Developmental Disabilities and Co- Occurring Mental Health Disorders

1
Developmental Disabilities and Co- Occurring
Mental Health Disorders

• Rick Blumberg, Ph.D.

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Developmental Disabilities

• A diverse group of severe chronic conditions that
  are due to mental and/or physical impairments.
  People with DD have problems with major life
  activities such as language, mobility, learning,
  self help and independent living.
• Onset prior to age 22
• Lifelong ( Centers for Disease
  Control)

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Intellectual DisabilityAAIDD Definition

• Mental retardation (ID) is a disability
  characterized by significant limitations both in
  intellectual functioning and in adaptive skills
  as expressed in conceptual, social and practical
  adaptive skills.
• Originates prior to age 18

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5 Assumptions

• Limitations must be considered within the context
  of the community, culture and peer group
• Assessment considers cultural and linguistic
  diversity
• Limitations co-exist with strengths

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5 Assumptions

• The purpose of describing limitations is to
  create a profile of supports
• With appropriate supports, over time, the life
  functioning of a person will improve

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The Concept of Support

• The resources and individual strategies necessary
  to promote the development, education and
  personal well being of a person with mental
  retardation.

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Nine key areas of support
Human Development Teaching /Education Home Living
Community Living Employment Health and Safety
Behavior Social Activities Protection and Advocacy
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ID/Mental Retardation APA

• Characterized by significantly subaverage
  intellectual functioning that is accompanied by
  significant limitations in adaptive functioning
  in at least two of the following areas
• Communication, self-care, home living, social
  interpersonal skills, community resources, self
  direction, contd.

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ID/Mental Retardation

• Functional academic skills, work, leisure, health
  and safety.
• Onset must occur prior to age 18
• Many different etiologies, resulting in
  pathological processes that affect the
  functioning of the central nervous system

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ID/Mental Retardation

• Subaverage intellectual functioning is defined as
  an IQ of 70 or below obtained by an assessment w/
  a standardized individually administered
  intelligence test (Weschler Intelligence Scales
  for Children-R, Woodcock-Johnson, Kaufmann
  Assessment Battery for Children)

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Adaptive Functioning

• Refers to how effectively individuals cope with
  common life demands, how well they meet the
  standards for personal independence for persons
  of similar age.
• Measures of adaptive functioning include AAMR
  Adaptive Behavior Scales, AAID Supports Intensity
  Scale

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Degrees of ID/Mental Retardation

• Mild MR IQ of 50-55 to 70 (85)
• Moderate MR 35-40 to 50-55 (10)
• Severe MR 20-25 to 35-40 (3-4)
• Profound MR below 20 or 25 (1-2)

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Etiology of ID/MR

• Heredity (5) include chromosomal aberrations
  such as Downs Syndrome and Fragile X, errors of
  metabolism as in Tay-Sachs disease, single gene
  abnormalities as in tuberous sclerosis.
• Alterations of embryonic development (40)
  prenatal damage due to toxins, infections,
  maternal alcohol consumtpion

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Etiology of ID/MR

• Pregnancy and perinatal problems (15) fetal
  malnutrition, prematurity, infection and trauma.
• Medical conditions in infancy and childhood (15)
  trauma, infection, etc.
• Environmental influences (25) , toxic substances
  deprivation, abuse

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ID/Mental Retardation

• Prevalence Approximately 1 of the population
  (dependent on measures used)
• Course Before 18 years
• Familial Pattern No familial pattern

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Communication

• Tendency to say what others want to hear
• Cloak of competence- devise fictions that make
  them appear more skilled than they are
• If given choices- tendency to favor the
  first/last choice
• Problems with comprehension- frustration

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Thinking, Feeling Behaving

• Thinking concrete- problems with abstraction,
  immature reasoning (rule orientation), problems
  with perspective taking
• Feeling emotional over-responding, quick to
  anger, problems with personal boundaries
• Behaving tendency to act out feelings, inability
  to anticipate the consequences of actions

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Down Syndrome

• One of the most common genetic disorders
• Affects 1 in 800 children
• Characteristics result from extra copy of
  chromosome 21 ( 3 copies instead of 2- trisomy
  21)
• Diagnosis can be made prenatally by amniocentesis

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Diagnostic Features

• 90 have IQs in the range of mental retardation
  or borderline functioning (10 w/in normal range)
• Problems with articualtion
• Congenital heart defects

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Behavioral Effects

• Increased risk for dementia/Alzheimers
• Association with Autism being explored
• Some increased risk for major depressive disorder
  has been noted
• Tendency to act out feelings, emotional
  over-responding

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Fragile X Syndrome

• Common genetic cause of IDD
• Affects 1 in 4,000 people
• Affects cognitive abilities, social interactions,
  behavior and physical health
• Wide spectrum of symptoms

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Typical Facial Features

• Long face
• Prominent chin
• Large, prominent ears
• Prominent forehead
• Small eyes
• Epicanthic folds
• High arched palate

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Behavioral Effects

• Distractibility- short attention span
• Hyperactivity
• Hypersensitivity to sensory stimuli can lead to
  sensory overload and tantrums
• Social anxiety
• Other behaviors avoidance of eye contact, hand
  flapping/biting, perseveration

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Diagnosis

• Genetic testing on a blood sample at any age
• Amneocentesis in early pregnancy
• Clinic checklists for screening

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Cerebral Palsy

• A neuro-motor impairment
• A non-progressive disease resulting in motor
  difficulties associated with communication and
  mobility problems

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Cerebral Palsy Spastic Type

• Rigid muscle tone
• Stiff jerky movements
• Difficulty shifting position, letting go of
  something they are holding
• About half of people w/ CP have this type

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Ataxic Cerebral Palsy

• Low muscle tone
• Poor coordination
• Tremors
• Poor balance
• Require more time to complete tasks

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Athetoid Cerebral Palsy

• Muscle tone is mixed
• Difficulty maintaining position for sitting
  standing, walking
• Random involuntary movements
• Difficulty grasping and maintaining grasp

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Quadriplegia

• Involves all four limbs
• Difficulty moving all parts of the body
• Difficulty speaking and eating
• Require assistance w/ ADLs and positioning
• Communication and eating difficulties

30
Hemiplegia/Diplegia

• Hemiplegia affects one side of the body,
  difficulty w/ movement, environmental
  modifications needed.
• Diplegia lower limbs are affected, usually have
  god ability to hold themselves upright and use of
  arms and hands

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Causes of Cerebral Palsy

• Injury to the brain, before, during or soon after
  birth
• In-utero typically caused by infection or injury
  to mother, high blood pressure, diabetes.
• Birth lack of oxygen, injury to brain
• Infancy Prematurity, infection, injury to the
  brain

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Associated Features

• Learning problems in one fourth to one half of
  persons
• Seizures occur in about one half of persons with
  cerebral palsy

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Behavioral Concerns

• Difficulty with articulation, being understood by
  others
• Frustration due to mobility impairment, fine and
  gross motor coordination
• Physical pain due to positioning, muscle
  contractions
• Difficulty with emotional regulation

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Autism Spectrum Disorders

• Includes Autism, Aspergers Syndrome, PDD NOS
• Usually evident in early childhood
• Often associated with some degree of mental
  retardation
• Severe and pervasive impairments in several areas
  of development

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Areas of Impairment in ASDs

• Reciprocal social interaction
• Communication skills
• Stereotypical behavior
• Restricted interests
• Sensory abnormalities

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Autistic Disorder

• Markedly abnormal or impaired development in
  social interaction and communication
• Restricted repertoire of activities and interests

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Social Interaction

• Impaired non-verbal behaviors eye to eye gaze,
  facial expression, posture and gestures
• Failure to develop peer relationships
• Poor understanding of social conventions
• Lack of social or emotional reciprocity

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Communication

• Delay or lack of verbal communication skills
• Impairment in ability to sustain conversation
• Presence of repetitive or idiosyncratic language
• Disturbances in comprehension

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Behavior

• Restricted repetitive or stereotyped patterns of
  behavior
• Inflexible adherence to routines
• Insistence on sameness
• Stereotyped body movements
• Attachments to objects

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Associated features

• 75 function w/in range of ID
• Neurologic symptoms sometimes present (reflexes),
  seizure disorder in 25 of cases
• Rates are 4-5 times higher in males
• 5 cases per 1000 in pop.
• Increased risk for siblings

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Aspergers Disorder

• Qualitative Impairment in social interaction
• Marked Impairment in use of nonverbal behaviors
• Failure to develop peer relationships
• Lack of interest to share enjoyment, interests or
  achievements of others
• Lack of social/emotional reciprocity

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Restricted patterns of behavior interests
activities

• Preoccupation with one or more interest
  abnormal in intensity or focus
• Inflexible adherence to non-functional routines
  or rituals
• Stereotyped motor mannerisms
• Preoccupation with parts of objects

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Aspergers

• Clinically significant impairment in social,
  occupational functioning
• No delay in language
• No delay in cognitive or self help skills

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Aspergers

• More common in males
• Increased frequency among family members
• Often occurs with ADHD or OCD

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Aspergers Syndrome/HFA

• A neurological disorder that impacts thinking,
  feeling and behavior
• Many children and youth display poor auditory
  processing and modulation
• Under stress, display limited self control

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Generalization

• Difficulty applying information and skills across
  settings and people
• Child may be able to memorize facts as
  unconnected bits of information
• Child may memorize rules or procedures, but be
  unable to apply them when needed

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Rote Memory

• Because of well developed rote memory, may appear
  to understand concepts when they do not
• May be able to recite the steps in a procedure
  but be unable to perform it
• Inability to answer open ended questions

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Theory of Mind Deficits

• Difficulty understanding emotions
• Predicting the behavior or emotions of others
• Understanding the perspective of others
• Inferring the intentions of others
• Understanding how behavior affects others

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Theory of Mind Deficits

• Social conventions turn taking, politeness, self
  monitoring
• Distinguishing Fantasy vs. Reality

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Problem Solving

• Black and white (concrete) thinking, rule
  orientation
• Tendency to apply a single problem solving
  strategy across situations and regardless of
  outcome
• Lack of self monitoring and adaptation or
  flexibility

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Communication

• Good structural language skills (pronunciation,
  syntax)
• Poor pragmatic communication
• Repeat phrases, exaggerated inflection, monotone,
  discuss single topics, difficulty sustaining
  conversation

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Non-Verbal Communication

• Nonverbal communication and related social
  context problems
• Proxemics distance maintained while speaking to
  another
• Intense staring or lack of eye contact
• Abnormal body posture

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Non-Verbal Communication

• Lack of expressive facial gestures to signal
  interest or approval
• Inability to understand the facial gestures of
  others

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Visual Processing

• Typically stronger than auditory processing
• Visually presented information is more readily
  understood
• Visual aides, graphic organizers, study guides
  and schedules

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Socialization

• Inability to establish and maintain social
  relationships with peers
• Lack of understanding of social cues
• Interpret words or phrases concretely
• Language comprehension problems

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Social skills

• Inability to understand and use the rules
  governing social behavior
• Initiate and/or maintain a conversation
• Saying what comes to mind no censorship
• Extensive monologues on restrictive topics
• Rigid adherence to learned rules

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Video Modeling

• Video modeling (VM) typically involves a person
  viewing a clip of someone performing the steps of
  a task/skill, and then performing that task
  themselves. It involves visual and auditory
  prompting
• Recent research suggests that VM can be used to
  successfully teach a variety of skills (academic,
  career, social, self care) to individuals with
  IDD. (Rehfelt at al, 2003 Mangiapello Taylor,
  2003 Nikopolous Keenan, 2003)

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A Promising Practice

• VM appears to improve the pace of learning,
  improve task accuracy/quality, improve
  generalization, and increase independence (Van
  Laarhoven et al, 2009
• Students may prefer VM to traditional forms of
  systematic instruction (Hume, Loftin Lantz,
  2009)
• It does not appear to matter if the student views
  him/herself or others modeling the task/skill

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A Pilot Demonstration

• To get some experience with VM and its
  application to College students with IDD, we
  conducted a pilot demonstration in Fall 2001
  semester
• We wanted to see how iPAD technology could be
  used to help students learn job skills and the
  social skills associated with them.

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Our Process

• Task analyze on-campus work experiences
• Demonstrate the tasks for students
• Direct students to perform the tasks
• Provide a hierarchy of prompts until students
  complete the task (gestural, verbal, physical w/
  verbal direction, modeling w/verbal direction
• Take observational data on the types of prompts
  needed

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Using video

• Create film clips of the task analysis using
  student models
• Provide visual and verbal directions within the
  video
• Have students view the video prior to performing
  the task
• Remind students that they can view the video as
  needed
• Take observational data on the number of times
  students view the video to independent task
  completion

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Ateev

• Sophomore
• Polite, wants to be liked by others
• Does not respond well to social cues, difficulty
  with social interactions
• He has difficulty initiating interactions/conversa
  tions with peers at lunch

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Baseline Data Ateev
Steps Steps Steps Steps Trial Trial Trial
Steps Steps Steps Steps 1 2 3
1 Walk up to the person. Walk up to the person. Walk up to the person. Walk up to the person. 2 0 1
2 Look them in the eyes and say hello. Look them in the eyes and say hello. Look them in the eyes and say hello. Look them in the eyes and say hello. 1 2 2
3 After they respond, ask them how their day is going. After they respond, ask them how their day is going. After they respond, ask them how their day is going. After they respond, ask them how their day is going. 2 2 2
4 Once they answer, them them know how your day is going. Once they answer, them them know how your day is going. Once they answer, them them know how your day is going. Once they answer, them them know how your day is going. 0 0 0
5 Ask that person if they would like to sit with you for lunch. Ask that person if they would like to sit with you for lunch. Ask that person if they would like to sit with you for lunch. Ask that person if they would like to sit with you for lunch. 2 0 2
6 If they say yes, guide them to your seat. If they say yes, guide them to your seat. If they say yes, guide them to your seat. If they say yes, guide them to your seat. 1 2 2
7 Continue conversation by saying, "What classes do you have this afternoon?" Continue conversation by saying, "What classes do you have this afternoon?" Continue conversation by saying, "What classes do you have this afternoon?" Continue conversation by saying, "What classes do you have this afternoon?" 2 x 4
8 Do not repeat any questions you have asked or anything you have said. Do not repeat any questions you have asked or anything you have said. Do not repeat any questions you have asked or anything you have said. Do not repeat any questions you have asked or anything you have said. 0 0 0
9 Do not repeat anything your friend has said. Do not repeat anything your friend has said. Do not repeat anything your friend has said. Do not repeat anything your friend has said. 0 0 0
               
0 Independent Response 0 Independent Response 2 Verbal Prompt Only 4 Modeling Prompt w/ Verbal Direction        
      Total 10 6 13
1 Gestural Prompt Only 1 Gestural Prompt Only 3 Physical Prompt w/ Verbal Direction 5 Direct Physical Assistance w/ Verbal Direction        
        Date 9/30 9/30 10/4
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Video Initiating Conversation
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Post-Data Ateev
Steps Steps Steps Steps Trial Trial Trial Trial Trial Trial
Steps Steps Steps Steps 4 4 5 5 6 6
1 Walk up to the person. Walk up to the person. Walk up to the person. Walk up to the person. 0 0 0 0 0 2
2 Look them in the eyes and say hello. Look them in the eyes and say hello. Look them in the eyes and say hello. Look them in the eyes and say hello. 0 0 0 0 0 0
3 After they respond, ask them how their day is going. After they respond, ask them how their day is going. After they respond, ask them how their day is going. After they respond, ask them how their day is going. 0 0 0 0 0 0
4 Once they answer, them them know how your day is going. Once they answer, them them know how your day is going. Once they answer, them them know how your day is going. Once they answer, them them know how your day is going. 0 0 0 0 0 0
5 Ask that person if they would like to sit with you for lunch. Ask that person if they would like to sit with you for lunch. Ask that person if they would like to sit with you for lunch. Ask that person if they would like to sit with you for lunch. 0 0 0 0 0 0
6 If they say yes, guide them to your seat. If they say yes, guide them to your seat. If they say yes, guide them to your seat. If they say yes, guide them to your seat. 0 0 0 0 0 0
7 Continue converstaion by saying, "What classes do you have this afternoon?" Continue converstaion by saying, "What classes do you have this afternoon?" Continue converstaion by saying, "What classes do you have this afternoon?" Continue converstaion by saying, "What classes do you have this afternoon?" 0 1 0 1 0 0
8 Do not repeat any questions you have asked or anything you have said. Do not repeat any questions you have asked or anything you have said. Do not repeat any questions you have asked or anything you have said. Do not repeat any questions you have asked or anything you have said. 0 0 0 0 0 0
9 Do not repeat anything your friend has said. Do not repeat anything your friend has said. Do not repeat anything your friend has said. Do not repeat anything your friend has said. 0 0 0 0 0 0
                     
0 Independent Response 0 Independent Response 2 Verbal Prompt Only 4 Modeling Prompt w/ Verbal Direction              
      Total 0 1 0 1 0 2
1 Gestural Prompt Only 1 Gestural Prompt Only 3 Physical Prompt w/ Verbal Direction 5 Direct Physical Assistance w/ Verbal Direction              
        Date 10/20 10/20 10/21 10/21 10/25 10/25
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Graph Data
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Sensory Issues

• Anecdotal information suggests
• Hypersensitivity to auditory or visual stimuli
• Obsessive preference for certain foods and food
  textures
• Tactile sensitivity
• In some, high tolerance for pain

68
Problem behavior (functions)

• Lack of social skills
• Lack of understanding
• Environmental variables
• Obsessive pursuit of certain interests
• Defensive panic reaction

69
Epilepsy

• A brain disorder in which normal patterns of
  neuronal activity becomes disturbed , causing
  strange sensations, emotions and behavior.
• Sometimes causes convulsions, muscle spasms, and
  loss of consciousness
• Co-occurs with IDD about 25 of the time

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Epilepsy Causes

• Brain injury (trauma) e.g. during birth process
  (lack of oxygen) or later by fall, car or bike
  accident
• An infection or illness during pregnancy
• Meningitis, encephalitis or other infection that
  affects the brain
• Brain tumors or strokes
• Poisoning (lead or alcohol)

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Absence or petit-mal

• Brief lapses in consciousness
• May appear to be daydreaming or not paying
  attention
• Child may lose important information during
  seizure, is not attending to environment or
  people around him/her

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Simple- partial

• Environment may seem distorted or strange
• Inexplicable, disturbing feelings
• Children may display bizarre behavior patterns

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Complex Partial Seizures (focal)

• Start in one part of the brain and may move to
  other parts or remain localized
• Person may lose consciousness
• Observable twitching of facial muscles, fingers,
  hand, arm, leg or foot
• Speech may become slurred, unclear or unusual
• Vision may be affected

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Generalized (tonic/clonic)

• Electrical disturbances occur across the brain at
  one time
• Child may appear to be daydreaming, stare off
  into space, or pass out
• Muscles may stiffen, followed by convulsions
• Generally followed by confusion, fatigue
• Sometimes loss of memory for events

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Epilepsy and behavior

• Prior to seizures, increase in irritability and
  decrease in impulse control
• Headaches and body aches/pain
• Fear and/or anxiety
• Mood
• Repeated seizures can lead to problems with
  memory, cognition and ability to plan and reason

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Mental Health in Intellectual Disability

• Assessment of Mental Health Problems in Children
  and Youth

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Comorbidity

• Two distinct/separate disabilities within the
  same person
• 30-42 of children with ID have a co-occurring
  mental health diagnosis (Rutter et al, 1976)
• Chicago study reported incidence rate of 60 with
  39 requiring hospitalization ( Reiss, 1990)
• Canadian study suggested 67 (Goldman, 1995)

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Diagnostic problems

• Masking IDD disability inhibits expression of
  thoughts and feelings
• Overshadowing behavioral manifestations assumed
  to be a part of, or caused by IDD

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Effective Diagnosis

• Adapting assessment procedures use of adapted
  instruments (Beck Depression Inventory, Reiss
  Screen of Maladaptive Behavior, Behavior
  Assessment Scale for Children-BASC)
• Use of Functional Behavioral Assessment (Fuller
  Sabatino, 1998, Baker Blumberg, 2003)
• Use of behaviorally descriptive instruments (AAID
  Supports Intensity Scale)

80
Depression

• Vulnerability to risk factors including stressful
  early experiences, poor social/communication
  skills, and learned helplessness
• Greater risk for abuse and neglect
• Lower levels of social support
• Generally negative social conditions
• (Glenn et al
  , 2003)

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Depression

• Increased tendency for children with ID to engage
  in externalizing behaviors (aggression, tantrums)
  when distressed or irritable ( Reiss, 1992,
  Charlot et al, 1993, Johnson,2010)
• Limited behavioral repertoire
• Central nervous system deficits may impair
  pathways responsible for inhibitory responses and
  problem solving

82
Depression

• Externalizing behaviors may mask typical
  clinical signs of depression
• Changes in appetite, sleep patterns, activity
  levels, lack of pleasure during typically
  preferred activities
• Cognitive symptoms feelings of hopelessness,
  negative statements about self, others

83
Common Behaviors

• Somatic complaints, tantrums, run away, school
  refusal
• Depressed appearance
• Anxiety
• Social withdrawal (Johnson et al, 1995)

84
Bi-Polar disorder

• Depression alternating with mania
• Sleep problems and over-activity that co-occur
  over a period of weeks
• High rates of aggression or self injury
• Irritability
• Increased vocalization, gestures

85
Bi-Polar Disorder

• Rapid cycling associated with central nervous
  system dysfunction
• Non-verbal children may alternate from complete
  silence during depressive episodes to continual
  vocalization (Parry et al, 1999)
• Changes of ability level (basic skills), moving
  from one activity to another (without completion)
  (Friedlander Capone, 1999)

86
Anxiety

• All DSM-IV-4 criteria for Anxiety Disorder are
  applicable for children w/ ID
• Problems with cognitive functioning and
  communication make application more difficult
• Incorporating behavioral equivalents makes
  diagnosis possble

87
Anxiety General Symptoms

• Cognitive apprehension, tension, fear- panic
• Somatic dry mouth, difficulty swallowing,
  flushing, pallor, palpitations, tremor,
  hyper-ventilation, chest pain, headache,
  backache, urinary frequency
• Behavioral avoidance, heightened startle
  response, diminished concentration, insomnia
• (nightmares) (DMID,
  2007)

88
Anxiety in Children with ID

• Symptoms are similar as in children without ID
• Increased brooding, sleep disorders, somatic
  complaints (Masi et al , 2000)
• Increased fearfulness, particularly among females
  ( Gallone, 1996)

89
PTSD in Children with ID

• Symptom experience is likely to be much like that
  of non-disabled children
• Ability to understand and express may be limited
• Caregiver report may be necessary for children
  with more severe disability

90
Assessment

• Trauma may be recent or remote
• Trauma may not seem objectively to be severe, but
  may have been experienced as severe by the child
• Individuals with Mild ID may be able to describe
  the re-experiencing component
• Individuals with more severe impairments may act
  them out

91
Symptoms

• Non-compliance may represent persistent
  avoidance of stimuli reminiscent of the trauma
• Re-experience may be acted out on others, or be
  expressed in self injury (skin-picking, head
  banging)

92
Schizophrenia

• In the general population clinicians look for
  characteristic symptoms including delusions,
  hallucinations, disorganized speech, disorganized
  or catatonic behavior, negative symptoms (flat
  affect, loss of energy/interest)
• In children, failure to achieve expected level of
  interpersonal relationships, academic achievement

93
Schizophrenia

• In children and youth with IDD diagnosis is
  difficult
• If child is highly verbal, delusions may be
  expressed, or inferred from fearful behavior if
  this is a change from typical functioning
• Auditory hallucinations are the most common
  symptom (command or critical)
• Understanding or typical functioning is essential
  to identification of positive symptoms

94
Schizophrenia

• Negative symptoms Regression from typical
  functioning, withdrawal, loss of interest, energy
  and or enjoyment
• Bizarre behavior that is atypical, echolalia,
  emotional and aggressive outbursts, speaking to
  self, bizarre rituals, disorganized thinking

95
Environment matters

• Students that are segregated in special schools,
  have poorer social skills, more difficulty
  establishing social relationships, and display
  higher levels of emotional distress and
  depression than students in self contained
  classes and inclusive settings (McMahon, 1987
  Stephanik, 1987 Kennedy et al, 1989)

96
Intervention

• Individuals with mild ID benefit from treatments
  used with persons of average intellectual
  functioning
• Family, couples and sibling therapy enable
  families to be more supportive
• Teaching appropriate behaviors (social/communicati
  on skills) paired with consistent reinforcement
  is effective
• Adaptive technology supports intervention

97
Intervention

• Strong support for teaching that focuses on
  communication and awareness of feelings (role
  play, color codes)
• Teaching adaptive coping skills ( how to seek
  support, self relaxation, positive thoughts,
  etc.)
• Teaching independent living, vocational and
  recreational skills
• Use of peer and adult mentors

98
Cognitive Interventions

• Cognitive interventions to reduce emotional
  stress by improving self awareness, correcting
  faulty thinking, and providing strategies for
  emotional coping
• Mood charts use numbers, words and images to help
  children monitor and manage moods
• Technology Touch and learn- a free APP that
  prompts children to match mood to facial
  expressions

99
Cognitive Interventions

• Cognitive restructuring identifies erroneous or
  problematic thoughts and modifying them or
  replacing them
• Help children and youth replace self defeating/
  problematic thoughts with statements that
  facilitate positive emotional and behavioral
  responses

100
Affective Interventions

• Help the child to identify and express feelings,
  alter or effectively cope with feeling states,
  and alter or inhibit problematic responses to
  feeling states
• Child or youth who is experiencing depression or
  anxiety can be exposed to experiences that induce
  feelings of positive emotions and well-being
• Relaxation techniques, journaling, exercise