Mental Health in Pediatric Practice

• Bowlby Attachment Theory

  • early attachment behaviors allow the infant to express needs to their caregiver (e.g. hunger, touch, soothing)

    • critical for social-emotional buffering

    • resilience, emotional flexibility, empathy, cognitive functioning, social functioning

  • Strange Situation - Ainsworth - Characterized four types of attachment

    • Secure Attachment - best for building resilience; child feels safe when the caregiver is there, & shows distress when separated from the parent; child avoids the stranger unless the caregiver is there & child will be happy when they return

    • Anxious Avoidant-Insecure Attachment - mistrust others, lack social skills, 

    • Anxious Resistant Attachment - 

    • Disorganized Attachment - 

Mental Health in Childhood

• As achildren age & develop, their social-emotional skills are expected to develop as well

  • increase in problem-solving abilities

  • focusing for extended periods of time

  • development of morality & deeper moral reasoning

  • typically develops around 7-8 yrs (2nd grade)

• Social emotional skills

  • self-awareness - capacity to identify one's own feelings (e.g. utilize Zones of Regulation or ALERT program)

    • identification of emotions

    • accurate self-perception

    • recognition of strengths

    • self-confidence

    • self-efficacy

  • self-management - constructively manage strong emotions

    • impulse control

    • stress management

    • self-discipline

    • self-motivation

    • goal-setting

    • organizational skills

  • social-awareness - develop empathy - how does what we are doing impact others around me?

    • perspective-taking

    • empathy

    • appreciation for diversity

    • respect for others

  • relationship skills

    • communication

    • social engagement

    • relationship building

    • teamwork 

  • responsible decision-making

    • identification of problems

    • analysis of situations

    • problem solving

    • evaluation

    • reflection

    • ethical responsibility

• Other factors that impact social-emotional development

  • temperament - personality traits someone is born with

  • physical & social environment - if never experienced social emotional skills, how can they be expected to be modeled?

  • parenting interactions - how the parent interacts (or doesn't) impacts the child?

  • gender - boys tend to develop skills later than girls; girls are expected to display better social emotional skills

    • can explain why females are diagnosed later for ASD

Protective Factors & Resilience

• resilience: positive patterns of adaptation in the context of adversity & implies that there has been a significant threat to the adaptation of the child in their environment

• protective factors: characteristics at the biological, psychological, family, or community level that are associated with a lower likelihood of problem outcomes or that reduce the negative impact of a risk factor or problem outcomes

  • temperament

  • physical health

  • social experiences

  • family income

  • community resources

• As OTs, emphasize protective factors as much as possible - how can we help our clients respond to situations appropriately - that is what will increase resiliency 

Common Conditions

• autism

• intellectual disabilities

• ADHD

• anxiety

• physical disabilities

• diversity, SDOH: SES, religion, culture, ethnicity, gender identity, parental status, disability, sexual orientation, physical characteristics, etc.

• trauma & stress-related disorders

• disruptive, impulse control, & conduct disorders: ODD, intermittent explosive disorder, antisocial personality

• eating disorders

• personality & mood disorders

• schizophrenia & schizoaffective disorder

• substance abuse

Traditional Therapy in Mental Health

• Cognition - attention, memory, & executive functions; distorted thoughts/behaviors - cognitive beliefs

• sensory processing - sensory modulation, strategies to reduce agitation & aggression, task & environmental analysis

• coping & resilience - development of strategies to deal with emotions

• motivation - understanding interests & values that can promote self-efficacy

• emotion - emotional regulation & development of adaptive strategies to deal with issues (DBT)

• communication & socialization - helping to develop leisure, interpersonal skills, & IADLs (CBT)

• pain regulation - experienced differently by those with mental health disorders; need to blend physical and psychosocial aspects of the person

• time use & habits - focus on participation and engagement in routines (AOI—Action Over Inertia, program to enhance time spent in meaningful activities and reducing excessive sleep)

Toxic Stress

• cumulative stress effects on the brain & social-emotional development

  • ex. emotional neglect, physical, sexual & verbal abuse, violence, poverty

  • children with parents with limited education & mental illness have higher rates of toxic stress exposure

• constant activation of stress responses & neurotransmitters can impact the development & functioning of the brain

  • hippocampus, amygdala, corpus callosum, cerebellum, prefrontal cortex, & insula

• neurological impacts include:

  • decreased regulation of impulsive behavior & aggression

  • decreased executive functioning

  • decreased capacity for learning and retaining new information 

  • differences in arousal and emotion 

Adverse Childhood Experiences (ACEs)

• potentially traumatic events that may include:

  • physical, sexual, & emotional abuse

  • parental divorce

  • domestic violence

  • parental incarceration

• those with 4+ ACEs are significantly more likely to engage in risky behaviors as adolescents & adults

• outcomes for children who experiences ACEs are best when:

  • parents are resilient & have good parenting knowledge

  • social connectedness

  • concrete support

  • competent social & emotional skills

• developmental ages for children who experience ACEs may not match their biological age

Childhood:

• changes in school performance

• excessive worrying or anxiety (e.g. fighting to avoid going ot school or bed)

• frequent nightmares

• frequent disobedience or aggression

• frequent "temper tantrums"

• hyperactivity

Adolescence

• difficulty focusing, concentrating, or problem-solving

• avoidance of friends or social activities

• multiple physical symptoms (ie: headaches, stomachaches, vague pains)

• difficulty carrying out hygiene routines or daily activities 

• changes in eating habits 

• safety

• trustworthiness & transparency

• peer support & mutual self-help

• collaboration & mutuality

• empowerment, voice, & choice

• cultural, historical, & gender issues

Best Strategies for OTPs

• DO:

  • ask permission before doing anything (safety, collaboration & empowerment)

  • acknowledge what you cannot change (trustworthiness)

  • always ask preferred pronouns (cultural)

  • recognize that trauma manifests in many different ways (safety)

• DON'T

  • assume an individual's comfort level

  • ignore things over which you cannot control

  • assume based on appearance, etc.

  • automatically attribute challenging behaviors to personality

Tier 1: Universal

• bullying prevention programs

• trauma-sensitive school program

Tier 2: At-risk

• CBITS

• social skills groups, leisure skills access

Tier 3: Intensive, Individualized

• receive Tier 1 & 2 services as well

• specific, targeted intervention strategies for an individaul student

Interventions

• building self-regulation skills

  • regulating emotions

  • understanding size of problem & responding as needed

  • focusing on tasks, especially those that are less desired

• bullying prevention

  • AOTA

  • school mental health toolkit

  • every moment counts & comfortable cafeteria