Week7 6446 Social Work Practice with Children and Adolescents
Mood disorder and Self-Harm
Readings
· Bosmans, G., Poiana, N., Van Leeuwen, K., Dujardin, A., De Winter, S., Finet, C., … & Van de Walle, M. (2016). Attachment and depressive symptoms in middle childhood: The moderating role of skin conductance level variability. Journal of Social and Personal Relationships, 33(8), 1135-1148.
· Greville, L. (2017). Children and families forum: Suicide prevention for children and adolescents. Social Work Today. Retrievedfrom http://www.socialworktoday.com/archive/SO17p32.s html
· Pirruccello, L. M. (2010). Preventing adolescent suicide: A community takes action. Journal of Psychosocial Nursing and Mental Health Services, 48(5), 34–41.
· Document: Child and Adolescent Counseling Cases: Mood Disorders and Self-Harm (PDF)
· © 2014 Laureate Education, Inc. Page 1 of 4 Mood Disorders and Self-Harm A significant change in the DSM-5 was to separate the bipolar disorders from the depressive disorders. These two new classifications—formerly combined in the DSMIV under “Mood Disorders”—represent a shift to enhanced understanding of the differences between these groups, despite some common criteria. In addition, the DSM-5 includes suicidal behavior disorder, nonsuicidal self-injury, and persistent complex bereavement disorder under the chapter “Conditions for Further Study.” These are not recognized as clinical disorders (for purpose of diagnosis) at this time; however, the specific descriptions provided can enhance clinicians’ understanding of these presentations and provide guidance for treatment. Below is a brief overview of significant changes to the diagnostic criteria and classifications. Bipolar and Related Disorders As noted above, this is a new classification in the DSM-5 and is placed between the schizophrenia spectrum and depressive disorders to help represent its presence along the continuum of diagnostic criteria. Bipolar and related disorders includes bipolar I disorder; bipolar II disorder; cyclothymic disorder; substance/medication induced bipolar and related disorder; bipolar and related disorder due to another medical condition; other specified bipolar and related disorder; and unspecified bipolar disorder and related disorder. This group includes several new or revised diagnoses. Changes to Criterion A for both manic and hypomanic episodes now includes and emphasis on change to activity or energy. In addition, the diagnosis of “bipolar I, mixed episode” has been removed. Specifiers for all bipolar disorders are described together and provide for specific presenting characteristics related to the diagnoses. The DSM-5 also includes explanations for using these specifiers, their clinical significance, and suggested treatment approaches. In an attempt to more accurately diagnose this group of disorders, these represent considerable expansion from the DSM-IV specifiers. A new specifier “with anxious distress” was added to both the bipolar and depressive classifications to more expressly identify anxiety symptoms not part of the diagnostic criteria of bipolar or depressive disorders, yet commonly observed in both of these classifications. The diagnosis bipolar disorder not otherwise specified has been removed, and two new diagnoses added: other specified bipolar and related disorder and unspecified bipolar disorder and related disorder. Both of these diagnoses represent significant clinical distress or impairment based on bipolar diagnostic criteria but do not meet full criteria for a specific bipolar class diagnosis. Clinicians should use other specified bipolar and related disorder with the specific reason for the more general diagnosis (e.g., short duration manic or hypomanic episode). The latter diagnosis—unspecified bipolar disorder and related disorder—is used when clinicians cannot (or choose not to) identify reasons for the inability to make a more specific diagnosis, yet clearly observe multiple criteria from the bipolar and related disorders classification. © 2014 Laureate Education, Inc. Page 2 of 4 Depressive Disorders This is a new classification, separated from the more general class of mood disorders in the DSM-IV. Several depressive diagnoses were added to the DSM-5, including one specific to children. In addition, there have been several revisions to existing diagnoses in an attempt to make the diagnostic process more clear and reliable. As with the bipolar and related disorders, specifiers for all depressive disorders are described together and provide for specific presenting characteristics related to the diagnoses. Many of these specifiers are identical to those found in the bipolar classification; however, the clinical significance and treatment considerations discussed vary. Included in the discussion of clinical significance for specifiers is relation to suicide risk, potential precursors to other mood-related diagnoses, and suggestions for additional differential diagnoses. The diagnosis depressive disorder not otherwise specified has been removed, and two new diagnoses added: other specified depressive disorder and unspecified depressive disorder. Both of these diagnoses represent significant clinical distress or impairment based on depressive diagnostic criteria but do not meet full criteria for a specific depressive disorder diagnosis. Clinicians should use other specified depressive disorder and add the specific reason for the more general diagnosis (e.g., short duration, insufficient symptoms). The latter diagnosis—unspecified depressive disorder—is used when clinicians cannot (or choose not to) identify reasons for the inability to make a more specific diagnosis, yet clearly observe multiple criteria from the bipolar and related disorders classification. Disruptive Mood Dysregulation Disorder For this new diagnosis, partial intent was to minimize the misdiagnosis of bipolar disorder in children. It is important to note that this disorder is included in the depressive disorder classification rather than the bipolar disorder classification—this is largely due to the research supporting stronger correlations between this symptomology in youth and the development of depressive (or anxious) disorders in adolescence and adulthood. This diagnosis is characterized by persistent and recurrent outbursts of temper significantly incongruent with circumstance and present in at least two settings (e.g., home and school). The diagnosis cannot be made before age 6 nor after age 18, and the initial age of onset must be before age 10. The diagnosis cannot be comorbid with bipolar disorder, intermittent explosive disorder, or oppositional defiant disorder. In addition, the observed symptomology cannot be due to substance effects nor to general medical or neurological condition. Persistent Depressive Disorder This new diagnosis is a combination both chronic major depressive disorder and dysthymic disorder from the DSM-IV. It was determined that there were few significant © 2014 Laureate Education, Inc. Page 3 of 4 differences between these two diagnoses; specifiers are now used to identify features, onset, and severity. Major Depressive Disorder The most significant change to the diagnostic criteria for major depressive episode is the removal of the “bereavement exclusion.” In the DSM-IV, a required criterion to meet this diagnosis included that the observed symptoms were not better explained by bereavement. This has been removed in the DSM-5, with emphasis given to clinical judgment to differentiate these. Further, the DSM-5 notes the considerable variations in symptom presentation as influenced by individual history and culture as well as guidance for differential diagnosis between bereavement and major depressive disorder. It is of note that bereavement has previously been considered a condition or state of mind rather than a disorder. However, in the DSM-5, “persistent complex bereavement” has been described in the “Conditions for Further Study” (see section below). Premenstrual Dysphoric Disorder This new diagnosis is included in the depressive disorders classification and is characterized by mood lability, anxiety, dysphoria, and irritability, and well as physiological changes. The pattern of occurrence is cyclical and associated with menstrual cycle. The diagnosis includes significant interference with normal daily functioning and observed symptoms that are not merely an exacerbation of already existing diagnoses. Conditions for Further Study This section of the DSM–5 includes a number of “conditions” not yet recognized as clinical disorders for diagnostic and classification purposes. However, these conditions are recognized for the patterns in presenting characteristics – thus, improved understanding of these can enhance clinicians’ treatment planning and facilitate future research. Persistent Complex Bereavement Disorder This disorder is marked by the persistence of sorrow; preoccupation with a deceased loved one; reactive distress associated with the death; and social or identity disruption. In adults, the loss must have occurred at least 12 months prior to diagnosis; in children, the loss must have occurred at least 6 months prior. There must also be significant impact on functioning, and the expression of symptoms must be inconsistent with cultural norms. The disorder can occur at any age after 1 year. Expression of symptomology may begin shortly after the loss or be delayed by months or years. In children, the impact of loss can be highly traumatic, and may be expressed differently than in adults. Complex bereavement in children may be expressed through play, regressive behaviors, and/or intense separation distress. Risk for comorbid depression rises in children and adolescents. © 2014 Laureate Education, Inc. Page 4 of 4 Suicidal Behavior Disorder The key feature of this disorder is the existence of a suicide attempt within the last 24 months. If an attempt was made in the last 12–24 months, the disorder may be considered “in early remission.” The behaviors do not include self-injury for the purpose of emotional release nor simply suicidal ideation (as can be common with disorders of affect). The diagnosis can be comorbid with many other disorders; it rarely exists alone. The disorder can occur at any age but is generally absent in children under the age of 5 years. Nonsuicidal Self-Injury The key feature of this diagnosis is the persistent physical harm to oneself without the intention of death. Purpose of this behavior may be to diminish undesirable emotions; it may also be a form of self-punishment. The behavior tends to become increasingly frequent, with individuals often reporting a “craving” for the behavior; the behavioral expression may ultimately resemble addiction. Onset of nonsuicidal self-injurious behavior generally occurs during adolescence, and impairment or distress caused by the behaviors must be significant. However, as many individuals who participate in this behavior do not seek treatment, age of onset and severity of impairment may be difficult to reliably determine. Reference: • American Psychiatric Association (2013). Highlights of changes from DSM-IV-TR to DSM-5. Retrieved from http://www.dsm5.org/Documents/changes%20from%20dsm-ivtr%20to%20dsm-5.pdf
· Document: DSM-5 Bridge Document: Mood Disorders and Self- Harm (PDF)
Child and Adolescent Counseling Cases: Mood Disorders and Self-Harm © 2014 Laureate Education, Inc. Page 1 of 2 Cases Week 7: Case 1 Salena is a 16-year-old Native American girl who is a sophomore at a local high school. Her mother, who accompanied her to the initial session, referred her for counseling. During the first session, you spent about 25 minutes with Salena and her mother and then about 25 minutes with Salena alone. While you are interviewing Salena along with her mother, you observe that they appear to have a reasonably good relationship. Her mother is worried about her and primarily attributes Salena’s symptoms to the fact they recently moved from the Indian reservation to a more urban area. She believes Salena is having trouble adjusting to the new school and neighborhood. The move was prompted by the fact that Salena’s mother is in a new romantic relationship; Salena and her mother moved in with the mother’s boyfriend. Salena’s father has not been involved in her life since she was about 6 years old. Salena’s mother reports that Salena is often irritable and difficult at home. This irritability has increased substantially in the past 3 months. Salena basically agrees with her mother on this point. They also both agree that Salena is engaging in fewer recreational activities and reporting little enjoyment from the activities in which she participates. During the interview, Salena’s mother describes one of her major concerns: “Salena keeps talking about not really caring if she’s alive or not anymore.” Salena interrupts at this point and says, “Mom, you’re making way too much of that. It’s not that big a deal.” But her mother goes on and says, “What about the other day when you said, ‘Maybe if I get hit by a truck I won’t have to take that algebra test’? What am I supposed to do when you say things like that?” Salena responded that she was just expressing her feelings about her upcoming algebra test. Based on your time with Salena and her mother and with Salena alone, you discover she has unintentionally lost 14 pounds and reports little appetite. She also recently quit her part-time job. Her grades have been going down (from low As to low Bs and high Cs) and her attendance has been poor recently; otherwise, she has a relatively positive behavioral record at school. Salena also reports to you that she is having difficulty concentrating and that school is “boring and stupid.” Also, Salena denies using alcohol/drugs, and this seems to be valid information as it is consistent with what her mother reports. Finally, there is no evidence that Salena is suffering from any medical disorders. She has no history of any mental disorders and no trauma history. Child and Adolescent Counseling Cases: Mood Disorders and Self-Harm © 2014 Laureate Education, Inc. Page 2 of 2 Week 7, Case 2 Monte is a 9-year-old white male who has been referred to you by a local school. In the referral, Monte was described as exhibiting several behaviors that are very difficult to manage in the classroom. Specifically, he quickly becomes verbally aggressive toward teachers, regularly accuses them of picking on him, and he verbally insults most of the other students in his classroom. The school counselor who has worked with Monte reports that Monte comes from a very chaotic family. He has two older sisters who are often left to care for him. He complains about his sisters being mean, but other than significant parental absence, there is no evidence of abuse in the family. The school counselor further notes that she believes Monte has a tremendously low self-esteem. She says that when other students are not around, he is clingy with teachers and seems to solicit their approval. She reports that Monte was doing better in early elementary school, but over the past 2 years, his behavior has generally declined. She further reports that he has difficulty concentrating and that he states things like, “School is stupid. I always get bad teachers. Things will never get better for me.” In the past year, Monte has displayed a pattern of overeating, and there is some concern about him developing a weight problem. He also complains of frequent headaches, and his attendance at school is poor.
· Stebbins, M. B., & Corcoran, J. (2016). Pediatric bipolar disorder: the child psychiatrist perspective. Child and Adolescent Social Work Journal, 33(2), 115-122.
· Sommers-Flanagan, J., & Sommers-Flanagan, R. (2007). Tough kids, cool counseling: User-friendly approaches with challenging youth (2nd ed.). Alexandria, VA: American Counseling Association.
· Checklist of General Suicide Assessment Procedures Table 8.1 (p. 179) (PDF)
· Suicide Assessment Documentation Checklist Table 8.2 (p. 180) (PDF)
· Hallab, L., & Covic, T. (2010). Deliberate self-harm: The interplay between attachment and stress. Behaviour Change, 27(2), 93– 103.
· Van de Walle, M., Bijttebier, P., Braet, C., & Bosmans, G. (2016). Attachment anxiety and depressive symptoms in middle childhood: The role of repetitive thinking about negative affect and about mother. Journal of Psychopathology and Behavioral
· Assessment, 38(4), 615-630.• Document: Child and Adolescent Suicide Risk Factors and
· Warning Signs (Word document)
· There are different approaches to conducting suicide assessments, but all approaches acknowledge the need to be familiar with suicide risk factors. The good news is that there have been many suicide risk factors identified through research and clinical work. The bad news is that suicide is essentially unpredictable. Despite this bad news, you should definitely be familiar with the following risk factors and warning signs. Generally, the risk factors are more research based, and the warning signs are more clinical based.
·
· Suicide Risk Factors
· ___ 1. Vulnerable group due to age/sex/ethnicity
· ___ 2. Previous suicide attempt
· ___ 3. Using alcohol/drugs excessively or abusively
· ___ 4. DSM diagnosis
· ___ 5. School problems
· ___ 6. Isolated or harassed
· ___ 7. Physical health problems
· ___ 8. Recent significant personal loss (of ability, objects, or persons)
· ___ 9. Struggling with sexuality issues
· ___ 10. Victim of childhood or current abuse
· ___ 11. Diagnosis of depression
· ___ 12. If depressed, the teen is also experiencing:
· ____ Panic attacks
· ____ General psychic anxiety
· ____ Lack of interest and pleasure
· ____ Alcohol abuse increase
· ____ Diminished concentration
· ____ Global insomnia
· ___ 13. Significant hopelessness, helplessness, or excessive guilt
· ___ 14. Suicidal thoughts are present.
· Note: Evaluate for:
· ____ Frequency of thoughts (How often do these thoughts occur?)
· ____ Duration of thoughts (Once they begin, how long do the thoughts persist?)
· ____ Intensity of thoughts (From 1 to 10, how compelling are the thoughts?)
· ___ 15. There is a history of impulsive behavior.
· ___ 16. A suicide plan is present (evaluate the plan based on the SLAP acronym, which refers to specificity, lethality, accessibility of means, and proximity of social support).
· ___ 17. There is a moderate to high intent to kill self (or a previous lethal attempt).
· ___ 18. Recent prescription of an SSRI and associated disinhibition or agitation
· ___ 19. Possession of or access to firearms
·
·
· Suicide Warning Signs
· ___ 1. Suicide threats, both direct and indirect
· ___ 2. Obsession with death
· ___ 3. Sudden or abrupt loss of interest in usual activities
· ___ 4. Sudden social withdrawal
· ___ 5. An increase in dangerous or illegal or risk-taking activities
· ___ 6. Poems, essays, and drawings that refer to death
· ___ 7. Dramatic change in personality or appearance
· ___ 8. Irrational, bizarre behavior
· ___ 9. Overwhelming sense of guilt, shame, or rejection
· ___10. Severe drop in school or work performance
· ___11. Giving away or throwing away important possessions
· ___12. Recent extreme stress (e.g., romantic breakup, parental abandonment, parental/sibling/friend suicide)
· ___13. Possession (often secretive) of a dangerous weapon
· ___14. Recent and significant increase in drug or alcohol use
· ___15. An unexplained surge of cheerfulness or energy following a prolonged period of depression
·
· Media
· Laureate Education (Producer). (2014b). Child and adolescent counseling: Mood disorders and self-harm [Video file]. Baltimore, MD: Author.
Assignment
Application: Self-Harm The Assignment (2–3 pages):
• Analyze the standard components of an adolescent suicide
assessment and explain the importance of each component in
assessing for suicide risk and why.
· Describe at least one component you might add or take away
from the suicide assessment and explain why.
· Explain two differences between suicidality and self-mutilation in
terms of the severity of each issue. Then, explain how severity relates to possible intention of a child or adolescent presenting with suicidality or self-mutilation. Be specific and use the week’s resources and current literature to support your response.
Support your Assignment with specific references to all resources used in its preparation. You are asked to provide a reference list for all resources, including those in the week’s resources for this course.
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