ((GAF), ), which is based on a 100 point p scale

Psychiatric Disorders • Mood Disorders ((Depression, p , Bipolar, p , …NOS)) • Anxiety Disorders (OCD, PTSD, Generalized Anxiety)

• Personality P lit (Schizoid, Borderline, Narcissistic, Histrionic, Antisocial)

• Psychotic (Schizophrenia, (Schizophrenia Substance-Induced Psychotic, Psychotic D/O NOS)

• Eating (Anorexia Nervosa, Bulimia, Pica) • Developmental (MR, PDD) • Behavioral/Emotional Disorders (ODD, C d t ADHD, Conduct, ADHD RAD)

Psychiatric Disorders Mood Disorders are a group of diagnoses in the DSM IV classification system where a disturbance in the person's person s emotional mood is hypothesised to be the main underlying feature feature. • Mood Disorder • Bipolar Bi l Di Disorder d • Major Depressive Disorder

Evaluations – The Clinical Evaluation of Language Fundamentals (CELF-4) – The Clinical Evaluation of Language Fundamentals-Preschool 2nd edition (CELF-P2) – The Preschool Language Scale –4th edition (PLS-4) – The Test of Language Development (TOLD) – The Oral and Written Language Scales (OWLS) – The Test of Reading Comprehension (TORC) – Test of Adolescent and Adult Language g g ((TOAL-4)) – Test of Problem Solving-Adolescent (TOPS-2) – Test of Problem Solving-Elementary (TOPS-3) – Comprehensive Assessment of Spoken Language (CASL) – The Differential Screening Test for Processing (DSPT) – The Social Skills Rating System – Social Language Development Test- Adolescent (SLDT) – Social-Emotional S i l E ti l Skill Skills Rating R ti S Scalel Student St d t Form F – CELF-4 Observational Rating Scale – Clinical observations

Research At College Hill

• 2010: 52% of all inpatient admissions at College Hill fail receptive/expressive language screenings i • A snap shot of Residential units for children with pragmatic language deficits revealed: – 100% of the children in March 2010 – 100% of the children in June 2010 – 100% of the children in December 2010

• A snap shot of Residential units for children with significant i ifi t receptive/expressive ti / i llanguage deficits: – 74% of children in April 2010 – 83% of children in June 2010 – 71% of children in December 2010

DSM IV DSM-IV The Diagnostic and Statistical Manual of Mental DisordersIV (DSM-IV) groups an array of psychiatric signs and symptoms into recognizable diseases and syndromes syndromes.

Axis I: Clinical disorders disorders, including major mental disorders, as well as developmental and learning disorders (mood, anxiety, psychosis, dementia, etc.) Axis A i II II: Underlying U d l i pervasive i or personality lit conditions, as well as mental retardation (Personality Disorders causing impairment in social or occupational functioning and/or subjective distress)

Psychiatric Disorders Continued Personality Disorders are experiences and behaviors that deviate markedly from the expectations of the individual's individual s culture culture. • Paranoid • Antisocial A ti i l • Borderline • Narcissistic • Schizoid

Psychiatric Disorders Continued Anxiety Disorders cover several different forms of abnormal pathological anxieties abnormal, anxieties, fears fears, and phobias. • Generalized anxiety disorder • Panic Attacks g p • Agoraphobia • Obsessive-compulsive disorder – Impulse Control • Intermittent Explosive Disorder

• Social Anxiety Disorder • Post-traumatic Post traumatic stress disorder • Separation anxiety

Psychiatric Disorders Continued Psychotic Disorders have a loss of contact with reality • Schizophrenia • Schizoaffective disorder • Delusional disorder psychotic y disorder • Substance-induced p

Psychiatric Disorders Continued

Ben • PTSD and Bipolar • 4 IP Psych admissions • 2008 speech-language hl evaluation l ti completed (8 years old at the time) – Mod-severe deficits in language and pragmatics

• Initiated therapy 2009

Ben- in 1 year y Before therapy

Eating Disorders are a compulsion to eat, or avoid eating, that negatively affects physical y and mental health. both one's p • Anorexia nervosa • Bulimia • Pica • Binge eating • Orthorexia nervosa • Compulsive Comp lsi e e exercising ercising

• Did not turn take • Struggled to ask or answer simple questions during conversation • Decreased listening b h i behaviors • Did not engage in g in problem solving communication

After therapy • •

•

• •

Communicate his ideas and emotions independently Can engage and maintain a conversation with known and unknown communication partners Able to offer positive and realistic solutions in problem situations Process information more quickly and easily C fid Confidence and d attitude ttit d h has dramatically improved

Donna • • • •

9 yy.o. o with PTSD and RAD Residential patient 9 month th stay t Moderate receptive, severe expressive, mild articulation, and mild pragmatic language • No IEP

Psychiatric Disorders Continued Developmental Disorders are disorders that occur at some stage in a child’s development often retarding the development, development. • Pervasive Developmental Disorder • Autism • Asperger’s • Mental Retardation • Genetic Disorders

Donna in 9 months Prior to therapy: py • Difficulty turn-taking • No memory strategies • No N awareness off articulation distortions • Difficulty following more than 3-step directions • Trouble following directions with sequential concepts (first, middle, etc.). • Expressive vocabulary • Difficulty understanding body language

At discharge g from hospital: p • Awareness of distortions; however, unable to consistently produce at syllable level • Receptive skills WNL (per standardized testing) • Expressive skills from severely deficient to moderately d t l d deficient fi i t • Utilizes “chunking” strategy gy • Provides synonyms to common emotion words

Behavioral/ Emotional Disorders Reactive Attachment Attention Deficit/ Hyperactivity Oppositional Defiant Conduct

Alexandria • • • • • • • • •

15 y years, 10 months Regular education classroom School refusal (failing everything) and SI 1st admission d i i tto partial ti l hospitalization h it li ti program S Sept. t 2009 Failed language screening Evaluation revealed severe receptive and expressive language deficits Referred for psych testing because of low language scores IQ= 68 (mild MR) Upon discharge, the school made appropriate accommodations and speech-language therapy was added to her IEP

Psychiatric Disorders Continued Behavioral/ Emotional Disorders are a broad category which is used to group a range of more specific perceived difficulties of children and adolescents. adolescents • Reactive Attachment • Attention Deficit Hyperactivity • Oppositional Defiant • Conduct • Tic Disorders • Enuresis • Encopresis

Conduct Disorder Conduct May y Exhibit: • Aggression • Lying • Stealing St li • Difficulty following rules • Impulsive • Learning Disability

Older version of ODD

Conduct Interventions: • Build trust and relationships • Be consistent • Identify strengths and build on them • Relate how feelings and thoughts direct behaviors • Be patient • Avoid power struggles • Use rewards/tokens • Teach anger management

Exposure to Childhood Risk Factors: A Population Pyramid of Exposure The pinnacle of this pyramid is made up of the small population of severely maltreated children exposed to a broad array of abuse abuse, neglect neglect, and/or violence violence.

The middle comprises children exposed to a y g deg degrees ees a and d numbers u be s o of moderate ode ate varying risk factors such as poverty, singleparenthood, teenage parents, etc. This population is the focus of most policy initiatives and programs (e.g., Head Start, ) No Child Left Behind).

The majority of children are at the bottom of the pyramid with little to no exposure to risk i k ffactors t that th t adversely d l impact i t school h l readiness and development.

More on Complex Trauma • Social deprivation has been reported to delay children’s development of both g g and literacy y skills language – (Bowey, 1995; Burt, Holm &Dodd, 1999; Dodd & Carr, 2003; Duncan and Seymour, 2000; L k Gi Locke, Ginsborg, b &Peers, &P 2002; 2002 R Raz &B &Bryant, t 1990.

• Violence affects children’s health, their ability to learn, learn and even their willingness to go to school. (Westby, 2007)

Reactive Attachment Disorder RAD May Exhibit: • Love/ Hate Relationship • Problems with Eye Contact • Need to Control • May be Hyperactive but Lazy in Performing Tasks • Trouble with Cause and Effect • Poor Impulse Control • Frequent Tantrums • May have Problems with Food (Hoarding/Refusal) • Few Friends • Developmental/Learning D l Delays

RAD Intervention: • Trust building activities • Teach emotions • Work on relationship repair • Use calm tones and slow pace • Do not have others in and out of room (students, etc) • Praise good choices at every opportunity • Address bad choices with facts • Post expectations

Attention Deficit and Hyperactivity Di d Disorder ADHD May y Exhibit: • Trouble following directions • Disorganized • Attention to tasks • Looses things • Poor memory • Easily distracted • Trouble with turn turn-taking taking • Can't play quietly • Blurts out answers • Interrupts people

ADHD Interventions: • Make a schedule • Post rules • Reward R d good db behavior h i • Use lots of eye contact • Gain their attention before giving a direction • Make “Take a Break” cards • Incorporate social skills training • Write Pros/Cons • Repetitions • Movement time

Oppositional Defiant Disorder ODD May y Exhibit: • Loosing temper g g • Arguing • Trying to be annoying • Blaming others for their mistake • Difficulty maintaining friendships • Academic problems

ODD Interventions: • Encourage adult relationships ( (teachers, h coach, h pastor) • Encourage PCIT • Use CARES • Work on collaborative problem solving • Remain calm and unemotional • Use a schedule

Impairments associated with trauma

Biology The neurological g and other p physiological y g systems y that interact are involved in feeling states, cognitive abilities, and behavioral responses – 95% of the brain is developed by 3 years old

Impairments include: • Sensorimotor developmental problems • Increased medical problems across a wide span (ex Pelvic pain, (ex. pain asthma, asthma skin problems, problems etc.) etc ) • Hypersensitivity to physical contact • Frontal lobe deficits (j (judgment, g , emotional memory) • Difficulty linking left and right hemispheres (language)

– Attachment – Biology – Affect regulation – Dissociation – Behavioral control – Cognition – Self-concept Self concept

Biology Interventions Interventions should focus on: • Avoiding triggers • Developing D l i coping i skills kill • Incorporating relaxation exercises • Working on interhemispheric transfer activities • Teaching emotions

Affect Regulation Difficulties The ability to modulate feelings without being overwhelmed Impairments include: • Difficulty with emotional self self-regulation regulation • Difficulty describing feelings and internal experience • Difficulty communicating wishes and desires • Difficulty with intimate relationships

Attachment Difficulties The affiliation between p parents and children – Seeks to obtain an internal feeling of security – Relationships that involve the offer of attention and emotional availability

Impairments include: – – – – – – –

Problems with boundaries Social isolation Uncertainty U ce a y abou about the ep predictability ed c ab y o of the e world o d Interpersonal difficulties Difficulty attuning to others’ emotional states Distrust Difficulty with perspective taking

Attachment Interventions Interventions should focus on: • Trust-building activities • Building relationships • Teaching Emotions • Relationship R l ti hi repair i • Use Calm tones, slow pace, and rhythm • Unconditional Positive regard • Compliment good choices • Address bad choices with fact

Behavioral Control Difficulties

Affect Regulation Interventions

Without the words to put with the experience, unconsciously acting it out through their behaviors becomes a way for many children to get their story out.

Interventions should focus on: • Building trust and relationships • Be consistent • Teaching I statements • Identifying Id tif i ffeelings/ li / th thoughts ht that th t accompany feelings and how that is linked to behaviors • Teach positive ways of dealing with emotions • Be patient Use rewards/ tokens

– Aggression, self-injurious, and sexualized behaviors

Impairments include: • Self-destructive behaviors • Poor modulation of impulses • Aggression • Sleep disturbances • Eating disorders • Substance S b t abuse b • Oppositional behavior • Difficulty understanding/ complying with rules • Communication of traumatic past by reenactment

Behavioral Control Interventions Interventions should focus on: • A chance to talk about self • Schedule S h d l • Expected and unexpected behaviors • Relating emotion words to behaviors • Positive reinforcements

Cognition Difficulties The p process of thought g – Sensory and emotional deprivation in an infant’s development can lead to delays in receptive and expressive language deleopment

Impairments include: • Difficulties in attention • Difficulty with executive functioning • Problems processing new information • Problems focusing in and completing tasks • Difficulty planning and anticipating • Problems understanding own contribution to what happens to them • Impaired comprehension of complex visual-spatial tt

Dissociation A response to an environmental cue or trigger that has created stress. It is activated to protect the individual from further exposure to the stress response. Impairments include: • Alterations in states of consciousness • Amnesia p memory y for state-based events • Impaired • Depersonalization and derealization

Dissociation Intervention Interventions should focus on: • Orientation to self, time, and place • Keeping K i th the environment i t stimuli ti li llow • Redirecting back to reality • Encourage eye contact • Encourage topic maintenance

Stress Model of Crisis Outburst Phase

Escalation Phase

Violence

Aggression Recovery Phase

Triggering Phase

A it ti Agitation

ENCOUNTER — ENGAGE OR ENRAGE

Pre-Crisis State

Language to Use with Patients in Ci i Crisis • Slow y your speaking p g rate • Use a low volume and soothing tone of voice • Simplify vocabularywatch out for jargon • Use visuals to reduce talking • Keep directions short and direct • Restate directions. Use different words or expand to add meaning

• Pause after each short direction to give extra time to process the message • Ask the patient to repeat the direction to check his/her understanding • Provide positive feedback about behaviors that comply with your directions • One person talking at a time

Thank you!!! • Dawn R R. Girten: [email protected] dawn girten@cchmc org • Chris Lackey: [email protected]

Cognitive Interventions Interventions should focus on: • Visual schedules/ visual aids • Simple directions • Reinforcements • Receptive R ti and d expressive i llanguage skills kill activities • Labeling L b li ffeelings li • Cause/effect activities • Sequencing activities

Self-Concept Self Concept Difficulties Composed p of relatively yp permanent self-assessments, such as personality attributes, knowledge of one's skills and abilities, one's occupation and hobbies, and awareness physical y attributes. of one's p – Infants that receive nurturing, caring, and attention develop a sense of self that is positive, worthy and competent

Impairments include: • Poor sense of separateness • Disturbances Di b off b body d iimage • Low self-esteem • Shame and guilt • Lack of a continuous, predictable sense of self

Self- Concept Interventions Self Interventions should focus on: • Validating feelings • Self-esteem S lf t building b ildi activities ti iti • Be specific • Give Positive statements • Maintain boundaries • Set clear boundaries and limits