Final Exam Flashcards
A framework of psychosocial Factors
core domain:
Performance:
Experience:
core domain is occupation
integral to the performance and experience of all activities of occupation
Performance: observed behaviours
Experience: self-agency, sense of belonging and contributing, integrity, pleasure, investment, sense of well-being
A framework of psychosocial Factors
Foundation:
Motivation:
Meaning:
Foundation of occupational engagement
Motivation: a natural human process for directing energy to accomplish a goal
Meaning: our search for uniqueness and self-hood with our search for community and belonging
Psychological emotional and social elements of occupation
what are the 5 circles
Elements that enable occupation, and are enabled by occupation:
- Self-perceptions
- Affect/mood
- Thought processes
- Interpersonal processes
- coping processes
Occupational self-evaluations
such as:
self-esteem Body image Self-comparison self-identity -Locus of control
Occupational mood/affect
Emotions:
- Happiness, love, joy
- Flow
VS
- Distress
- Anxiety
- Fear
- Boredom
- Grief
Occupational Thought Processes:
- Perceptions
- Interpretations
- Reasoning
- Logic
- Rationality
Occupational Interpersonal Processes:
Receiving and interpreting social information
- Empathy and understanding of the needs and feelings of others
- Respect
- Trust
- Interactional style
Occupational actions:
- Coping/resilience
- Self-regulation
- Self-monitoring
Context:
Context can both enable and interfere
Such as: access to resources, economic status, family. relations, social networks, cultural influence, life experiences
-Developmental factors are important too
The recovery model:
Common Ideas about recovery
4 points
- It is a process s well as an outcome
- it is a personal journey….. People recover - We can’t male them recover
- Recovery does not depend on a “cure”
- Involves (re)defining self identity with illness conceptualized as only one element of the self
Recovery Model (key points 4)
hope is powerful
- recovery can occur even when symptoms persist
- Recovery can occur even when symptoms persist
- Recovery is not linear process
- The consequences of the illness may be more difficult to recover from than the illness itself
Stages of Recovery (4 stages)
- Discovering a more active self
- Taking stock of the self
- Putting the self into action
- Appealing to the self
The recovery Benefits of activity participation (look at slide)
- Becoming empowered and exercising citizenship
- Finding social support
- Assume Control
- Manage symptoms
- Overcome Stigma
- Live a full life not an illness
- Redefine self
- Renew hope
Criteria of recovery
Criterion
- Hope
- Taking Personal Responsibility
- Getting on with Life ( OT)
Components:
- Spirituality
- Illness Management and Healthy Lifestyle
- Identity, Relationships, Work Recreation
OT interventions in Mental Health
identifies 7 categories
- employment/education ;
- psychoeducation
- creative occupations/activity;
- Time use/occupational balance
- skills/habit development;
- Group/family approaches; and animal-assisted therapy
The continuum (experiences with Indigenous)
Cultural Awareness --> Acknowledging Differences Cultural Sensitivity --> Recognition of importance of respecting differences Cultural Competence --> skills --> Knowledge --> attitudes
Cultural Competence
A compilation of attitudes, knowledge, and skills necessary for a person to interact effectively with individuals and groups of the same and different cultures
Cultural Safety
is an outcome based on respect engagement that recognizes and strives to address power imbalances inherent in the health care system . It results in an environment free of racism and discrimination, where people feel safe when receiving health care.
Cultural Humility
A lifelong process of slef-reflection and critque that emcompasses the recognition of power imbalances and the development of mutually beneficial partnerships between client and provider”
Model of Cultural Humility
Cultural Humility
- -> openness
- ->self-awarness
- ->egoless
- ->supportive interactions
- Self-Reflections and Critique
Lifelong learning
- –>empowerment
- ->Mutual Benefit
- -> Partnership
- -> Optimal care
- -> Respect
These two things have double arrows than surrounding them to make a circle is Diversity and Power Imbalance.
Points from Dana S. Edge
-Co-existing of tradition and western medical beliefs (the pregnant lady tradition )
-Importance of language and not making assumptions i.e.misuse of alcohol - go beyond the immediate questions so you don’t miss things
-Recognize the importance of culture i.e singing group on saturday morning
-Harmless Beliefs - occur in every culture and you just have to let it go, you will run into these things during work and you have to make a decision is something to intervene in and most of the time it’s not (i.e chewing gum when pregnant causes baby to drool)
You need to know the context»»»> try to understand their story
-Indian health service -sunk into the permafrost
Humor to discipline children
Profound effect of poverty
-Vicariously experienced blatant racism
How history really affects the present - federal and provincial government took care (presence of the missionary presence) really affected health-care
What contributions does employment make to health and well-being ?
IDK
What differences does paid work va unpaid (volunteerism)?
IDK
Employment and mental health
Mental Health commision of Canada reports
- Individuals with a mental illness are much less likely to be employed than other canadians. Unemployment rates are as high as 70% to 90% for people with the most severe mental illnesses
- In any given week, at least 500, 000 employed Canadians with long term or temporary disability are unable to work due to mental health problems
- The cost of a disability for mental illness is about double the cost of a leave due to a physical illness
What are the personal barriers for people with Mental Disability
- Gaps in educational/vocational preparation
- Performance challenges due to medication, symptom management, attention and concentration, energy level
- Intrapsychic factors (eg. Low self esteem, Self stigma, paranoia)
What are the environmental barriers for people with mental disabilities
- Stigma
- Structure of HR/workforce entry procedures
- Lack of needed supports/services
- Lack of financial resources to manage diert, dental health, clothing, transportation
Cognitive Work Hardening (CWH)
A return-to-work intervention for people on disability leave associated with pression * (and other health conditions associated with cognitive, psychological and emotional issues)
Theoretical Basis: CMOP-E PEO Social learning theory recovery
Intervention matches job demands to address job-specific challenges
- ->cognitive performance and energy
- -> interpersonal Abilities
- ->coping skills
CWH- Multi-element Intervention
Collaborative identification of desired behavioural and environmental outcomes
-Therapist/worker together determine meaningful work simulations
-Gradual progression of work schedule
-Work receive feedback to build insight and self-efficacy
-Focused interventions addressing, assertiveness, time management, organization on the job etc.
Workplace specific return to work places
4 Identified categories of employment status
Work challenges experienced by employed persons
employment interruption or separation
Developmental Disruption in productivity roles
Employment Marginalization
Work challenges in employed persons
Employed in community workforce; evidence of employment continuity
Experiencing health-related disturbances of work performance (presenteeism)
-Disruption may not be”public” or know to others
-The disruption may be temp or ongoing, even while work participation continues (intermittent work capacity)
Key Issues:
Worsening of condition in absence of treatment
-Employer/workplace uncertainty; financial loss
-Fractured social relationships in workplace
Employment Interruption Or Seperation
Employment is interrupted by disability, injury or health condition and involves time away from work beyond regular sick days, vacations, etc
The absence from work typically has a formalized status (as in work/sick leave, short or long term disability
-once formalized can involve multiple systems: workplace, financial , health care, social services
Key issues:
Time away from work is predictive of return to work status - extended absence = low probability of return
-Impact of leave on participation in non-work roles and activity
Developmental Disruption in productivity role
work-related disruption occurring pre-or early work years
- Disruptions in typical age and socially expected norms
- Concerns arise about course of the health-related issues
- Social and economic dependence emerges
- Future social and economic status threatened
Examples: Early onset Psychosis street youth School-work transition Mental Illness in post secondary setting
Employment Marginalization characterized by individuals who
Lack formal/informal connections to employment (on the fridges of the workforce)
- have limited work experiences or lengthy periods of absence from work roles
- social position leads others to not “expect” employment/culture of low expectations
- significant material deprivation, poverty conditions
- social and self-devaluation
- Financial dependency (often on the government) and financial disincentives to working
Employment Attached- Person focused interventions
Individuals Level
cognitive work hardening
CBT with a work focus
-adjuvant work-focused occupational therapy
-work focused collaborative care
Employment attached - Employer/workplace strategies
Employment as if people and their health mattered
- Workplace anti-stigma programs
- National standards for psychological health and Safety in the workplace
Employment Unattached- person focus interventions
Supported employments/supported education
Social enterprises and other forms of entrepreneurship
paid positions within the mental health system
Historical approaches employment
Vocational assessment
Work adjustment training
Sheltered work
Current Approaches employment
Rapid place and train
Supportive treatment to help maintenance and growth of worker role
Principles Of Supported Employment
-Rapid entry to real work setting dynamic assessments in context ongoing employment support -work accommodations -Integrated vocational and treatment services -Employer education -Financial Literacy
Work Integration Social Enterprise (WISE)
Businesses created to build employment capacity
- ->Created by community agencies
- ->created by mental health consumers themselves
Best Practices in WISE
Fair remuneration
Opportunity for skill development and career building
contact with the public, stigma reduction
sense of belonging and empowerment within the business
Key messages from Employment Lecture
There is a need for shared meanings in discussion employment challenges for persons with mental health related disabilities
- Think about the individual and their connection to the labour market
- Identify assets and weaknesses, opportunities for success
- Consider not only the person but their social role;seek to minimize marginalizing forces
Skills for Retail
A college-based program that provides classroom-based and practical training in retail sales and service
-Developed based on observed needs
Program Design:
-12 week classroom instruction
-3 week (unpaid) internship in local Businesses
-Fitness Program through SLC “FItness and Health Promotion” program
Skills For Retail -Outcomes
Programs was repeated at least 4X
- Wait lists for the program entry
- 70% of trainees gained and retained competitive employment
- Partnership seen as beneficial to both the agency and the college
What was similar between Skills for Retail and Cognitive Work Hardening
- both helped with transition to work
- both provided physical and cognitive or behavioural skills
- -> both provided an internship job so they could feel successful
What are the differences between Skills for Retail and Cognitive Work Hardening
Skills for Retail:
- Fitness program
- pretty bad mental illness
- trying to build experience
- entry level program
Cognitive work Hardening:
- Simulated environment
- Are attached to a workplace
- Insurance wants them back
One’s connection to the labour market
Foundational preparation
–> education work experiences
Work Stability
–> Consistency of involvement in work activities and role
-Level of prosperity, security, self-sufficiency
–> social connections related to employment
–> within the workplace
–> in society broadly
Employment Challenged Goals
- Maintenance of work role
- Disability prevention
- Disability Management
Employment Interrupted Goals
Enabling successful return to work
- Facilitating employee-employer relationship
- Building skills/confidence for work re-entry
Development Disruption Goals
Skill development
Help create work role entry pathway
-Establish age appropriate work experiences
Employment Marginalized goals
Enable participation in the mainstream workplace
-Establish work Identity
Environmental and occupational Therapy Practice Models
Ecology of Human Performance
Occupation adaptations
Kawa Model
Person-Environment-Occupation
Components of the Environment
Cultural Personal Physical Social Temporal Virtual
Environmental Obstacles to Recovery and Empowerment (a lot of things but I didn’t know how to break it down)
Attitudinal barriers -->stigma Poverty War and violence --> Serving military members -->refugees Complex physical environments -->Accessibility for Ontarians with Disabilities Act (AODA) -->Advances in technology Lack of integrated physical and mental health care --> Occupational therapy practitioners are trained to address both physical and mental health and can work in settings such as primary care Lack of Choice Segregation and isolation Criminal justice system
Environmental Resources
Peer-led organization and other support -->Increasing in numbers -->Clubhouse -->Day programs -->Families Community Resources -->Food pantries and soup Kitchens
Features of environments
In-patient
short stay Acute -->illness/disorder/disruption Intensity of services Number of services Number of people to be served Space Separation from natural occupations and environments
features of Environments Community
Occupational issues unfold in natural but dynamic context
Length of service/time opportunities for meaningful occupations/real citizenship
Enable occupation within natural environments
Philosophy/vision of the service
Influence of client resources
In-patient OT Practice Individual Level
- Engage the individual in a therapeutic relationship
- Identify (community) occupational problems and plans
- Evaluate community occupational performance in relation to needed community support
- Engage the individual in meaningful occupations through individual and program level activities
- Evaluate (“test out”) occupational performance
- Provide “best practices” to enable positive change in occupation and its determinants (psycho emotional)
- Prepare reports related to the OT process that are consistent with the approach of the program
- Ensure that the individual establishes a link with community resources to support occupation
In Patient Program Level
Development of a program that allows for engagement in a range of meaningful occupations, connected to community life
Deliver best practices consistent with the identified occupational needs of the client population served
Community-Individual Level
- Engage the individual in a therapeutic relationship
- Identify occupational goals-problems and strengths
- Evaluate community occupational performance
- Engage and support the individual in personally and socially meaningful occupations
- Provide “best practices” to enable positive change in occupation and its determinants (psycho emotional)
- Prepare reports related to the OT process that are consistent with the mission/approach of the program
- Implement environmental interventions to support occupation
- Link to and support engagement in resources to enable occupation
Community- program Level
Engage in community development
- Design and deliver program to be consistent with best practices in the field
- facilitate program evaluation and development related to client-centred processes and occupational outcomes
What si Transition?
Process of moving from one life phase to another
-unfolds over time
-Change in nature (eg roles, status, etc)
“[A] discontinuity in a person’s life space”
Tied to life course
Occupational History
occupational transitions throughout the life course
Occupational Transitions
shifting from one set of occupations to another
Micro, meso, macro
Self-initiated or triggered by life transitions or events
Occupational Adaptation
Response to challenge (such as a transition)
Transition and mental health includes: (diagram)
mental health transition and surrounding is context
Transitions to miliary, Veteran and Family Populations
- Civilian-to-military transitions
- Military-to-civilian transition
- Transitioning home after combat or other deployment
- Separation cycle in families
- Military related injuries
- Geographic transitions between posting
- School transitions for children in military families
- Employment transitions for spouses
- Other?
What is Military-to-Civilian Transition (MCT)
Generally understood as the process of leaving military services and transitioning to civilian life
(this includes working or running a business)
Elements of MCT: Nature of the transition
voluntary and medical
soldier–> Civilian
- A natural aspect of a military career
- Usually anticipated
Medical:
no disability –> disability
Involuntary/lack of control
May be sudden
Elements of MCT: Trigger/starting point
voluntary and medical
No agreement, but some suggestion include:
- at enlistment
- when member decides to leave service
- Official release process commencement
Medical:
onset of illness/injury
Elements of MCT: Period of Intensity
voluntary and medical
Peri-release period
- can be the most stressful point in the process
- greatest potential for long term health implications
Medical:
Timeframe around the injury/illness onset
-May also include transition from hospital to home/community
Mental Health and MCT stats
Life after service survey 2016
-30% have MH condition
24% have a comorbid MH and PH condition
More likely to have difficult MCT adjustment and health-related activity limitations
Factors Impacting Adjusting to MCT
voluntary and medical
- Military related factors (e.g. service element, rank)
- Available Support and preparation
- Loss and /or change in roles
- Cultural shift
- Personal Identity
Medical Release
- Severity of functional limitations
- Type of functional limitation
- Degree of Independence
- Prognosis `
Using an MCT Framework to understand Mental Health
Look at slide don't want to type it out 3 main parts : well-being domain Life-Course and Phases Roles of veterans and their Families
Role of Occupational Therapy in MCT: Working with Individual CAF Members/Veterans
- Addressing loss of valued and meaningful roles
- Addressing issues related to aspects of well-being
- -> e.g. community engagement and meaningful activity
Role of Occupational Therapy in MCT: Medical Release
- Addressing unique challenges of MCT and injury/disability
- Supporting vocational roles outside the military
Role of Occupational Therapy in MCT: Advocacy
- Addressing stigma and stereotypes associated with veterans
- -> e.g. combating “broken veteran” stereotypes to enable vocational occupations
Role of Occupational Therapy in MCT: Challenges
- Lack of support during peri-release period
- Lack of consensus on a definition/framework for MCT `
CAF and VAC
- canadian forces health services
- Operational Stress Injury Clinics
- VAC rehabilitation Program
OT role expanding in VAC `
Hiring 35 full-time positions over the next two years
Military Lifestyle Factors: Frequent Relocation
- Military families relocate three times more frequently than civilian families
- In 2017 10,000 military families in Canada relocated, of which 8,000 moved to a new Province
Military Lifestyle Factors: Regular Absence
- Deployments, training exercises, Imposed Restrictions (IR), etc
- CAF personnel spend a quarter of their time away from their families
Military Lifestyle Factors: Risk
- Permanent injury, illness and/or death of serving member
- -Dependent on the occupational role hld within the CAF
Who are Canadian Military Families and why is this relevant `
63269 regular Force Personnel
34906 spouses
57639 child
40% of Canadian military families live in Ontario
-Ontario has the largest number of military bases compared to any other province
School Transition Models
Ecological contextual Factors (look at slide) and PEO
School Transitions and Military-Connected Children
Frequent relocation can impact school-based occupations for children and youth:
Academic and social
Academic:
- children can experience curricular gaps and/or redundancies
- For adolescents, graduation and post-secondary opportunities may be put at-risk
Social:
children are required to leave behind old peer networks and develop new relationships
-Children might lose out on the oppertunity to participate in extracurricular activities
School Transition and Military-Connected Children with Special Needs
- 8.2% of military-connected children have special needs
- ->many families report having children with ASD.
- Frequent relocation often requires families to nativage new special education systems, which often leads to frustration due to varying eligibility for special education services
- Families may make career decisions around available supports and services for their child(ren)
Frequent Relocation, School Transition and Mental Health (research)
- To date, research has focused overwhelmingly on the American experience
- Frequent relocation and deployment have an impact on mental health
- Frequent relocation and deployment often have great impacts on adolescents in comparison to younger children
Considerations for Practice (School transitions)
- Occupational therapists should consistently inquire and document whether a child is from a military connected family and adjust services accordingly
- Occupational therapists should explicitly consider the mental health challenges military-connected students may be experiencing when working with them
- Occupational therapists can engage in community development strategies to create innovative collaborations among schools, community institutions, and military-affiliated family support agencies
What is PTSD
Posttraumatic Stress Disorder (PTSD)
-Named post-Vietnam
-Impacts: Sense of safety/security, self-worth, sense of self, vulnerability to re-victimization
DSM-V (APA, 2013)
-History of exposure to trauma with four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity
-Impairs social interactions, capacity to work, fucntion in daily life
Operational Stress Injury (OSI)
- Used in military/Veteran context
- Psychological difficulty resulting from military
- May include anxiety, depression, PTSD, as well as less severe conditions
- Includes trauma, fatigue, grief, moral injury
Trauma (operational stress)
- an impact injury
- Due to events provoking terror, horror, or helplessness
Fatigue (operational stress)
A wear-and-tear injury
-Due to the accumulation of stress over time
Grief (operational stress)
- A loss injury
- Due to the loss of people who are cared about
Moral Injury (operational stress)
- a loss injury
- Due to disruption in trust in moral values
Other Trauma-related diagnoses: Dissociative Disorders
- A disruption in the usually integrated functions of consciousness, memory, identity, or perception
- A break with contact with present reality
Other Trauma-related diagnoses: Borderline Personality Disorder
- Early childhood trauma or neglect
- Elements of emotional and identity instability
- Experiences of dissociation
Comorbidities of operational stress
Depression Anxiety Disorders Addictions -May mask trauma -Self-medication -Maladaptive coping -Can set the stage for developing new coping skills -PTSD and comorbid alcohol misuse ranges 9.8-61.3% `
Prevalence of PTSD in the Canadian Force
- in 2013, the most common conditions were major depressive episode (8.0%), PTSD (5.3%), and generalized anxiety disorder (4.7%)
- The prevalence of PTSD, GAD, ad panic disorder has increased significantly since 2002
- The comorbidity of mood and anxiety disorders increased from 27.4% and 41.0% of those with mental disorders in 2002 and 2013
Life After Service Study, 2016
- Canadian Veterans reported chronic conditions, including arthritis (29%), depression (21%), anxiety (15%), and PTSD (14%), higher prevalence than Canadians of comparable age and sex.
- Veterans also reported higher rates than Canadians for hearing problems, pain, and activity limitations
CIPSRT National Prevalence Survey
- First national survey looking at OSIs among first responders such as police,paramedics, firefighters and 911 operators
- 5813 participants, 44.5% “screened positive for clinically significant symptom clusters consistent with one or more mental disorder
- Much more likely to develop a mental disorder than the general public
Remission (OSI)
- Spontaneous long-term rates from global systematic review and meta-analysis of 42 studies
- ->81,642 participants, observed over ~ 40 months
- ->Remission varied from 8 to 89%, within an average of 44% demonstrating spontaneous remission
- ->PTSD related to natural disaster most likely to remit
- ->PTSD comorbid with physical disease least likely to remit
- Strong indication that intervention is essential for the majority of folks living with PTSD
Traumatic Exposures for military personnel and public safety personal (PSP) circle with outer circles
Common Exposures:
- Fear of death
- Proximity to peril
- Unsafe work
- Helplessness
- Futility
- Litigation/blame
- Split second decisions
- Moral injury
- Violence
Organizational Culture and stigma (PTSD)
- Call volume, shift work, sleep disruption as the norm
- Psychologically tough,compartmentalized
- Policies and procedures
- ->to whom is it reported
- ->Career repercussions
- Generally, non-mental health treatment seekers
Occupational Therapy and PTSD
- A variety clinical populations have traumatic experience
- Sleep, work, and maintenance of relationships are common occupational issues
- Occupational therapists are utilizing unique assessments and interventions within multidisciplinary teams
Assessments and interventions:
- Common use of COPM as an assessment tool
- Focus on evaluating and enhancing occupational performance
- Focus on daily activities: sleep, driving, work
- Engaging in meaningful activities
- Exploring narratives and moving forward with new purpose
Theoretical Background (PTSD intervention guidlines)`
- Trauma informed services
- Readiness for change
- OT Enablement Skills
- Do-Live-Well Framework
Assessment
Treatment
Special focus on self-regulation
Trauma-Informed Services
- Recognize impact and coping strategies
- Recovery as primary goal - integrate with other services
- Empower client
- Maximize choices
- Relational collaboration and therapeutic relationship (respect, information, connection, hope)
- Atmosphere, physical setting and procedures are respectful
- Strength based (adaptation and resilience)
- Minimize re-traumatization e.g. silencing, body language
- Cultural compentence
- Consumer/survivor input and involvement in service design and evaluation
Stages of Change
Precontemplation Contemplation Preparation Action Maintenance
Readiness Ruler (what is it)
Targets readiness for change -Motivational Interviewing origins -Helpful for exploring ambivalence Questions: -How important is it for you to change -How confident are you that you can change -How ready are you to begin to change?
Readiness Ruler has shown: `
- Construct validity
- Predictive validity for change
- Concurrent validity with other change readiness measures
- High clinical utility
- -> Ideal due to brevity and ease of use
Do Live Well
Dimensions of Experiences: range of experiences are needed
Activity Patterns: the nature of the experience matters
Health and wellness outcomes: Everyday activities have an important impact on health and well-being
Below (personal and Social forces: Many forces can affect experiences, activity patterns and outcomes
Resilience and Occupational Adaptation
- Resiliency and vulnerability are important factors in occupational adaptions
- Self-evaluations are key
- Resilient individuals have:
- ->Positive sense of self
- Internal locus of control
- Occupationally engaged lives
- Seek assistance and social support
Post Traumatic Growth (PTG)
Positive psychological change, post-trauma
- Appreciation of life
- New priorities/possibilities
- Personal strength
- Stronger relationships
- Spirituality
- Coping, meaning-making, interpretation
- If I could handle that,I can handle anything
Trauma Informed Approach during COVID-19
-people may be coming to this current crisis with past traumatic experiences on board
-COVID-19 Spreads through the very things we need to flourish, like being close to friends, family, ad colleagues, and participating in meaningful community activities:
Tips for coping:
-Be active in seeking supportive relationships
-Take care of your body and mind (self-care)
-Nurture yourself (self-compassion)
-Process your experience (write, read, talk sing)
What is Infant and Early Childhood Mental Health
- Social, emotional and cognitive well being of infants and young children
- Developing the capacity of the child from birth to five years of age to form close and secure adult and peer relationships, experience, manage and express of full range of emotions, and explore the environment and learn - all in the context of family, community, and culture
Why is Infant Mental Health Important
- The mental health experienced by an infant has potential short and long term health outcomes
- Significant brain growth and development takes places and is influenced by child’s environment
- Experienced gained in first three years created foundation for future relationships and emotional regulation
What impacts early childhood mental health
- Early experiences
- Genes
- Temperament
- Social Determinants
- Early Interventions
Significance of Early Experiences
- Infants early experiences lay the foundation for personality development and behaviour in later life
- Disruptions in this developmental process can impair a child’s capacities for learning and relating to others (which lifelong implications)
- Adverse childhood experiences (ACEs)
- Poverty, maternal and paternal mental health disorders, violence, and disruptions to caregiving relationship are all sources of chronic stress.
- By improving children’s experiences and environments early in life, we can improve life pathway
What do infants need?
- Positive attachment to responsive caregiver
- Relationships that provide positive experiences
- Relationships where caregiver’s response is based on the child’s developmental needs
- Consistent and appropriate developmental support
Impact of genes and Experiences (infants)
- interaction of genes and experiences affect childhood mental health
- Interactions between genetic predispositions and sustained stress-inducing experiences early in life can result in an unstable foundation
- Stress can damage brain architecture and increase likelihood of mental health issues to emerge (early or later in life)
- Stress can impair school readiness, academic achievement, physical and mental health
- Stress = poverty, neglect, abuse, domestic violence, parental mental health, substance abuse
Temperament
- Biologically based
- ->Sensory reactivity
- -> Activity Level
- -> adaptability (slow to warm or easy to adapt)
- ->Persistence (quick to frustrate or keep trying)
- Shapes how we experience the world
- Understanding child’s temperament can help understand why the child acts who it does
Impact of Social Determinants on Early Childhood Mental Health
- Mental health is correlated with a number of social determinants, including income and income distribution, education, employment, food security, gender, race, ability, housing, aboriginal status
- Chaotic and unpredictable situations and environments activate stress response repeatedly
Early Interventions (infants )
- early intervention can minimize developmental delay and enhance the capacity of parents to meet the needs of their child
- Treatment is never too late, however, earlier is better
- Even when children are removed from traumatizing circumstances and placed in nurturing homes, improvements are often accompanied by challenges with self-regulation, emotional adaptability, and relating to others
Diagnosis in early childhood
- Significant mental health problems can occur in young children (0-6)
- Children can show characteristics of anxiety disorders, attention disorders, attention deficit/hyperactivity disorder, PTSD, neurodevelopmental disabilities, depression at a very early age
- Children process and respond to emotional experiences and trauma different than adults and older children, therefore diagnosis is challenging
Developmental Ages
Before birth
-Stressed mothers
Birth to 2 months
- Learn to regulate physiological systems
- emerging engagement
- Social smiles
2-6 Months
- increased engagement
- Social Development - distinguishes
- Identifies primary caregivers
6-15 months
- Stable attachment patterns with caregivers
- Stranger anxiety
- Increased autonomy
- Increasing language and expression
15 months to 3 years
- Alternating pattern of autonomy
- Emerging emotional regulation skills
3-5 years
- Cognitive changes
- More complex interactive relationships with peers
- Understand rules (emotional display)
Signs of Risk (Parents)
- Were abused as children
- Mental health challenge or issue
- Drug or alcohol issue
- Relationship issue
- Violet or abusive or in conflict
- Lack of Support
- Are teenagers
- Had a difficult or scary birth experience
Signs of Risk (child)
- Issue with feeding or sleep
- Over or under responds to environment stimuli
- Doesn’t want to be held
- Cannot be comforted or upset for extended time
- Doesn’t maintain eye contact
- Doesn’t interact with others
- Doesn’t make noises very often eg. Cooing, babbling
- Doesn’t use language in age appropriate way
- Loses skills they could once do
Signs of Risk (Child-parent)
-Poor attachment between infant and caregiver
Conceptual Practice Models and Theoretical Frameworks
Psychobiological Attachment Theory
- Infants become attached to caregivers who interact with them through consistent, close and comforting communication (secure base)
- Link between patterning and quality of attachment in infancy and the quality of the child’s adaption to later developmental challenges (internal working model)
Conceptual Practice Models and Theoretical Frameworks (developmental Systems Theory)
- Child social and cognitive competence
- Familial patterns of interactions
- Resources that promote health and development
Conceptual Practice Models and Theoretical Frameworks(Transactional Model)
- interaction between nature and nurture
- Risk factors within the child, environmental risk factors
Conceptual Practice Models and Theoretical Frameworks (Sensory Processing Model)
-Understand sensory processing profile of self and infant
Signs of Secure Attachment
- Comes to the parent when hurt, needing help, or comfort
- Shows affection
- Greets the caregiver after they have been apart
- Explores and also interacts with their parent while doing another activity (for example: looks back and makes eye contact when playing)
- Is more comfortable with the caregiver than strangers
- Ability to self regulate
- Emotional adaptability
- Ability to relate to others
- Self understanding
Essential Component of assessment and treatment
(Families) about the environment……
-Treat children’s mental health issues within context of their families, homes and communities
Focus of Early Intervention (infant)
- Preventative
- Enhance parent’s competence in meeting child’s needs
- Family centred
- Relationship focused
- Promote family capacity to care for and support the child’s development
- Play based
Comprehensive Assessment (Comprehensive developmental assessment)
- Social-emotional, cognitive, sensory abilities
- Multidisciplinary
Comprehensive Assessment (Observation) children
- Interactions of child in expected tasks and activities
- Natural environment
- Daily routines
Comprehensive Assessment (Family as partner) goals ….
- Identify child’s strengths and weaknesses
- Determine priorities for intervention
OT Role in Assessment
Occupational Profile
- Child’s strengths and needs
- Current family concerns
- Family daily routine
Comprehensive Assessment (Occupational Performance Evaluation) also looking at parent
- Observation
- ->Play
- -> Interactions with parents
- —> Physical interactions - comfort holding, feeding., changing
- —->Quality of parent-child interactions - interest, vocalizations, smiling at one another
- ——> Parent expression of feelings about being a parent,
- ->Feeding
- ->Natural environment
Assessment Tool Use
-Evaluate performance - Sensory, motor, cognitive social emotional
Intervention Strategies (infant)
Natural Environment
Everyday Experiences
Enhance family capacity to meet their child’s needs
-Modeling, practice with support
-Coaching
-Informal - fact sheets, videos, websites
-Collaborate together - priorities, concerns, needs, supports
-Connect with community
Family Focused Interventions
Families learn strategies through explicit learning
- Active modeling
- Practice with professional
- Increases follow through
Parenting focused coaching
- How parent is interpreting child’s cues
- How parent is responding to child’s needs
- How to enjoy interactions and responsibilities
Predictability and Routines
- Importance of serve-and-return interactions between caregivers and children
- Through experience, children learn whether to trust that their needs will be met
- Importance of routine
- ->predictability
- -> Quality interactions in daily activities
- Effects for lack of routine
- -> Unpredictability negatively impacts sleep, eating
- ->child difficult to sooth
- ->tired, stressed parents
Importance of Routines
Routines are sequenced tasks and activities that provide natural structure
Examples of family routines: feeding, sleeping, preparation to leave home, bath time, play time
Essential principles of service and policy
Support responsive relationships for children and adults
- Promotes healthy brain development and provides buffering to prevent stressful experiences from
- Serve-and-return
- Resilience - one stable committed relationship essential
- -> OT role
- —->Coach parents/caregivers in service-and-return
- —> Devote time to forming relationships with parents/caregivers
- –>Policy role
Essential principles of service and policy
strengthen life skills
- promote executive functioning and self regulation skills
- Support development of routines, goal setting, social skills
OT role
-Use coaching to support goal setting, planning and achievement
Essential principles of service and policy
Reduce sources of stress in the lives of children and families, OT role
- strengthen parents ability to create stable. predictable home environment eg routine
- regularly ask about family stressors
- link with community programs
OT role: Policy Development
- Promotion
- Prevention
- Early intervention
What is meant by “child and adolescent mental health”
- refers to social, emotional, and behavioural well-being or children and adolescents, and is considered an integral part of healthy development
- Approx 1 in 5 children and youth in Ontario has a mental health challenge
- About 70% of mental health challenges have their onset in childhood and youth.
Signs that a child might be experiencing a mental health problem or mental illness? Changes in behaviour:
- Active to quiet/withdrawn
- Good student to suddenly gets poor grades
Signs that a child might be experiencing a mental health problem or mental illness? Changes in feelings:
unhappy, worried, guilty, angry, fearful, hopeless, rejected
Signs that a child might be experiencing a mental health problem or mental illness? Changes in thoughts:
Expressing thoughts that suggest low self-esteem, self-blame, or thoughts about suicide
What are other signs a child is experiencing mental health problems
Physical symptoms
Drug and/or alcohol abuse
-Difficulty coping with regular activities and everyday problems
-Consistent violations of the rights of other
-Intense fear of becoming fat
-Odd or repetitive movements such as spinning
-Unusual ways of speaking that are hard to understand
- **However many children/youth show some of those characteristics and behaviours as part of typical childhood development
- They may indicate the presence of mental health problems when they are:
- are intense
- Persist over long periods of time
- Are inappropriate for the child’s age
- Interfere with the child’s and families life
Factors affecting Mental Health:
- Biological: genetics
- Environmental: neglect, abuse, exposure to family violence
- Situational: response to major life change
- Developmental: attachment. emotional regulation, social, emotional, intellectual, resiliency
What does mental health issues look like in a child
- Struggles at school
- Living with DCD
- The outsider
- The risk taker
- The socially awkward child
- Military deployments and tummy aches
Issues and challenges (kids with mental health)
- Attention issues
- Behavioural issues
- Learning Challenges
- Autism
- Mood challenges
- Psychosis
- Eating issues
Attentional issues
most common neurobehavioural condition
-5% of pop, twice as many boys as girls
Two main categories:
- Poor sustained attention
- Hyperactivity-impulsivity
- intelligence often average or above
- Can be hidden, often diagnosed when symptoms impact school perfromance
- Impairment in executive functions
- Difficulty managing schedule, collecting all required information, difficulty problem solving, difficulty managing time and materials
Oppositional Defiant Disorder
- Angry, irritable mood, argumentative/defiant behaviour
- Not aggressive towards people or animals, do not destroy property
Conduct disorder
- Repetitive and persistent pattern of behaviour in which the basic rights of others or social norms
- Aggression towards people and animals, destruction of property, theft or deceitfulness, violations of rules
Fetal Alcohol Spectrum Disorders
Range of difficulties in attention, cognitive, executive functioning, memory, adaptive behaviour
Learning Issues
- Reading
- Writing
- Spelling
- Organization
Autism Spectrum Disorder (ASD)
- Complex neurodevelopmental condition
- Difficulties with social interaction and communication
- -> Difficulty making and keeping friends
- Repetitive patterns of behaviours/interests
- Sensory processing differences (filtering adjusting)
- Executive functioning challenges
Anxiety (children)
-Most common mental health concern in children and adolescents
-Monitor intensity, level of distress, impact of daily life
Fight Flight Freeze = F3
Free Mindshift app as April 22, 2019
Eating Disorders
- Anorexia Nervosa
- Bulimia Nervosa
- Binge Eating Disorder
How many children/youth get help for mental health issues?
80% never receive help
- “if mental health services generally are the orphan of the health care system, then children’s services are the orphan of orphan”
- 70% of adults living with mental health problem developed symptoms before thy were 18
Emotional Regulation: Zones of regulation
systematic, cognitive behavioural approach used to teach self-regulation
- Identifies the different ways we feel and states of alertness we experience into four colour zones
- Provides strategies to teach student to become more aware and able to control their emotions and impulses, manage their sensory needs, and improve their ability to problem solve conflicts.
- Incorporates Social thinking concepts and visuals to teach students to identify feeling/level of alertness, understand how their behaviour impacts others, and learn what tools they can use to manage their feeling and states.
Emotional Regulation Alert program
- Developed to teach children how to change how alert they feel and to teach adults how to support learning, attending, and positive behaviour
- shows parents, teachers, and therapists how to choose appropriate strategies and activities so children’s engines are running “just right” to improve participation in daily activities including academic work
Emotional Regulation: SNAP (stop, Now and Plan)
- Evidence-based, cognitive behavioural, gender-specific model that provides a framework for teaching children struggling with behaviour issues, and their parents effective emotional regulation, self-control and problem solving skills
- Primary goal is to keep children and youth in school and out of trouble by helping them make better choices “in the moment”
- Risk factors targeted include: poor self-control and problem-solving, impulse control, bullying, anxiety, delinquency, aggression, and violence, antisocial values and conduct, cognitive distortions or thinking errors, problematic parent management strategies and parent-child interactions, authority contact, school failure and isolation
MindMaster2
- helps children to develop social and emotional skills through relaxation, positive thinking and mindfulness
- Teach children to learn positive living skills: relaxation, stress control, highlights, positive thinking, positive imagery
PEO -Child/Youth (behaviors and cognition)
- Temperament
- Attachment
- Personality
- Attention
- ->Ax - Conner 3, test of everyday Attention for children (TEA-Ch)
- ->Tx - Environmental modifications, education of parents and teachers, learning strategies, AT, self-regulation
- Executive Functioning
- -> Ax- BRIEF, BADS-C
- TX-organization, chunking, checklists, planning, task initiation, self regulation, assistive technology
PEO-Child/Youth: Social Skills
Ax:
-Children Behaviour checklist
-Participation and Environmental Measure for children and Youth (PEM-CY)
TX: - individuals, dyads, groups, vide and peer feedback, homework, social stories
PEO-Child/Youth: Motor Coordination
Ax:
-Perceived Efficacy and Goal Setting (PEGS)
-Movement Assessment Battery for children (M-ABC)
TX: -CO-OP
PEO-Child/Youth: Acedemic Skills
- Ax - Test of written Productivity, Test of written Spelling, Gray Oral Reading Test
- Tx. - AT, learning strategies, time accommodation
PEO-Child/Youth: Sensory Processing
Ax- The Sensory Profile, Sensory Processing Measure (SPM)
-Tx - Environmental modifications, coping strategies, self regulation, exercise
PEO-Child/Youth: Anxiety
Ax-completed by psychologist
-Tx- CBT, coping skills, mindfulness, mediation, desitization,
PEO-Environment
- School
- Home
- Community
- Leisure/Play
PEO-Occupation
- Student
- Family member
- Friend
- Teammate/Group participant
Components of mental Health
- Positive affective or emotional state
- Positive psychological and social function
- Productive
- Resilience in the face pf adversity and the ability to cope with life stressors
- “feeling well” and “doing well”
Executive Functioning
Required for complex, novel, dynamic goal-directed behaviour (variable/inconsistent performance is a hallmark feature)
- Involves both the components (eg. attention, memory, etc.) and the performance itself
- Issues on the rise
- Associated diagnosis
- Its development reciprocally intersects with many factors
Executive Functioning includes
- Response inhibition
- Working memory
- Emotional control
- Sustained Attention
- Task initiation
- Planning/prioritization
- Organization
- Time management
- Goal-Directed Persistence
- Metacognition
Developmental Process:
Preschool
-Share toys, sit in “circle time”, tidy up with assistance, one step instructions
Developmental Process: K-Grade 2
-2-3 step tasks, wait for adult to finish talking before speaking, start and finish small chores
Developmental Process: Grade 3-5
-Follow routines without reminders, bring materials to and from school, keeping track of belongings, complete homework
Developmental Process: Grade 6-8
Follow more complex routines (chang teachers/classrooms/expectations), say no to fun if other plans have been made, longer term projects, inhibit rule breaking without visible authority
Developmental Process: High School
Manage schoolwork (study, create timelines for longer term assignments), good use of leisure time, inhibit dangerous behaviours)
Common Executive Occupational Performance Issues
- Following multi-step routines
- Difficulty organizing (time, ideas, stuff)
- Transferring learning to new tasks
- Connecting the dots
- Managing school projects
- School dificulties
- Square peg round hole
Executive (mal)Function is Universal Experience
- To different degrees, and at different times in our lives
- Typically, we notice it when it isn’t working well, when we are tired, stressed or overwhelmed
- When we are presented with challenging demands to do (eg. curriculum expectations shift)
- Executive functioning is a wide range of processes that can be understood as a spectrum
Executive Functioning Red Flags: Parent or Teacher
- He’s lazy
- He just needs to try harder
- If he only applied himself … .
- He doesn’t seem motivated
- He’s not realizing his potential
- He could do it if he puts his mind to it
- He doesn’t seem to have any problem doing things he likes
- He seems to miss the boat
Executive Functioning Red Flags: Child
- I’m stupid
- I’m a loser
- Why can’t I do it like everyone else ?
- How come my friends don’t have to try as hard?
- I’m not interested.
- I’m not interested
- That’s boring
- Everything takes too long
- What’s the point
Assessment of Executive Function: Informal
- Interviews
- Classroom Observation
- Work Samples
- Checklists
- ->Child Behaviour Checklist,
- ->Behaviour assessment System for Children
- ->Executive Skills Questionnaire for parents/Teachers and students
Assessment of Executive Function: Formal
- BRIEF
- Test of Everyday Attention
OT Intervention executive functioning
OTs modify or simplify a difficult task or break the task down into steps for improved performance
- OTs can target occupational performance in their interventions by seeking answers to the following questions
- -> What can be done to make the task easier for the child?
- ->What can be done to make the context supportive to learning?
- ->what can be done to enhance the child’s capacity to process information required for learning about task performance
Key Principles to Interventions kids
- Intervene at the level of the environment
- Intervene at the level of the student
- Home-school colloboration
Environmental Strategies
- Change physical or social environment
- Change how cues are provided
- Change nature of the task
- Change the way adults interact with students
Student Level Strategies
- Teach the skill (individual or whole-class)
- Self-talk/scripts (goal-obstacles-plan-do-review)
- Motivation
Home-School Collaboration
- Study Periods
- Homework club
- Coach
- Mentor- in-class or older student
Expectations and Executive functioning
- For many with difficulties in their executive functioning, their IEP’s suggest that they need to be
- Organized
- Self-advocating
A catch-22?
- How can you be more organized when you don’t know how to be organized
- How can you ask for help when you don’;t know what you don’t know? when your parents efforts have yielded little?
-Expectations increase at home and at school with age
Issues with Executive Functioning can translate into: Inefficiencies
- Low accuracy
- Low Speed
Issues with Executive Functioning can translate into: Negative Secondary Consequences
- Negative experience of school
- Years of learning that efforts are useless
- Disengagement
- Mental health issues
Issues with Executive Functioning can translate into: Learned helplessness
- Failure is a known quantity and therefore safe
- Very risky to try something new
Achievement Gap
- Curriculum expectations shift and demand more and more independent executive skill competence
- Developmental overlays can mask the true issue
- Societal expectations ramp up of how students will fare after graduation
- Foundation skills are presumed
- Products/Outcomes valued
- ->Attention to the process dwindles
- “classroom instructions generally focuses on the content, or the what, rather than the process, or the how, of learning…. As a result, a large gap separates the skills and strategies taught in school from executive function processes needed for success there and in the workplace
