Mental Health 🪴

Conduct Disorder

-Disregard for laws/rights of others leading to aggression and criminal behaviors

Behavioral FOR

-Idea that behavior is learned and can be unlearned

-Practice assertiveness through role playing

-Shape client’s behavior in safe environment

-Use relaxation/breathing activities for anxiety

mild intellectual disability

-can acquire ADL, IADL, vocational skills to be independent
-min support needed, some support for new things (moving, job)

moderate intellectual disability

-independence in routine daily skills, when provided with support
-supervised living required
-mod support for specific occupations (meal prep, use of public transport)

severe intellectual disability

-acquires communication skills, some health habits (brush teeth)
-impairment to motor and physical development
-assistance for most tasks

Selective Attention

Blocking out anxiety-inducing things

Immediate Memory

-aka short-term memory

-recalling material w/i seconds-minutes

-ex: putting in verification code to login

Working Memory

-aka recent memory

-recalling events of past few days

-ex: remembering where you parked your car at the airport after a short trip

Long-Term Memory

-aka remote memory

-recalling events of distant past

-ex: answering security question about high school mascot

Procedural Memory

-automatic sequence of behavior ~conditioned response

-ex: performing morning routine tasks

Declarative Memory

-fact recall

-OT student naming cranial nerves

Semantic Memory

-knowing meaning of words and being able to classify info

Episodic Memory

-knowledge of one’s personal experiences

-ex: remembering where you celebrated your birthday last year

Prospective Memory

-remembering to carry out actions in the future

*clinically important because it relates to a person’s ability to live safely and independently

-ex: person remember to turn stove off before leaving kitchen; paying bills by due date; remembering scheduled doctor’s appointments

Retrograde Amnesia

-inability to remember events that happened before the amnesia set in

OT mental health eval

-determine values, interests, roles, and goals
-identification of strengths and deficits
-identification of coping skills, stressors, and supports

OT MH intervention acute hospital

-during acute hospitalization, management of behaviors that threaten safety, stabilization of behaviors with activities that are brief and structured
-relax/stress management techniques, activities to inc communication

OT MH intervention long term hospital

-create self determined plan for goal achievement
-graded activities that inc ADL, IADL, social, leisure, work
-develop skills/external supports for post discharge roles

OT MH intervention for community setting

-facilitation of recovery, maintain skills
-skills needed for community living, social participation
-skills for ongoing recovery
-skills to get practical resources (SSI, afforable housing)

Recovery model

-self-direction
-individualized
-empowerment
-nonlinear
-peer support
-hope
-family

Wellness recovery action plan (WRAP):

Developmental Group Overarching Purpose

get skills for group interactions

Evaluation Group Overarching Purpose

gather info on persons task and group interaction to make goals and interventions

Instrumental Group Overarching Concern

-concerned with meeting health needs and maintaining function through socialization and participation in activities

-not about skill development or expressing emotions

Model of Human Occupation (MOHO)

Three Main Elements

• volition

• habituation

• performance capacity

Environment

• physical and social components

• environment impacts individuals with opportunities, demands, resources, constraints

PEO model

-occ performance is dynamic in nature
-transactional relationship of the 3 elements
-eval emphasizes the occupational performance issue, environment

-OT intervention should involve improving fit between person, environment, and occupation

Cognitive Disabilities Model

-Based on cog development from Piaget
-Cognition is based on biological factors, and if it cannot change, adaptations the activity provides opportunity for success

-Use client’s strengths to allow for function
-When max level reached, compensation must be made to person, or environment

-Train caregiver to provide appropriate environmental supports for the client

Ecology of Human Performance (EHP)

-emphasis on the role of the person’s contexts (culture, physical, social) and its impact on performance
-ecology: interaction of person and environs
-person+task+context= performance
-skills can be inc/dec d/t illness
-contexts are dynamic
-roles are made up of tasks
-people are empowered by inc self-determination

5 Strategies of Ecology of Human Performance (EHP)

⚡️Elves wear A CAPE (EHP goes with a. c.a.p.e.)

alter: change the context the person is trying to perform in (environ mods)

create: supporting optimal performance without assuming there is a disability; designing new environs, contexts, tasks (workspace layout, new program)

adapt/mod: changes to the context and task for better performance (AE, simplifying tasks)

prevent: minimize problems that may develop by changing the client, context or task; assumes there is a disability or one is likely to occur

establish/restore: teaching skills lost d/t illness; improve ability and function

Occupational Adaptation (OA)

-focused on the process person goes thorough internally to adapt to environment
-person consists of cognitive, psych social components- desires mastery
-occ environment is physical, social, cultural systems- demands mastery
-outcome of interaction of those two is the occ response

-Expected improvements through OT are improved self-initiation, generalization, and relative mastery

Role acquisition

-person uses tasks and social skills to meet demands of roles
-performance addressed through task skill, interpersonal skill, family interaction, ADL, school, work, play
-focus on getting skills to function in environs

Lifestyle performance model

-match the environment and the persons needs
4 hypotheses
-competency in valued/prioritized occupations-society cares about having greater meaning and social efficacy
-activity has symbolic and reality-based meaning
-activites that mesh well with our neuro/psychological structures make us feel better
-competence is more easily seen with end products

Sensory models

-known as sensory processing, sensory modulation, sensory motor model
-the use of sensory modalities or activities to prepare someone for therapy/occupation
-such as snoezelen rooms, multisensory environs, weighted blankets, self-soothing toys, sensory diets
-includes brushing patterns for sensory defensiveness (avoidance pattern)

Dunn Model of Sensory Processing

Sensory seeking
Sensory avoiding
Sensory sensitivity
Poor registration

Psychodynamic FOR

-behavior determined by unconscious forces, resolved when brought to conscious thought
-behavior patterns begin in early childhood, and early childhood experiences can affect clients in the future
-interventions include open ended/ unstructured/ task oriented groups to explore the inner psyche (discussion, journaling, painting, etc.)

Cognitive Behavioral Therapy (CBT)

-effective for depression,schizo, anxiety, bipolar, OCD, eating disorders
-works to alter negative thoughts about self, life by correcting misinterpretations
-changes in cognitive processes to facilitate behavior and emotional changes

OT Interventions:

-learn to manage anxiety with relaxation skills

-systematic desensitization- exposure to anxiety producing stimulus with graded contact, reframing & relaxation, until trigger no longer produces anxiety (NEED specialized training for this approach)

-assist in identifying current problem/solution
-identify distorted/unhelpful thinking
-scheduled activities to inc mastery
-cognitive rehearsal/ role playing

Dialectical Behavior Therapy (DBT)

-focuses on helping people accept the reality of their lives/behaviors & help them learn to change their lives

-good for clients with difficulty managing and regulating emotions (borderline personality disorder)

-talk based therapy
OT Interventions

• Assertiveness, coping skills, distress tolerance, interpersonal skills

• Mindfulness, emotional regulation

Recovery Model

-fostering ppls intrinsic motivation for hope
-focus on improving QOL
-recovery from illness as a journey of healing
-self-direction: ppl identify their own goals
-person-centered: recovery is unique to each person
-empowerment: people take control over lives and recovery
-peer support: reciprocal relations with others with lived experiences

Psychiatric rehab

-to help ppl develop skills to compensate, adapt, control the influence of symptoms on their function/life
-should be community-based where ppl live
-vocation focused: work is healing

Reasons to use one-to-one interventions in lieu of group

-refusal of group, inability to tolerate group, disruptive behavior, suicide precautions/danger to self/others

Indicators for group intervention

-more cost effective, for those who need to learn to live in social environments, take advantage of group dynamics

Developmental Group Levels of Interaction

• parallel: individual tasks with no required interaction with others; OT is directive and supportive

• project: common, short term activity, some interaction is required to complete task; OT chooses activity

• egocentric-cooperative: joint interaction on long term task; clients choose task rather than OT; OT acts more as role model

• cooperative: learning to work together, to enjoy company, gain sense of fulfillment; completion of task is secondary to sharing emotions/expressing ideas/self-expression; OT acts as an advisor

• mature: carrying out task and meeting needs of people in the community; completion of project and group interaction are equally important; OT acts as peer

Task-Oriented Groups Purpose

-purpose is not to complete a task, tasks are used as a means of exploring feelings, thoughts, and needs

-ex: painting, journaling

-aligns with psychodynamic FOR

Thematic Group Overarching Purpose

-learning a specific skill with a structured/simulated activity that can be graded

-ex: making a birdhouse

⚡️thrive with thematic

Topical Groups Overarching Purpose & Two Types

-focus on discussion of activities and issues of the group

-Concurrent Topical Group- talking about current events

• ex: parents talking about raising child with SCI

-Anticipatory Topical Group- talking about topic that has not yet happened but will happen in the future

• ex: retirement planning; caregiver support group about supporting loved one after hospital discharge

Managing Difficult Behaviors

(Hallucinations, delusions, akathisia, offensive physical/verbal acts, lack of initiation, manic/monopolizing behaviors, escalating behavior, kids acting out)

• Hallucinations: make environs free of distractions, highly structured, concrete activities, redirect to reality-based thinking
  

• Delusions: dont refute the delusion, redirect to reality, avoid discussions that validate the belief
  

• Akathisia (cant sit still, restless, shaky legs, hand tremors): allow to move w/out disruption, select gross motor activities
  

• Offensive physical/verbal: set limits and immediately address behavior, reasons its not accepted should be explained, needs of entire group should be first thought

• Lack of initiation: id reason for lack, make interaction w/i area of interest, success/fun is motivator, curiosity/food is motivator

• Manic/monopolizing: highly structured activities, redirect attention to others

• Escalating behavior: avoid challenging them (direct eye contact), actively listen, calm voice, clearly present what you want them to do

• Acting out kids: put words to why the kid is behaving that way, redirect to assignment, limit setting, time out

Attention disturbances

- Ability to focus on various aspects of an activity
- Distractability is inability to concentrate one's attention without being drawn to irrelevant stimulus
- selective inattention is blocking out those activities that produce anxiety
- Hypervigilance is excessive attention to guard against danger

Disturbances of Consciousness

- Disorientation- changes to orientation of person, place, or time
- Delirium- acute/ reversible marked by confusion liability and disturbances in behavior
- Confusion- inappropriate reactions to environmental stimuli
- Sundowner syndrome- happens in the late afternoon with people with dementia. Drowsiness confusion agitation and aggression

Emotional Disturbances

- Physiological disturbances associated with mood are autonomic in nature
-Inappropriate affect- inconsistent with accompanying thoughts or ideas
- Blunted Affect- lack of affect and does not change
- Flat Affect- absence of signs of emotion
- Labile Affect- rapid and abrupt changes in emotion

Disturbances in Motor Behavior (echopraxia, catatonia, psychomotor agitation, hyperactivity, psychomotor retardation)

• Echopraxia- imitation of other person’s movements

• Catatonia- immobility or rigidity

• Stereotypy- repetition of fixed patterns of movement

• Psychomotor Agitation- excessive motor and cognitive activity

• Hyperactivity- restless sometimes aggressive activity

• Psychomotor Retardation- decreased/slowed movement

Hallucinations vs. Illusions

- hallucinations are false sensory perceptions not linked to external stimulus (just responding to internal stimuli ~voices in head)
- illusions are misperceptions or misinterpretations of real sensory events

Disturbances of Perception (agnosia, astereognosis, apraxia, adiadochokinesia)

• Agnosia is inability to understand and interpret sensory input

  • visual agnosia- inability to recognize people and objects

    • prosopagnosia- face blindness
      

• Astereognosis- inability to identify objects through touch

• Apraxia- inability to carry out specific motor tasks

• Adiadochokinesia- inability to perform rapidly alternating movements

Disturbances of Conversion and Dissociative Phenomena (derealization, depersonalization, dissociation)

- Derealization- sense that the environment is unreal
- Depersonalization- sense of unreality about one's self

• Fugue- state of serious depersonalization involving travel where they take on a new identity with amnesia about former identity

- Dissociation- separation of a group of mental/behavorial processes from rest of persons brain activity ~doing activity while being totally zoned out

Disturbances of Speech (pressured, poverty, poverty of content, non-spontaneous, stuttering, perseveration)

- Pressured speech- rapid and increased in amount
- Poverty of speech- limited in amount
- Poverty of content and speech- does not give information
- Non spontaneous speech- responses that are given only when spoken to
- Stuttering- repetition of sounds or syllables
- Perseveration in speech- continued repetition of word or phrases

Disturbances of Thought (circumstantiality, tangentiality, flight of ideas, loosening of associations, perseveration, thought blocking, delusions, compulsions, obsession, concrete thinking)

Form:

-Circumstantiality- speech that is delayed in reaching the point
- Tangentiality- abrupt change of focus or loosely associated topic
- Flight of ideas- rapid change in thoughts
- Loosening of associations- ideas shift from one subject to another with no obvious connection

-Perseveration- persistent focus on previous topic/behavior after a new topic/behavior has been introduced

-Thought Blocking- interruption of a thought before it is carried through to completion

Content:
- Delusions- false beliefs about external reality
- Compulsions- need to act on a specific impulse to relieve anxiety

-Obsession- persistent thought or feeling that cannot be eliminated by thought

-Concrete Thinking- inability to think abstractly (difficulty understanding idioms/jokes)

Schizophrenia Diagnosis & OT Interventions

- Two or more of the following symptoms

• delusions

• hallucinations

• disorganized speech

• catatonic behavior

- Negative symptoms

• flat affect

• anhedonia (difficulty in experiencing pleasure)

• alogia (decreased thought/speech),

• anergia (lack of energy)

  • DON’T mistake for lack of motivation

• inability to relate to others
  

-disturbances in work, relations, self care
-ongoing signs of illness 6 month
-other things have been ruled out
-not caused by illness or drugs

OT Interventions for Schizophrenia & Related Psychotic Disorders

• Communicate clearly/simply/concretely

• Provide external structure/consistency to help organize thinking

• Ensure activities are simple and structured

• Provide supports/tools for recovery like a Wellness & Recovery Action Plan (WRAP)

Common Short Assessments of Mental Status

-Mini-Mental State Examination aka Folstein Mini-Mental

-Short Portable Mental

-MoCA

• assesses orientation, short-term memory, executive function, language, abstraction, animal naming, and attention

-SLUMS

Schizoaffective Diagnosis

- Uninterrupted period of illness which there is major depressive/manic episode concurrent with positive or negative symptoms associated with schizophrenia

Schizophreniform Disorder

- person meets criteria for schizophrenia however lasts less than six months

Delusional Disorder

- Presence of one or more delusions for the duration of a month or longer and the criteria for schizophrenia has not been met

Brief Psychotic Disorder

- presence of one or more sensory behavioral cognitive or psychomotor symptoms
- Symptoms range from one day to one month

Side Effects & Complications of Traditional Antipsychotic Medications

Common Meds: Haldol, Thorazine

Side Effects

• Photosensitivity- teach sunburn precautions

• Orthostatic Hypotension- watch for increased fall risk

• Dystonia

• Dry mouth, blurry vision, constipation, cardiovascular disorders

Complications

• Neuroleptic malignant syndrome- autonomic emergency leading to increased blood pressure, tachycardia, convulsions, coma

• Tardive dyskinesia- abnormal involuntary irregular, slow, rhythmic movements of the head, tongue, fingers that results from long-term use of antipsychotic meds

  • OT should use Abnormal Involuntary Movement Scale to measure uncontrollable movements during every intervention session to monitor symptoms & side effects

• Neuroleptic Induced Parkinsonism- muscle stiffness, cogwheel rigidity, shuffling gait (usually no pill rolling tremor)

Side Effects & Complications of Second Generation Antipsychotic Medications

Common Meds: Clozaril, Risperdal, Seroquel, Abilify

• Generally much less side-effects/complications than first gen

Side effects

• Vary between each med

• Clozaril can cause agranulocytosis where WBCs to decrease to fatal level; need close monitoring

Complications

• Metabolic Syndrome- high blood glucose, low good cholesterol, high level of triglycerides, high BP. Increases risk of heart attack & stroke

Bipolar I

- One or more manic episodes, may be combined with major depressive episode

Bipolar II

- One or more major depressive episodes, must be at least one hypomanic episode
- No history of manic episode

Manic Episode

-3 or more symptoms for a week
- Mood is uncharacteristically and inconsistently elevated/irritable
- increase in targeted goal directed behavior or restless purposes behavior (psychomotor agitation)
- inflated self esteem or thoughts of grandeur
- decreased need for sleep
- pressured or quick speech
- increased engagement and subjectively pleasurable HIGH-RISK activities
-marked impairment in daily functioning

-Suggestive dressing, gambling, promiscuity, irritable, suicidal
-Lithium commonly used for mood stabilizing, as well as anti psychotics

• side effects: excessive thirst, tremors, excessive urination, weight gain, nausea, diarrhea, cognitive impacts

• *high levels of lithium can cause nerve damage and death- blood levels should be carefully monitored to ensure lithium levels are in therapeutic window

• *early symptoms of toxicity include motor disturbances

-Anticonvulsants are another medical treatment

• Tegretol, Depakote, Lamictal

• Side effects can lead to increased risk of falls (drowsiness, ataxia, dizziness)

-Antipsychotic meds are also commonly prescribed

• Seroquel, Risperdal, Zyprexa, Abilify

OT int: Limit setting to improve boundaries/promote safety, engagement in structured activities to release energy, period between episodes should be used to educate about symptom management

Major Depressive Episode Diagnosis, Meds & OT Intervention

- Five or more symptoms must be present for two weeks
- Depressed mood or loss of interest
- fluctuations in weight
- changes in thinking or behavior such as slowing down and thinking
- fatigue or loss of energy
- changes in mood or self perception including feelings of worthlessness
- decrease the ability to concentrate on tasks
- Suicidal thoughts
- difficulty falling asleep

- Behavior is either irritable, anxious, difficulty with social interactions
-SSRIs- Prozac, Zoloft, Paxil, Celexa, Lexapro

• Side effects increased HR, dysrhythmias, seizures, disturbed balance/OH can increase fall risk

-MAOIs- Nardil, Parnate

• Interaction with tyramine can cause stroke/serious cardiac issues

• Must avoid various “picnic” items: aged cheese, pickled foods, processed meats, fermented foods, fruits that ripen to eat (bananas, avocados), chocolate, beer, red wine, soy products

• Must also avoid cold, sinus, and hay fever medications, nasal decongestants, inhalers, and appetite suppresants

• STOP MED & NOTIFY DOC IMMEDIATELY if pt complains of severe headache or palpitations (first signs of hypertensive crisis)

OT Interventions

• Provide safe environment and manage behaviors that threaten safety/well-being

  • Look out for suicidal behavior

  • *Most dangerous time for this is when signs of depression seem to vanish, ex just before discharge from inpatient

• Use cognitive approaches to therapy (CBT)

• Can still use therapy after pt has received electro convulsive therapy (ECT) just keep in mind that they may have temporary memory loss/confusion and may need a simpler task to complete

Persistent Depressive Disorder

- At least two years of depressive mood most days with depressive symptoms

Disruptive Mood Dysregulation Disorder

- Severe and recurrent verbal behavioral episodes, uncharacteristic for expectations consistent with developmental level
- Diagnosis may be made between the ages of six and 18

Premenstrual Dysphoric Disorder (PMDD)

- Marked affective lability, irritability, increased personal conflict, depressed mood, anxiety during PMS period

Substance Related Disorders

- Diagnosed on taking the drug, the side effects, the exposure to toxins
- use: consumption that causes impairments that affects daily functioning
- Intoxication: causes problems both behaviorally and mentally
- withdrawal: stopping significant consumption causes physical symptoms

Substance Use Disorder & OT Considerations

- Two of the following symptoms must be present within a 12 month.
- Substance reviews in large quantities which may develop to a tolerance for the substance
- Significant amount of time is dedicated to the use of the substance
- Desired use substance is stronger throughout the day, behavior continues despite the physical harm, attempts to cease fail
- Ongoing substance use causes disruption in social, occupational, educational, and daily life

OT Considerations

• Try to avoid overestimating client’s abilities d/t their survival skills

  • Rely on observation and assessment of actual skills

• Help pt to ID reasons for substance use

• Help pt to develop healthy coping skills for life stressors

  • Communication/social skills to support substance free social participation and advocate for needed services

  • Skills for work/school/home management

  • Leisure exploration

• Refer to support groups for sustained recovery (ex: AA, NA, halfway house)

Gambling Disorder

- Thoughts of gambling occupied the mind
- multiple unsuccessful attempts usually irritable and unhappy
- gambling increases with stress
- serious financial trouble
- gambling behavior continues even after loss
- lies to downplay the frequency of gambling

Panic Attacks

-Just a symptom not a diagnosis

- Discrete period of fear/discomfort with four or more symptoms developed within minutes

• Heart palpitations, sweating/chills, trembling, shortness of breath, nausea/vomiting, dizziness

• Derealization feelings of loss of control, fear of dying, paresthesia

Generalized Anxiety Disorder

- Six months of persistent and excessive unfocused anxiety

Panic Disorder

- Recurrent panic attacks with concern for recurrence

Selective Mutism

- Consistent inability to speak in social situations when expected, despite being able to speak in other circumstances (i.e. being totally silent at school, but talking at home)
- must be present for at least one month and not attributable to a communication disorder

Separation Anxiety Disorder

- excessively attached to another individual, the level of anxiety is considered developmentally inappropriate and unwarranted

OT Considerations for Anxiety Disorders

- Skills training and using cognitive behavioral approaches may reduce anxiety
- Relaxation and stress management skills
- graded activities designed to promote self efficacy
- systematic desensitization which involves incremental exposure to specific fears with imagery and relaxation and then contact with the image/actual object (used with phobias) *requires special training

Personality Disorder Clusters & General OT Considerations

-Skills training and cognitive behavioral approaches (CBT/DBT)

-Relaxation and stress management skills

-Graded activities to promote self-efficacy

Antisocial Personality Disorder

-fka sociopathy

- Characterized by continual antisocial or criminal acts
- and ability to conform to social norms
- no regard for the safety or feelings of others

-no remorse

-Conduct disorder is often a precursor diagnosis to antisocial personality disorder

Avoidant Personality Disorder

- Extreme sensitivity to rejection which may lead to social withdrawal
- Show great desire for companionship but think of themselves unworthy
- unusually strong need for uncritical acceptance

~inferiority complex

Borderline Personality Disorder

- Recurrent self destructive/ self mutilating behavior
- fear of abandonment
- Extraordinarily unstable affect, mood, behavior

-History of trauma (physical, sexual, emotional abuse) is common
- intense interpersonal relationships with alternating extremes of idealization and evaluation
- Chronic feelings of emptiness

-DBT can help to increase functional/coping skills and decrease symptomatic behavior

Dependent Personality Disorder

- Excessive need for others to take care of their physical/emotional needs
- Lack self confidence
- Experience discomfort when alone for more than a brief period

Histrionic Personality Disorder

- Colorful dramatic extroverted behavior
- Inability to maintain deep long lasting attachments

Narcissistic Personality Disorder

- Characterized by a heightened sense of self importance and grandiose feelings that they are special

Obsessive Compulsive Personality Disorder

- Emotional constriction, orderliness, perseverance, stubbornness
- Pervasive pattern of perfectionism and inflexibility
- NOT the same as obsessive compulsive disorder

Paranoid Personality Disorder

- Characterize my long standing suspicions and mistrust of people
- appear hostile irritable and angry

Schizoid Personality Disorder

- Lifelong patterns of social withdrawal
- discomfort with human interaction, bland/constricted affect

-often appear eccentric, isolated, or lonely

Schizotypal Personality Disorder

- Appear odd or strange in their thinking and behavior
- magical thinking, peculiar ideas, illusions, and derealization

Obsessive-Compulsive Disorder

- Obsessions are persistent thoughts or feelings that are unwanted intrusive and inappropriate
- Compulsions are irresistible urges that take on the form of repetitive behavior typically through strict or specific rules
- Obsessive thoughts and behaviors are time consuming and intrusive

-Individual realizes they are not rational

Body Dysmorphic Disorder

- Person is preoccupied with a perceived physical flaws
- repetitive thoughts or behaviors as an attempt to conceal these flaws
- can cause significant interruptions in social and occupational areas of functioning

Hoarding Disorder

- Perceive need to save items and difficulty or and difficulty or discarding possessions
- Accumulation of items results in cramped cluttery living conditions compromise safety

Trichotillomania

- Compulsive irresistible desire to pull out ones hair

Reactive Attachment Disorder (RAD) of Infancy or Early Childhood

- Child is characterized by social neglect or instability of primary caregiver
- interactions are excessively inhibited hypervigilant
- Inability to exhibit appropriate selective attachments
- overly affectionate with strangers

-frequent lying, hoarding, gorging, denial of responsibility, projecting blame

-OT considerations: Ongoing collaboration with child's family, assist child to form sense of self, limit exposure to multiple caregivers, provide high level structure

Disinhibited Social Engagement Disorder

- Child initiates active interactions with unfamiliar adults with little reservation when approaching unfamiliar people, child is willing to leave with unfamiliar adult without hesitation
- upbringing characters by social neglect, constantly changing caregiver

-Child has developmental age greater or equal to 9 months old

Post Traumatic Stress Disorder

- Exposure to threats are actual events which can result in sexual bodily injury or death
- first hand witness to a traumatic event, or learning about traumatic events
- repeated exposure to visual explanation of adverse details
- intrusive symptoms for more than 1 month intrusive memories related to the event, physical or mental exposure to the traumatic event
- Changes in patterns of behavior to avoid external stimuli that reminds them of the event

Adjustment Disorders

- Clearly identifiable stressor causes emotional or behavioral symptoms within three months
- symptoms resolve and disappear within six months of the stressor

Delirium

- Brain dysfunction, medication, endocrine disorders, cardiac disorders, fever can cause delirium

Anorexia Nervosa

- Low body weight due to difficulty maintaining weight, with fear of gaining weight or becoming fat
- alterations and self perception of body weight or shape
- food restrictive or binge eating/purging type

-often accompanied with low self-esteem/feeling less capable than others

Bulimia Nervosa

- Ongoing binge eating of larger portions than would be expected
- use of laxatives or vomiting or exercise to reduce weight
- person’s self conception defined by body proportions

-*teens with bulimia have higher rates of suicidal ideation/attempt than teens with anorexia