Keynote Innovation Conference Alameda County Behavioral Health Services

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Keynote Innovation ConferenceAlameda County
Behavioral Health Services
Carl C. Bell, M.D. Staff Psychiatrist Jackson
Park Hospital Family Practice Clinic Staff
Psychiatrist St. Bernard Hospital Inpatient
Psychiatry UnitFormer 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
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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 Brooks Family
  Interaction Theory, Hawkins Social Development
  Theory)
• See Petraitis, Flay and Miller (1995).

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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

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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
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Resource silos
Activity-driven
Different language
Different goals
How are we functioning?
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Evidence based
Common language
Outcome driven
Maximize resources
We need Synergy and a Integrated System
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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.

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Risk Factor - Culture Destroys

• 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).

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Risk Factor - Culture Destroys

• 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.

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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).

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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

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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.

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

• One-fifth of the U.S. adult population is
  flourishing - the rest are languishing in life.
• Culture helps people flourish!

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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.

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

• 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

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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

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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.

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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.

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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

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Oaklands 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

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Oaklands Innovations

• 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

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Oaklands Innovations

•  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

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Oaklands Innovations

• 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

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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
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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.

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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

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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.

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The Critical Role of Self-Regulation

• 1979 88.5 (246) of the 274 children in Pupil
  Service Center on Chicagos 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.

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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 mothers to provide a history

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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.

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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 childrens
  nutrition with choline, folate, and vitamin A.

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

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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?

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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 didnt 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?

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

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TABLE 3 - Standard set of interview questions to
explore the possibility of 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
  patients ability to get along with others and
  their employment history.

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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
• Impairment in global intellectual performance
  (i.e. IQ of 70 or below)
• Impairment in executive functioning (e.g. poor
  planning and organization, inflexibility,
  difficulty with behavioral inhibition)

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DSM 5 Neurobehavioral Disorder Associated with
Prenatal Alcohol Exposure

• B - Impaired neurocognitive functioning as
  manifested by one or more of the following
• Impairment in learning (e.g. lower academic
  achievement than expected for intellectual level
  specific learning disability)
• Memory impairment (e.g. problems remembering
  information learned recently repeatedly making
  the same mistakes difficult remembering lengthy
  verbal instructions)
• Impairment in visual-spatial reasoning (e.g.
  disorganized or poorly planned drawings or
  constructions problems differentiating left from
  right)

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DSM 5 Neurobehavioral Disorder Associated with
Prenatal Alcohol Exposure

• C. Impaired self-regulation manifested by one or
  more of the following
• Impairment in mood or behavioral regulation (e.g.
  mood liability, negative affect or irritability
  , frequent behavioral outbursts).
• Attention deficit (e.g. difficulty shifting
  attention difficulty sustaining mental effort).
• 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)
• Communication deficit (e.g. delayed acquisition
  of language difficulty understanding spoken
  language)
• Impairment in social communication and
  interaction (e.g., overly friendly with
  strangers, difficulty reading social cues
  difficulty understanding social consequences)

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DSM 5 Neurobehavioral Disorder Associated with
Prenatal Alcohol Exposure

• D. Impairment in adaptive functioning as
  manifested by two or more of the following, one
  of which must be (1) or (2)
• Impairment in daily living skills (e.g. delayed
  toileting, feeding, or bathing difficulty
  managing daily schedule)
• 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.

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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)

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