Keynote Innovation Conference Alameda County Behavioral Health Services Carl C. Bell, M.D. Staff...

Keynote Innovation ConferenceAlameda County

Behavioral Health ServicesCarl C. Bell, M.D.

Staff Psychiatrist – Jackson Park Hospital Family Practice Clinic

Staff Psychiatrist – St. Bernard Hospital Inpatient Psychiatry Unit

Former Director of the Institute for Juvenile Research(Birthplace of Child Psychiatry)

Professor Psychiatry and Public HealthDirector of Public & Community Psychiatry – Department of

PsychiatryUniversity of Illinois at Chicago

Triadic Theory of Influence

Sociological theories of social control and social bonding (Akers et al., 1979; Elliott et al., 1985)

Peer clustering (Oetting & Beauvais, 1986) Cultural identity (Oetting & Beauvais, 1990-91) Psychological theories of attitude change & behavioral

prediction (Fishbein & Ajzen, 1975; Ajzen, 1985) Personality development (Digman, 1990) Social learning (Akers et al., 1979; Bandura, 1977, 1986) Integrative theories (e.g., Jessor & Jessor's, Problem Behavior

Theory; Brook’s Family Interaction Theory, Hawkins’ Social Development Theory)

See Petraitis, Flay and Miller (1995).

Intra-personalStream

Social/Normative

Stream

Cultural/Attitudinal

Stream

Community Psychiatry Protective Factor Field Principles

Rebuilding the Village/Constructing Social Fabric Access to Modern and Ancient Technology –

Biotechnical and Psychosocial Connectedness Social and Emotional Skills Self Esteem - Activities that create a sense of power;

Activities that create a sense of connectedness; Activities that create a sense of models; Activities that create a sense of uniqueness

Reestablish the Adult Protective Shield/Safety Minimize the Effects of Trauma/Mastery

FIVE PROTECTIVE FACTORS STRENGTHENING FAMILIES

PARENTAL RESILIENCE

SOCIAL CONNECTIONS

KNOWLEDGE OF PARENTING AND CHILD DEVELOPMENT

CONCRETE SUPPORT IN TIMES OF NEED

SOCIAL AND EMOTIONAL COMPETENCE of CHILDREN

How are we functioning?

Different languageDifferent language Different goals Different goals

Resource silosResource silosActivity-drivenActivity-driven

We need Synergy and a Integrated System

Common languageCommon language

Evidence based

Evidence based

Maximize resourcesMaximize resources

Outcome driven

Outcome driven

Risk Factor - Culture Destroys

Canada's monocultural ethnocentric culture had little value for First Nation culture.

Thus, First Nation children were removed from their families and told them their culture was not acceptable, resulting in First Nation people having to give up their cultural protective factors which ultimately led to many First Native people engaging in the risky behaviors of suicide and intra-group homicide.


Within these communities, alcoholism is common and for every one child in Canadian juvenile detention centers without fetal alcohol syndrome there are 19 children with fetal alcohol spectrum disorders (Popova et al, 2011).

Bell (2012) has proposed many disruptive behaviors leading to incarceration results from fetal alcohol exposure (FAE).


Fetal Alcohol Exposure is the leading cause of speech and language disorders, ADHD, Specific Learning Disorders, & Mild Mental Retardation which are often responsible for affect dysregulation leading to disruptive behaviors leading to incarceration.

Stratton et al. (1996). Fetal Alcohol Syndrome: Diagnosis, Epidemiology, Prevention, and Treatment. Washington, D.C. National Academy of Sciences, Institute of Medicine.

Risk Factor - Culture Destroys Youth Risk Behavior Surveillance The prevalence of having carried a

weapon in general was higher among white males (27.2%) than among their black counterparts (21%).

The prevalence of having carried a weapon onto school property was higher among white males (7.8%) than black males (6.7%).

Risk Factor - Culture Destroys The prevalence of having ever used cocaine

was higher among white males (7.6%) than black males (4.2%).

Yet, people of color make up a higher proportion of children and young adults who are incarcerated.

In fact, in 2010, the imprisonment rate for black non-Hispanic males (3,074/100,000 U.S. black male residents) was almost seven times higher than it was for white non-Hispanic males (459/100,000) U.S. Bureau of Justice Statistics

Protective Factor - Culture Protects

While doing HIV prevention work in Durban, South Africa it was striking that 40 percent of the Zulu people were HIV-positive, 6 percent of the white South African people were HIV-positive, but only 1 percent of the Indian South African people were HIV-positive.

Photo by Aleta McLeod 2-29-08: Dr. Bell standing on 60ft cliff off Shipwreck beach in Kauai, Hawaii

Photo by Aleta McLeod 2-29-08: Dr. Bell jumping off a 60ft cliff off Shipwreck beach in Kauai, Hawaii

Fact

One-fifth of the U.S. adult population is flourishing - the rest are “languishing in life.”

Culture helps people flourish!

Positive emotions (i.e. emotional well-being)

Positive affect Regularly cheerful, interested in life, in good

spirits, happy, calm and peaceful, full of life.

Avowed quality of life Mostly or highly satisfied with life overall or in

domains of life.

Self-acceptance Holds positive attitudes toward self,

acknowledges, likes most parts of self, personality.

Personal growth Seeks challenges, has insight into own

potential, feels a sense of continued development

Positive psychological functioning (i.e. psychological well-being)

Positive psychological functioning (i.e. psychological well-being)

Purpose in life Finds own life has direction and meaning.

Environmental mastery Exercises ability to select, manage, and mold

personal environs to suit needs.

Autonomy Is guided by own, socially accepted, internal

standards and values.

Positive relations with others Has, or forms, warm, trusting personal relationships

Positive social functioning (i.e., social well-being)

Social acceptance Holds positive attitudes toward, acknowledges,

and is accepting of human differences

Social actualization Believes people, groups, and society have

potential and can evolve or grow positively

Social contribution Sees own daily activities as useful to and

valued by society and others.

Positive social functioning (i.e., social well-being)

Social coherence Interested in society and social life and finds

them meaningful and somewhat intelligible.

Social integration A sense of belonging to, and comfort and

support from, a community.

Community Psychiatry Protective Factor Field Principles

Rebuilding the Village/Constructing Social Fabric Access to Modern and Ancient Technology –

Biotechnical and Psychosocial Connectedness Social and Emotional Skills Self Esteem - Activities that create a sense of power;

Activities that create a sense of connectedness; Activities that create a sense of models; Activities that create a sense of uniqueness

Reestablish the Adult Protective Shield/Safety Minimize the Effects of Trauma/Mastery

Oakland’s Innovations

Helping people "rebuild their villages," – “Mental Health Friendly Congregations”

Providing access to modern and ancient technology - both biotechnical and psychosocial."– “Co-Occurring Healing”– “The Sakhu Project: Incorporating the Illumination of

Culturally Congruent Well-Being and Wholeness into the Planning and Delivery of Services to African American Populations”


Increasing connectedness," – “His Health: Gender Responsiveness &

Culturally Appropriate Counseling with African American Urban Male Youth”

Giving people a "sense of power, models, and uniqueness - a.k.a. self-esteem," – “Healthy Teens” & “Understanding the Impact of

Trauma on the Well-being of Young African American Children & Their Families”

– “Conscious Voices”


Teaching "social and emotional skills," – “Healing Trauma and Overcoming Stress:

Creating Health & Well-Being Through The Use of Cultural Genograms, Storytelling, and Mindful Based Practices”

Providing an "adult protective shield," – “Community Healing Circles: For African

American Men and Adolescents on Probation”– “African American Faith Mental Health Anti-

Stigma Campaign” & “Safe Transitions”


Minimizing trauma," – “Healing Trauma Through Support and Care:

Trauma Awareness Group (TAG)”– “Girls Far Above Rubies” & “Developing Trauma

Informed Practices for Young People Caught in the Crossfire”

The Critical Role of Self-Regulation

Neuroscience and behavioral research are converging on the importance of self-regulation for successful development

Children who do not develop the capacity to inhibit impulsive behavior, to plan, and to regulate their emotion are at high risk for behavioral and emotional difficulties

Bell CC & McBride DF. Affect Regulation and the Prevention of Risky Behaviors. Journal of the American Medical Association, Vol. 304, No. 5: 565 –566, August 4, 2010

Prevalence of FASD Fetal Alcohol Syndrome (FAS) occurs far

more frequently than generally believed: FAS: 1 per 1000 live births

Although estimates vary widely, when combined with the milder afflictions of Fetal Alcohol Spectrum Disorders (FASD), the Centers for Disease Control puts the frequency of FAS/FASD as high as one in 100.

Prevalence of Drinking while Pregnant

In the US 13% knowingly drink while pregnant 1% drink heavily while pregnant 3-4% binge drink during pregnancy (SAMHSA) 12% of pregnant women consume 5 or more

drinks per month 50% of pregnancies are unplanned

The Critical Role of Self-Regulation A - more than minimal exposure to alcohol

during gestation B - impaired neurocognitive functioning; C - impaired self-regulation; D - impairment in adaptive functioning; E - onset of the disorder occurs in childhood; F - the disturbance causes clinically significant

distress or impairment in social, academic, occupational functioning;

G - the disorder is not better explained by the direct physiological effects associated with postnatal use of a substance, a general medical condition, another known tetratogen, a genetic condition, or environmental neglect.

The Critical Role of Self-Regulation

1979 – 88.5% (246) of the 274 children in Pupil Service Center on Chicago’s Southside had Childhood Neurodevelopmental Disorders (CND)

1985 – 20% of inmates in Texas Department of Corrections were “mentally retarded.”

2011 - chart audit on 162 children in several nurse-based school clinics estimates 39% (63) of those children met the DSM-5 Condition for Further Study - “Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (NDA-PAE) a (CND).

2012 prior to the closure of the Community Mental Health Council, Inc. - chart audit of 330 randomly selected patients revealed that 12% (39 of 330 patients) met criteria for CND.

The Critical Role of Self-Regulation 2013 - work on an inpatient psychiatric unit at St.

Bernard Hospital (in the heart of Englewood - one of the poorest African-American communities in Chicago) reveals of 93 patients consecutively admitted patients, 32% (30) meet the criteria for CND-PAE.

2013 - a random sample of 20% of consecutively seen outpatients in Jackson Park Hospital's Family Practice Clinic (JPH-FPC) reveals that out of 100 patients, 29% (29) fit the criteria for NDA-PAE

2014 – of 613 psychiatric patients at JPH-FPC – 1/3rd have CNDs and half of those are NDA-PAE – the other half could not be confirmed due to absence of the mother’s to provide a history

IDEAS TO COMBAT THE EFFECTS OF FAE

Do public service announcements to grandmothers who are care giving for grandchildren who have learning disorders, mild intellectual disability, ADHD, speech and language disorders, explosive tempers and who know their daughters or daughters-in-law were drinking during pregnancy.

Have correctional facilities who incarcerate pregnant women screen those women for drinking while pregnant before they knew they were pregnant.

IDEAS TO COMBAT THE EFFECTS OF CND - PAE

Educate Obstetricians about the damage CND - PAE can do and suggest to them that choline supplements may decrease the outcome of FAE exposed children (let them know that prenatal vitamins do not have choline in them).

Work with Oakland Public Schools to identify children in special education who have the characteristic histories of CND - PAE, and have their parents supplement those children’s nutrition with choline, folate, and vitamin A.

IDEAS TO COMBAT THE EFFECTS OF CND - PAE

Work with Alameda County to identify children in their facility who have the characteristic histories of FAE, and supplement those children’s nutrition with choline, folate, vitamin A, and Omega-3.

Get in touch with the Oakland’s Child Protective Services and have them to identify children in their facility who have the characteristic histories of FAE, and supplement those children’s nutrition with choline, folate, vitamin A, and Omega-3.

IDEAS TO COMBAT THE EFFECTS OF CND-PAE

Get vitamin companies to put choline in their prenatal vitamins.

Get drug stores to supply choline supplements in their stores.

Others?

TABLE 3 - Standard set of interview questions to explore the possibility of Childhood

Neurodevelopmental Disorder 1) How far did you go in school? 2) If the patient did not finish grammar or high school

ask: Why didn’t you finish grammar school/high school?

3) Did you have problems learning – math, reading, or comprehension?

4) Were you in special education classes? 5) Did the teachers and adults in your family think you

were hyperactive? 6) Did you have speech or language problems in

school?


Neurodevelopmental Disorder 7) Were you teased as a child? 8) If the patient was teased, ask the patient: What

were you teased about? 9) Did you have a bad temper as a child/have you had

a bad temper your whole life? 10) Did you have poor emotional control as a

child/have you had poor emotional control your whole life.

11) How is your memory? 12) If the patient reports having a poor memory ask:

Has your memory been poor since childhood?


Neurodevelopmental Disorder 13) When you were in school did you have problems

with comprehension? 14) Serial 7 subtractions from 100, and spell “world”

forwards and backwards. 15) Gather evidence of clinically significant distress or

impairment in social, academic, occupational functioning by asking about the patient’s ability to get along with others and their employment history.

DSM – 5: Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure

A. More than minimal exposure to alcohol during gestation, including prior to pregnancy recognition– Confirmation of gestational exposure to alcohol may be

obtained from maternal self-report of alcohol use in pregnancy, medical or other records, or clinical observation.

B. Impaired neurocognitive functioning as manifested by one or more of the following:1.Impairment in global intellectual performance (i.e. IQ of 70

or below)

2.Impairment in executive functioning (e.g. poor planning and organization, inflexibility, difficulty with behavioral inhibition)


B - Impaired neurocognitive functioning as manifested by one or more of the following:3. Impairment in learning (e.g. lower academic achievement

than expected for intellectual level; specific learning disability)

4. Memory impairment (e.g. problems remembering information learned recently; repeatedly making the same mistakes; difficult remembering lengthy verbal instructions)

5. Impairment in visual-spatial reasoning (e.g. disorganized or poorly planned drawings or constructions; problems differentiating left from right)


C. Impaired self-regulation manifested by one or more of the following:1. Impairment in mood or behavioral regulation (e.g. mood liability,;

negative affect or irritability ], frequent behavioral outbursts).

2. Attention deficit (e.g. difficulty shifting attention; difficulty sustaining mental effort).

3. Impairment in impulse control (e.g. difficulty waiting turn; difficulty complying with the rules).

D. Impairment in adaptive functioning as manifested by two or more of the following, one of which must be (1) or (2):1. Communication deficit (e.g. delayed acquisition of language;

difficulty understanding spoken language)

2. Impairment in social communication and interaction (e.g., overly friendly with strangers, difficulty reading social cues; difficulty understanding social consequences)


D. Impairment in adaptive functioning as manifested by two or more of the following, one of which must be (1) or (2):3. Impairment in daily living skills (e.g. delayed toileting,

feeding, or bathing; difficulty managing daily schedule)

4. Impairment in motor skills (e.g., fine motor development; delayed attainment of gross motor milestones or ongoing deficits in gross motor function; deficits in coordination and balance.

E. Onset of disorder (symptoms in Criteria B, C, and D) occurs in childhood.

DSM – 5: Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure F. The disturbance causes clinically significant

distress or impairment in social, academic, occupational or other important areas of functioning.

G. The disorder is not better explained by the direct physiological effects associated with postnatal use of a substance (e.g. medication, alcohol or other drugs); medical condition (traumatic brain injury, delirium, dementia);

Keynote Innovation Conference Alameda County Behavioral Health Services Carl C. Bell, M.D. Staff...

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