Today’s newsletter discusses how a primary care provider, working within the time constraints of their office workflow might assess a youngster’s progress along these developmental stages by asking some simple questions about their future goals.   Doing so can create opportunities to provide encouragement and guidance to enhance healthy development.   Integrating simple Motivational Interviewing techniques into the dialogue is an element in this process.

While certainly not rocket science, nor a panacea for improving the lives of all young persons, the suggested interventions do leverage the influence and authority of the PCP by demonstrating their interest in the development tasks facing the child/adolescent patient(s).  This may help orient them (and their parents) toward their futures and encourage healthier social and emotional attitudes and behaviors.  Equally importantly, the effort may help to identify youth facing serious challenges or who are in deeper trouble— those who might then benefit from appropriate mental health referrals.

The following chart gives some examples of dialogue that could be used in the primary care clinic setting.

PSYCHOSOCIAL STAGES

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DIALOGUE 1:    Youth’s View of their Future:  Work

Question(s):                 “Boy you are surely growing each time I see you!  So I’m wondering…

                                       what do you think you want to do when you grow up?”

Follow Up:                  If youth’s response is idealized (e.g., I want to be in the NFL or be like  Angelina Jolie), ….

                                    “Sounds great, and that would be pretty cool.  What would be your backup plan if that didn’t work out?” 

——

[YOUTH RESPONSE]

——

As appropriate, discuss future steps that might be appropriate:

“Hmm, being a ________ means {getting training/going to college/etc.}, so I hope you continue {learning that skill/working hard at school} to get  ahead with that.  That’d be a real good thing to do.”

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DIALOGUE 2:           Youth’s View of their Future:   Family—Children & Marriage 

Question(s):  “It’s still real early in your life, but I think a lot about the future, so I am wondering… What do you think about your future?,… like, will you want to have a family of your own when you grow up– or will you want to live independently?”

                                                ——

                                    [YOUTH RESPONSE]

——

Follow Up:                 If “Yes”, “Hey, that’s neat. It is a big step to {have kids/get married}.” 

                                    If “No”, “Hey that’s good, being independent can be a big step.”                                                 

“You’ve got plenty of time to prepare for that part of your life.  In the  meantime, and, whatever you decide, I know that it is important for  a young person to take good care of themselves and to build friendships and to be involved with your family at home, your teachers at school and good people in your neighborhood.  Maybe next time we meet, you can tell me how those parts of your life                                    are going.”

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 DIALOGUE 3:           Risks & Vulnerabilities 

Question(s):                “Can you think of any risky things that you’d have to be careful about as

                                      you are growing up?” 

——

[YOUTH RESPONSE]

——

Affirm youth’s positive safety comments—e.g., drugs, sex, etc.

“That is real good thinking.  It can sometimes be hard to do what’s best, but it can make a real big difference. As you get older, it will be        important to think for yourself about what is safe and to ask for help if and when you feel you need it.” 

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In the above examples, the PCP aims to be conversational, future-focused, and encouraging, with efforts made to clarify and support the patient’s positive responses affirmatively.

It should never be a heavy lift for the interviewer, but rather, it works best when the locus of control remains in the youth’s hands.

As with all Motivational Interviewing, the interviewer’s job is to create an opportunity to identify their personal goals and wishes, and then offer encouragement and support.

 References:

• Erik Erikson’s Stages of Psychosocial Development, Kendra Cherry, David Sussman, PhD, https://www.verywellmind.com/erik-eriksons-stages-of-psychosocial-development-2795740 , 2021
• Motivational Interviewing, SmartCare BHCS e Weekly, https://www.vistahillccyp.org/motivational-interviewing-4-12-2018/

The seminal Adverse Childhood Experiences study demonstrated the strong correlation between the number of adverse events experienced in childhood and the risks for negative health and social outcomes in adult life.  A recent paper in the Archives of Psychiatric Nursing (Hambrick, Brawner, Perry, et al)¹ examines the timing of experienced adversity as a factor negatively impacting overall developmental outcomes. It demonstrates that disruptive and adverse experiences in the early years have significantly more troubling and pervasive consequences than the still harmful disruptions that occur later in childhood.   The study further identified that the presence of positive parent-child inter-relatedness is an important protective factor in the face of such early ACEs, and that the absence of positive relatedness is a damaging one, most particularly for infants and younger children.

This finding suggests that, while current efforts to identify all children and families with ACEs are important throughout childhood and adolescents, efforts to identify parents/families struggling with their own lives during the post-partum and their earliest years of their children’s lives can potentially mitigate some of the long-term risks to these children’s health and well-being.  This may be from current or future ACEs or from experiencing interpersonal and emotional neglect.

The context for the “Beyond the ACE Score” study referenced herein entailed awareness that social, emotional, cognitive, and physiological functioning of a child is impacted by a multiplicity of inputs, amongst which both overt trauma incidents (ACEs) and impairment in parent-child relatedness (relational poverty) are pivotal issues negatively impacting developmental outcomes.   The absence of a strong positive caregiver-child relationship in early childhood is in itself a challenge to healthy development, but its absence in the face of other stressors and adversity, magnifies the trauma load by removing from the equation the resiliency benefits that supportive caregiving, interpersonal engagement and responsive attention can provide to the traumatized child.

The importance of strong, and very importantly, early positive interactions between infants and their caregivers as a positive force in the child’s developing the core building blocks of social-emotional health (engagement, reciprocity, etc.) as well as in enhancing future cognitive and behavioral competency, is clearly supported by the study’s findings.

While adverse incidents and the lack of interpersonal support are problematic at any stage in childhood, the study clearly indicates that the earlier in time that exposure to these two negative factors (trauma and relational poverty) occurs, the higher the predictive risk for negative outcomes.   Conversely, but in no way surprising, the study indicated that greater levels of relational health were associated with better outcomes, even in the face of adverse events and challenges.

These findings provide strong support for providing screening and early intervention in support of parents and families (and their children) to mitigate the likelihood of harm and disruption in children’s overall development. Screening for maternal depression is one form of intervention that many primary care providers already do that are congruent with this goal.  Inquiries about the potential presence of other concerns such as food or housing insecurity, substance abuse in the home and community, and the presence of domestic conflict or domestic violence are other opportunities identify potential children and families at risk.

Making these inquiries can be awkward at times, but just as inquiries of youth and parents about ACEs and just as inquiries of teens about self-harm, substance use and sexuality can be challenging, framing the questions as a routine matter of health promotion can minimize discomfort on both sides of the interchange.    Asking about these risk factors in a calm and non-judgmental manner can open the door to discovery: “I hope this is not uncomfortable for you, but part of our work as healthcare providers is to ask all our patients’ parents about potential challenges that can have impact on health and well-being.  If you are OK with this, I’ve got a few personal questions.  Is this OK for you?  [If ‘No’, end of inquiry, but if ‘Yes’, proceed]   Is your family having challenges with: food insecurity; …..housing; …. substance use; ….interpersonal conflicts?”

If any replies are affirmative, an empathic and support comment (e.g., “That sounds tough” would be appropriate) followed by a recommendation about potential resources.  Responsive options could include the County’s 211 information line or referring to SmartCare’s Parent Line [868 956-5900] for further follow up and services.

Reference:

Hambrick, Brawner, Perry, et al; “Beyond the ACE score:  Examining relationships between timing of developmental adversity, relational health and developmental outcomes in children; in Archives of Psychiatric Nursing 33 (2019) 238-247

While there are resource challenges of both time and funding for families, and continued attention to the primary treatment needs of youth with mental health disorders should never be ignored, efforts to develop treatment plans that integrate diagnostic and treatment strategies across disciplinary boundaries is a sensible approach.  Though often not pursued with appropriate vigor, occupational therapy approaches can aid in identifying neurosensory, emotional regulatory, and cognitive ‘style’ considerations as part of the diagnostic process and can assist in identifying and promoting relevant social and emotional competency building experiences that can be incorporated in therapeutic intervention strategies to enhance self-esteem, social skills, and overall well-being in conjunction with psychological and psychopharmacologic interventions .

Two clinical examples:

• ADHD: Providing parents, teachers and the affected youth with a better understanding of their unique strengths and challenges in attending and in executing cognitive functions can often lead to the development of viable strategies in learning and can reduce feelings of helplessness.
• Anxiety: Recognition of an individual’s heightened sensitivities and reactivity to various environmental triggers can assist parents, teachers and the affected youth make choices about how to modulate exposure to stressors and to define social and recreational regimens that accommodate a youth’s individual needs.

Following are abstracts culled from the American Occupational Therapy Association’s Fact Sheet on this theme.¹

“Participation in meaningful roles (e.g., student, friend, family member) and activities (e.g., sports or hobbies) leads to enhancement of emotional well-being, mental health, and social competence. Social competence for children and adolescents includes doing what is necessary to get along with others, making and keeping friends, coping with frustration and anger, solving problems, understanding social etiquette, and following school rules. Recent studies indicate that behavior and social interaction skills (i.e., social competence), are stronger indicators of academic and lifelong success than academic skills.” ²

An occupational therapy evaluation can “assess all the components of social competence and determine whether a child’s motor, social-emotional, and cognitive skills; ability to interpret sensory information; and the influence from home, school, and community environments … impact” their “ability to meet the demands of everyday life.³ ”

“Occupational therapists use a client-centered evaluation process to develop an understanding of the child’s primary roles and occupations (activities), such as play, schoolwork, and age-appropriate self-care. A client-centered assessment for children also requires interaction with school staff, parents, care providers, and community members. Therapists then seek to determine what factors affect the child’s ability to meet the demands of these roles and activities and fully participate in them.”

“Interventions are used to promote social–emotional learning; regulate overactive or underactive sensory systems; collaborate with families and medical or educational personnel; and more. For example, occupational therapy practitioners can help the child incorporate sensory and movement breaks into the day to enhance attention and learning; and provide support to teachers and other school staff by breaking down study tasks, organizing supplies, and altering the environment to improve attention and decrease the effect of sensory overload in the classroom. Occupational therapy practitioners can also provide programming to establish social competence through planning and development of playground skill groups, bullying prevention, social stories, and after-school activities.”

“Occupational therapists … also collaborate with adults in the child’s life:

• Parents or care providers—to provide education about the social-emotional, sensory, and cognitive difficulties that interfere with a child’s participation in play, activities of daily living, and social activities; and to help develop emotional supports, structure, and effective disciplinary systems
• Educators and other school staff—to develop strategies for a child to successfully complete classroom, recess, and lunchroom activities, and to interact effectively with peers and adults
• Counselors, social workers, and psychologists—to provide insights into the interpersonal, communication, sensory processing, and cognitive remediation methods that aid emotional and social development
• Pediatricians, family physicians, and psychiatrists—to support medical intervention for persistent mental illness and to provide a psychosocial and sensory component to supplement medical intervention
• Communities—to support participation in community leisure and sports programs; encourage education, understanding, and early intervention for children with mental health problems; and develop advocacy and community programs for promoting understanding of the mental health diagnosis and decreasing stigma”

“Ultimately, the goal of” occupational therapy “intervention is to promote successful participation in” activities “that characterize a healthy childhood and set up the child for success throughout his or her life. Occupational therapy practitioners” can “help to promote safe and healthy environments for learning, growth, and development by addressing both physical and mental health.”

Bottom Line:  Judicious consideration of the potential benefits of referring an child and family for an occupational therapy evaluation and maintaining a focus on enhancing all elements in a child’s home, school and community environment can be important considerations in treatment planning and implementation in the face of underlying mental health and developmental difficulties.

References:

¹   Fact Sheet: Occupational Therapy’s Role with Mental Health in Children and Youth

Lisa M. Mahaffey, MS, OTR/L, for the American Occupational Therapy Association. copyright © 2016

²  Jones, D. E., Greenberg, M., & Crowley, M. (2015). Early social-emotional functioning and public health: The relationship between kindergarten social competence and future wellness. American Journal of Public Health, 105, 2283–2290. http://dx.doi.org/10.2105/ AJPH.2015.302630

³ Arbesman,M., Bazyk, S., & Nochajski, S. (2013). Systematic review of occupational therapy and mental health promotion, prevention, and intervention for children and youth. American Journal of Occupational Therapy, 67, e120–e130. http://dx.doi.org/10.5014/ajot.2013.008359

More work is necessary to examine the potential neurobiological mechanisms underlying this association. Emerging studies in neuroimaging and genetic research are starting to provide some clues. Neuroimaging studies have shown that irregularities in dopaminergic neurotransmission and prefrontal cortex dysfunction have been found in both ADHD and PTSD, leading to the possibility that abnormalities in specific neural circuits in ADHD may increase the vulnerability for both ADHD and PTSD. Genome-wide data has found substantial shared common genetic variation between these two disorders, and they also have some common specific genetic risk factors. Further research is needed to understand the clinical significance of these findings.

So what does all this mean clinically in a primary care setting? Awareness of this comorbidity between ADHD and PTSD alerts clinicians treating patients with one disorder to screen for the other.  Additionally, the association between symptoms also suggests that PTSD symptoms can exacerbate ADHD symptoms and vice versa. Patients with PTSD can develop an acquired ADHD-like syndrome, which includes reports of inattention, disorganization, and forgetfulness. This is related to the work showing that chronic uncontrollable stress impairs working memory and prefrontal cortex function. Awareness of this link also alerts prescribers to be aware of the possible side effects of stimulant medications used to treat ADHD symptoms on the anxiety and trauma symptoms of PTSD. Clinical experience supports the idea that in children with both PTSD and ADHD, the alpha-agonists can be helpful for both symptoms.