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What Symptoms Should You Look for?

Schizophrenia is the most chronic and debilitating of all psychiatric conditions. It is also the most widespread form of psychosis.

The symptoms of childhood onset schizophrenia are essentially the same as adult symptoms, but the degree of impairment tends to be greater when symptoms appear early in life. Symptoms can have a profound impact on a child's behavior and development.

Symptoms of schizophrenia vary depending on the age of the child. The earliest indications of childhood schizophrenia may include developmental problems, such as:

Language delays

Late or unusual crawling

Late walking

Other abnormal motor behaviors - for example, rocking or arm flapping

Some of these signs and symptoms are also common in children with developmental disorders such as autism. That's why one of the first steps in diagnosing psychosis is ruling out developmental disorders.

In teenagers, schizophrenia's symptoms are closer to those found in adults. Isolating those symptoms can still be a challenge, as some of the early symptoms of schizophrenia in teenagers are common for typical development during the teen years. These symptoms include:

Withdrawal from friends and family

A drop off in performance at school

Trouble sleeping

Irritability or depressed mood

Lack of motivation

Strange behavior

Substance use

Compared with the symptoms of schizophrenia in adults, teens may be:

Less likely to have delusions

More likely to have visual hallucinations

As young people with schizophrenia pass through their teen years, typical symptoms of the disorder begin to appear. These may include:

Delusions. These are false beliefs that are not based in reality. Delusions occur in most people with schizophrenia.

Hallucinations. These usually involve seeing or hearing things that don't exist. Hearing voices is the most common hallucination.

Disorganized thinking. Effective communication can be impaired, and answers to questions may be partially or completely unrelated.

Extremely disorganized or abnormal motor behavior. This behavior can include resistance to instructions, inappropriate or bizarre posture, a complete lack of response, or useless and excessive movement.

Negative symptoms. This refers to a reduced ability or lack of ability to function normally. For example, the person may neglect personal hygiene or appear to lack emotion. Also, the person may have reduced ability to engage in activities, such as a loss of interest in everyday activities, social withdrawal or the lack of ability to experience pleasure.

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Schizophrenia is the most chronic and debilitating of all psychiatric conditions. It is also the most widespread form of psychosis. The symptoms of childhood onset schizophrenia are essentially the same as adult symptoms, but the degree of impairment tends to be greater when symptoms appear early in life.

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Offering kids choices, safe spaces, and positive reinforcement can help teachers avoid problems-or manage them when they arise.

Elliott Golden / The iSpot

Most children will, at times, argue and test limits. Yet some kids are defiant and hostile to a degree that interferes with their daily lives-behavior that's sometimes diagnosed as Oppositional Defiant Disorder, or ODD, according to a story by WeAreTeachers.

"Students with ODD disrupt their own lives and often the lives of everyone nearby," write the report's authors. "[They] push the limits of defiance far beyond reason. Their problem behavior is much more extreme than that of their peers, and it happens much more often."

According to the American Academy of Child & Adolescent Psychiatry, kids with ODD exhibit "an ongoing pattern of uncooperative, defiant, and hostile behavior toward authority figures that seriously interferes with the child's day-to-day functioning," for six months or more. Symptoms like frequent temper tantrums, excessive arguing with adults, and mean and hateful speech when upset, are usually seen across multiple settings, but especially at home or school. While a direct cause remains unclear, "biological, psychological, and social factors may have a role," the academy notes. Up to 16 percent of children may have the disorder, and children with ADHD are especially prone.

Though a teacher's first reaction to ODD might be to react defensively, this can backfire and create a power struggle with the student, say experts. Instead, teachers who've worked with students with ODD recommend a set of strategies that will address challenging behavior, and help you start building relationships with hard-to-reach students.

"We all have the capacity to learn, change, and grow," writes special education teacher Nina Parrish. "When given the right tools and environment, students with problematic behavior can learn more productive strategies that will help them have positive and effective interactions with others."

1. Be Calm and Consistent: As a new teacher, Parrish says she quickly learned that reacting with anger when her students with ODD acted out made the behavior worse and students became "amused or encouraged by upsetting an adult." Instead, Parrish recommends trying to keep a positive tone to your voice, adopting neutral body language, and being "cautious about approaching the student or entering their personal space as this might escalate the situation."

Consistency with words and actions is also important when working with kids with ODD. Teacher Brandy T. tells WeAreTeachers she routinely uses the same set of "trigger words" so her students know she's serious. When students in her class begin to argue with her, "I simply say either, 'not now,' 'later,' or 'fix the issue.'" When her students hear 'fix the issue,' for example, she says that's the signal to "go to their chill-out space if they need to calm down."

2. Reinforce Positive Behavior: For all kids, but especially children with ODD, it's important to "switch your focus from recognizing negative behavior to seeking out demonstrations of positive behavior," writes Parrish. She sends home positive notes when students show behavior improvements, even if they're small gains.

Additionally, consider offering students the opportunity to earn certain privileges, suggests WeAreTeachers, rather than "taking those privileges away as punishment." For example, give kids the opportunity to earn rewards-like a bit of iPad time or lunch with a teacher.

3. Find Out What's Going On: Behaviors, notes Parrish, help students "obtain something desirable, or escape something undesirable." She suggests thinking about behavior as feedback, or a way of communicating, an approach that's "helped me work more effectively as a teacher with students who display problem behaviors." Figuring out factors that contribute to students with ODD acting out can help you develop a plan for addressing their difficult behaviors in the classroom.

Sometimes, it's a matter of picking up on a student's signals that their emotions are building long before things reach a breaking point. When students who've experienced trauma are beginning to feel upset, they often show physical signs of their mounting distress: balling up fists, withdrawing from classroom interaction, or clenching their jaw, writes Micere Keels, an associate professor at the University of Chicago and a trauma-informed educator.

"Many educators tend to ignore students' increasing signs of agitation, hoping they'll eventually calm down. But when disregarded, these minor behaviors can quickly escalate," writes Keels, who also recommends identifying students' triggers, like touch or emotionally difficult anniversaries, to avoid situations entirely.

4. Create a Safe Reset Space: Kids with ODD "can learn to recognize when they're feeling overwhelmed and getting ready to challenge or defy," according to WeAreTeachers. "Giving them a safe space to calm down and rethink their choices can be beneficial."

At Fall-Hamilton Elementary, a trauma-informed school in Nashville, Tennessee, for example, every classroom has a nook-called a peace corner-with a comfortable seat, a timer, and items like stuffed animals, sensory squeeze toys, and simple drawing and writing supplies. It's a spot where kids can take a break and reset. The school also recognizes that teachers may need a time out too. Using a strategy called Tap-in/Tap-Out, teachers can ask a colleague via text message to briefly cover their class if they are about to lose their cool.

"A dysregulated adult cannot regulate a dysregulated child," says school principal Mathew Portell. "Use strategies that honor the student's emotions and need for space while also getting their systems to calm in a safe way."

5. Offer Choices: It's important to "affirm your students' autonomy by giving them choices," writes Keels, about best practices for de-escalation. When kids feel respected, "their sense of belonging and mood will often improve."

She recommends avoiding ultimatums like "You better sit back down or I'll send you to the office." Instead, clearly communicate expectations and limits so kids understand. You might say, "I see you're upset, but it's not OK to yell at me. You can either go get a drink of water and come back in five minutes, or sit in the reading chair and I will check in with you in five minutes," says Keels.

In the heat of the moment, it's important to avoid an argument, teacher Holli A. tells WeAreTeachers. "State your choices, then walk away," she says. "Give the student time to process and decide which choice to make. If they don't like the choices, don't engage. When they try to argue, repeat the choices, and walk away again. If the student still will not choose, they do not get to participate in their preferred activity."

6. Build Connections: Often, kids with ODD "are looking for a relationship with a teacher who can help them deal with problems on their own, instead of making them stand out in a negative way," according to WeAreTeachers. "Building a connection with them will help get to the root of the behavior."

Though teachers can feel the need to create boundaries with students, simply talking with them informally can build invaluable connections that influence their behavior in the classroom, says middle school math teacher Cicely Woodard.

Woodard says she intentionally makes herself approachable to students and tries to learn interesting details about them. "Some of my students tell me stories about their lives during the five minutes between classes," Woodard says. "I stop what I am doing, look them in the eyes, and listen."

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Offering kids choices, safe spaces, and positive reinforcement can help teachers avoid problems-or manage them when they arise.

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The Difference Between IEPs and 504 plan

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The Difference Between IEPs and 504 plan

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Both Individualized Education Programs (IEPs) and 504 plans can offer formal help for K-12 students who are struggling in school. They're similar in some ways but very different in others. This chart compares them side by side to help you understand the differences.

A blueprint or plan for a child's special education experience at school.

A blueprint or plan for how the school will provide support and remove barriers for a student with a disability.

To get an IEP, there are two requirements: A child has one or more of the 13 disabilities listed in IDEA. The law lists specific challenges, like learning disabilities, ADHD, autism, and others. And the disability must affect the child's educational performance and/or ability to learn and benefit from the general education curriculum. The child must need specialized instruction to make progress in school.

To get a 504 plan, there are two requirements: A child has any disability. Section 504 covers a wide range of different struggles in school. And the disability must interfere with the child's ability to learn in a general education classroom. Section 504 has a broader definition of a disability than IDEA. (It says a disability must substantially limit one or more basic life activities. This can include learning, reading, communicating, and thinking.) That's why a child who doesn't qualify for an IEP might still be able to get a 504 plan.

There are strict legal requirements about who participates. With a few exceptions, the entire IEP team must be present for IEP meetings. The team must include:

The rules about who's on the 504 team are less specific than they are for an IEP. A 504 plan is created by a team of people who are familiar with the child and who understand the evaluation data and special services options. This might include:

* The child's parent or caregiver

* General and special education teachers

* The school principal

* The child's parent or caregiver

* At least one of the child's general education teachers

* At least one special education teacher

* A school psychologist or other specialist who can interpret evaluation results

* A district representative with authority over special education services

The IEP sets learning goals and describes the services the school will provide. It's a written document. Here are some of the most important things the IEP must include:

There is no standard 504 plan. Unlike an IEP, a 504 plan doesn't have to be a written document. A 504 plan generally includes the following:

* Specific accommodations, supports, or services for the child

* Names of who will provide each service

* Name of the person responsible for ensuring the plan is implemented

* The child's present levels of academic and functional performance - how the child is currently doing in school

* Annual education goals for the child and how the school will track progress

* The services the child will get - this may include special education, related, supplementary, and extended school year services

* The timing of services - when they start, how often they occur, and how long they last

* Any accommodations - changes to the child's learning environment

* Any modifications - changes to what the child is expected to learn or know

* How the child will participate in standardized tests

* How the child will be included in general education classes and school activities

When the school wants to change a child's services or placement, it has to tell families in writing before the change. This is called prior written notice. Notice is also required for any IEP meetings and evaluations. Families also have "stay put" rights to keep services in place while there's a disagreement about the IEP.

The school must notify families about an evaluation or a "significant change" in placement. Notice doesn't have to be in writing, but most schools do so anyway.

How to resolve disputes

IDEA gives families several ways to resolve disputes (usually in this order):

Section 504 gives families several options for resolving disagreements with the school:

* Mediation

* Alternative dispute resolution

* Impartial hearing

* Complaint to the Office for Civil Rights (OCR)

* Lawsuit

* Mediation

* Due process complaint

* Resolution session

* Civil lawsuit

* State complaint

* Lawsuit

And if you need help navigating special education law in your state, consider reaching out to your local Parent Training and Information Center. The people there can answer questions and give practical advice on issues specific to your area.

Do you want to learn more about how IEPs and 504 plans compare? Watch as an expert explains the differences between them.

About the author

About the author

The Understood Team is made up of passionate writers and editors. Many of them have kids who learn and think differently.

Reviewed by

Reviewed by

Andrew M.I. Lee, JD is an editor and attorney who strives to help people understand complex legal, education, and parenting issues.

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IEP vs. 504 Plan: What's the Difference?

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Individualized Education Programs (IEPs) and 504 plans are similar but different. See how they compare in what they provide and the processes and laws involved.

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Counseling Youth Who Have Bipolar Disorders 

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Counseling Youth Who Have Bipolar Disorders 

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ASCA Ethical Standards for School Counselors

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ASCA Ethical Standards for School Counselors

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ASCA Ethical Standards for School Counselors - American School Counselor Association (ASCA)

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ASCA School Counselor Professional Standards & Competencies

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ASCA School Counselor Professional Standards & Competencies

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ASCA Mindsets & Behaviors for Student Success 

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ASCA Mindsets & Behaviors for Student Success 

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Home - American School Counselor Association (ASCA)

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Signs, Symptoms, and Treatment of ADHD in Children

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Psychotic Disorders in Children and Adolescents: A Primer on Contemporary Evaluation and Management

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Psychotic Disorders in Children and Adolescents: A Primer on Contemporary Evaluation and Management

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Clinical Points

■ Hallucinatory experiences and delusions are more common in our patients than we may realize and occur frequently in the pediatric population. While not a benign occurrence, psychotic symptoms do not necessarily portend the future development of schizophrenia.

■ Psychotic symptoms in children and adolescents can occur in the context of a bevy of psychiatric disorders other than schizophrenia (eg, depression, anxiety, attention-deficit/hyperactivity disorder, posttraumatic states, and autism spectrum disorders) or can be secondary to a wide variety of medical conditions.

■ The onset of psychosis is usually preceded by a period of nonpsychotic symptoms known as prodromal symptoms. In recent years, there has been substantial research in early intervention efforts (eg, with psychotherapy or antipsychotic medicines) focused on the early stages of schizophrenia and on young people with prodromal symptoms. At present, outcome data are insufficient to draw definitive conclusions.

■ The pharmacologic treatment of psychotic symptoms in a pediatric population is similar in many ways to the treatment of infection with antibiotics-the clinician needs to choose the proper medication at a sufficient dose and then await therapeutic results while monitoring for potential side effects.

Over the past decade, psychiatric illnesses and, in particular, psychotic disorders in children and adolescents have been recognized more frequently. This increase in recognition, combined with changing trends in the provision of mental health care, has led primary care physicians and pediatricians to increasingly serve as the principal treaters of psychiatrically ill youth and their families. Primary care providers and behavioral health services (eg, in colocated care, embedded care practices, patient-centered homes, and consultation) form the backbone of contemporary psychosis evaluation and management. It is unclear whether psychotic disorders in younger individuals are actually becoming more prevalent, or whether educational efforts directed at enhanced screening and treatment have improved case detection. Efficacious and safe interventions should be employed to maximize beneficial effects and to minimize medication-related complications, such as weight gain, diabetes, and heart disease.

The question for today's health care providers is not whether psychotic symptoms will be encountered in daily practice, but how to confidently and effectively diagnose and treat the conditions in which they manifest. In order to frame this discussion, several areas of inquiry will be explored: "Have you ever been unsure about whether a young person in your practice was psychotic or simply imaginative? Have you wondered how to evaluate such a patient (eg, with laboratory testing or with neuropsychological testing) and what resources to recommend? Have you been concerned about using antipsychotics in young people? Does the potential for adverse side effects of antipsychotics in the short-term or long-term concern you?" For practitioners faced with these concerns, the following discussion should prove useful.

WHAT IS PSYCHOSIS AND HOW COMMON IS IT IN YOUNG PEOPLE?

Narrowly defined, psychosis denotes the presence of either delusions (false implausible beliefs) or hallucinations (false perceptions involving any sensory modality). Broader definitions of psychosis include manifestations of thought disorders, behavioral disorganization, or catatonia. Family members, particularly parents, are often concerned that children who manifest delusions or hallucinations might have schizophrenia. Fortunately, most forms of psychosis in children and adolescents are not a result of schizophrenia.

Population-based surveys show that the prevalence of psychotic symptoms may be far greater than had been previously considered, with a meta-analysis suggesting a prevalence rate of 5%-8% in the general population (which is nearly 10 times higher than the prevalence of diagnosed psychotic disorders). Prevalence rates of such symptoms may be even higher among young people. In 2000, Poulton and colleagues reported that 14% of 11-year-old children endorsed psychotic symptoms upon interview and showed that these symptoms were associated with a 5-fold to 16-fold increased rate of psychotic illness in early adulthood (depending on the strength of the initial symptoms). Since then, large, population-based studies surveying psychotic symptoms among adolescents have found rates of 9%-14% in interview-based studies, and rates greater than 25% in some studies using self-report questionnaires. ⁻ Positive answers on self-report questionnaires have been validated on clinical interview. This emerging body of research suggests that a sizable minority of young people experience psychotic symptoms.

DOES THE PRESENCE OF PSYCHOTIC SYMPTOMS NECESSARILY PORTEND A DIAGNOSIS OF SCHIZOPHRENIA?

However, rather than being a harbinger of schizophrenia, psychotic symptoms in childhood and adolescence more likely accompany other psychiatric conditions (eg, major depression, bipolar disorder, or dissociative states). lists psychiatric disorders that can be accompanied by psychosis. Differentiating early-onset schizophrenia or childhood-onset schizophrenia from other psychiatric disorders has important treatment implications. For example, a pediatric patient with bipolar disorder often experiences hallucinations and delusions but also has the clinical characteristics of mania, depression, or both. In children with psychological trauma-related hallucinations (typically associated with nightmares and trance-like states), psychotic symptoms may quickly abate with psychotherapeutic and/or social interventions. Compared to traumatized children, children with schizophrenia are more apt to display a formal thought disorder, negative symptomatology (eg, apathy, social isolation), and impulsive aggression. Like children and adolescents with schizophrenia, those with autism spectrum disorders may also have odd beliefs (eg, believing that they are able to communicate with valued inanimate toys). Children with milder forms of autism (eg, Asperger's syndrome) may be misdiagnosed with psychosis due to their idiosyncratic beliefs, social awkwardness, and concrete thought process. Taking a comprehensive clinical history helps to disentangle diagnostic uncertainties.

Table 1

Psychotic symptoms have been associated with, or are secondary to, a wide variety of medical disorders as well. Psychosis may develop in response to central nervous system lesions, as a consequence of medical illness, or after traumatic injury or drug use. Recently, reports have linked a particularly severe form of new-onset psychosis-often associated with insomnia, catatonia, and autonomic instability-to antibodies against the glycine-binding NR ₁ subunits of the anti- N-methyl-d-aspartate (NMDA) receptor. Overall, studies from the adult literature show that about 3% of new-onset presentations of psychosis can be attributed to a medical condition., Therefore, before making a diagnosis of a primary psychotic disorder, secondary causes should be ruled out by a thorough-but not indiscriminate-medical workup.

WHAT ARE PRESENTING CHARACTERISTICS OF PSYCHOSIS IN CHILDREN AND ADOLESCENTS?

The most common manifestations in young people with psychosis are hallucinations, impaired functioning, flattened affect, and social withdrawal., Caregivers are more likely than the child patients themselves to report these problems to the clinician, as children often minimize, misinterpret, or avoid mentioning their symptoms. Hence, a comprehensive psychiatric assessment should include interviews with the child and his or her family members, review of records, information gathered from other involved adults (including a detailed description of the presentation and course of the psychotic symptoms), attention to developmental delays, a family psychiatric history, a history of abuse and/or neglect, and a mental status examination.,

Unlike adults, children with psychosis rarely demonstrate waxy flexibility or become catatonic. On the other hand, they can be emotionally reactive or agitated. The majority of children with childhood-onset schizophrenia often exhibit "soft" neurologic signs, including primitive reflexes, abnormal stereognosis, 2-point discrimination, and dysdiadochokinesia (impaired rapid alternating movements). Affected youth may manifest either a decreased or increased rate of eye blinking, as well as paroxysmal saccadic eye movements (inability to follow an object with smooth eye movements).

HOW ARE CHILDREN AND ADOLESCENTS DIAGNOSED WITH SCHIZOPHRENIA?

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-5) made several changes to the category of schizophrenia, including raising the symptom threshold. A diagnosis of schizophrenia now requires 2 of the following conditions: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms such as affective flattening or paucity of thought or speech (in the manual's previous editions, the threshold was 1). To meet diagnostic criteria, symptoms must be present for at least 6 months (including at least 1 month of active symptoms); must result in deterioration in social, school-related, and self-care functioning; and should not be accounted for by a diagnosis of schizoaffective disorder, a mood disorder, a substance use disorder, or general medical conditions.

Additionally, an "attenuated psychosis syndrome" was included in the research section as a category for persons who do not meet criteria for a full-blown psychotic disorder but exhibit minor variations of relevant symptoms. This category seeks to identify individuals with an increased risk for developing a psychotic disorder, which may be significant for the implementation of effective early interventions.

Personality tests and projective tests should not be used to diagnose schizophrenia in youth; research indicates that tests, such as the Rorschach, do not increase the diagnostic accuracy in early-onset schizophrenia.

WHAT CAUSES SCHIZOPHRENIA IN CHILDHOOD AND ADOLESCENCE?

While there is no single confirmed etiology of childhood-onset or early-onset schizophrenia, it is likely that genetic, behavioral, and environmental factors all contribute to the development of this disease.

Genetic risk has been well-studied. First-degree relatives of patients with childhood-onset schizophrenia have a higher prevalence rate of schizophrenia and schizophrenia spectrum disorders, as well as impairment in smooth pursuit eye movements similar to those observed in patients with adult-onset schizophrenia. One study found that healthy siblings of patients with childhood-onset schizophrenia had decreased cerebral gray matter in the same pattern as was seen in the probands. In an investigation of youth identified as being at "high risk," the young relatives of patients with schizophrenia demonstrated an increased rate of Axis I psychopathology (eg, attention-deficit/hyperactivity disorder [ADHD], conduct disorder), soft neurologic signs, and a high level of outwardly expressed emotion. On neuropsychological examination, these "high-risk" nonprobands also demonstrated impairment in attention, spatial working memory, and executive function, as well as a volume reduction in the amygdala, hippocampus, and superior temporal gyrus.

WHICH NEURODEVELOPMENTAL AND NEUROBIOLOGICAL ABNORMALITIES ARE ASSOCIATED WITH YOUTH WHO DEVELOP SCHIZOPHRENIA?

Structural brain abnormalities are an established feature of schizophrenia, and recent evidence suggests a progressive nature of this pathology. Like adults with schizophrenia, youth with childhood-onset schizophrenia show bilateral enlargement of the lateral ventricles on neuroimaging. However, unlike adults, the abnormalities in brain morphology in patients with childhood-onset schizophrenia evolve during adolescence. Rapoport and associates, reported that adolescents with schizophrenia have significantly reduced frontal and temporal gray matter volumes compared with those observed in healthy age-matched controls. Moreover, youth with childhood-onset schizophrenia appear to lose more cortical gray matter compared to children who suffer from transient psychosis. Subsequent studies from this group have shown that the healthy siblings of afflicted patients also have reductions in cerebral volume and gray matter. Similar to patients with adult-onset schizophrenia, over the course of development, youth with childhood-onset schizophrenia appear to lose cortical thickness in prefrontal and temporal regions, regardless of their treatment with medications. In a systematic review of 66 articles comparing brain volume in patients with a first psychotic episode with the volume seen in healthy controls, a meta-analysis demonstrated that whole-brain and hippocampal volumes are reduced and that ventricular volumes are increased in affected patients compared to healthy controls. Future improvements in neuroimaging technology hold the potential to reveal more about neurobiological disturbances and their correlates in schizophrenia. Yet, at present, results of neuroimaging studies have not made the leap from bench to bedside.

WHICH NEUROTRANSMITTERS ARE THOUGHT TO BE INVOLVED IN SCHIZOPHRENIA?

The neurotransmitter most commonly implicated in the pathophysiology of schizophrenia is dopamine. Drugs that increase dopaminergic receptor activity (eg, cocaine, amphetamines) may induce an acute psychotic episode, whereas drugs that block postsynaptic D ₂ receptors help to alleviate psychotic symptoms. Furthermore, persons with schizophrenia also have fewer D ₁ receptors in the prefrontal cortex. Disturbances in a variety of other neurotransmitters such as glutamate, serotonin, and γ-aminobutyric acid (GABA) have been implicated in the pathophysiology of schizophrenia. Researchers are also interested in glutamate because phencyclidine (PCP or angel dust) is an NMDA/glutamine antagonist; NMDA receptor dysfunction can also cause psychotic symptoms. As mentioned earlier, anti-NMDA receptor antibodies, sometimes secondary to teratomas or autoimmune dysfunction, can cause psychosis in children, often in conjunction with autonomic instability and seizures. Serotonin may also be important; most second-generation antipsychotics share relatively potent antagonism of serotonin 5-HT 2A receptors coupled with relatively weaker antagonism of dopamine D ₂ receptors. Preliminary studies suggest that GABA may also play a role in the development of chronic psychotic syndromes. Overall, disrupted neurotransmission and cognitive functions are key components in the pathophysiology of schizophrenia; however, no single neurotransmitter is clearly responsible for the onset and progression of schizophrenia.

ARE THERE ENVIRONMENTAL RISKS FOR THE DEVELOPMENT OF SCHIZOPHRENIA?

It is clear now that "the grass is not greener," as data from 6 longitudinal studies in 5 countries have shown that regular cannabis use predicts an increased risk for schizophrenia and symptoms of psychosis. Cannabis use during early adolescence coupled with a specific genetic vulnerability and changes in brain development are correlated with risk for the development of schizophrenia and overall cognitive decline. However, the direction of the effect has been called into question. Some suggest that individuals with psychosis use cannabis to alleviate their psychotic symptoms or to improve their mood. Others, however, suggest that cannabis causes or exacerbates psychotic symptoms. A pooled analysis of 35 studies showed a dose-response effect, with greater risk of psychosis in people who used cannabis most frequently. Moreover, individuals with schizophrenia who are moderate to heavy cannabis users show a greater brain volume reduction over a 5-year follow-up compared with nonusers.

Despite the fact that fewer adolescents believe that regular cannabis use is harmful to their health and increasingly permissive state laws governing the use of medical marijuana, the medical literature presents clear evidence for a neurotoxic effect of cannabis on the adolescent brain. These findings highlight the importance of efforts targeting adolescent cannabis use, including policy measures and psychoeducation in the doctor's office.

HOW CAN ONE DISTINGUISH PRIMARY PSYCHOSIS FROM SECONDARY PSYCHOSIS?

A thorough medical workup is essential for distinguishing between primary and secondary psychotic disorders. lists medical disorders that have been associated with psychosis. Although there is no generally agreed-upon medical evaluation that every patient with psychosis should undergo,, screening tests should be ordered on the basis of a patient's personal and family history, as well as on the basis of one's clinical suspicion of conditions. Blanket testing for rare disorders may increase the risk of false-positive or false-negative results. On the other hand, the search for medical etiologies of psychosis may be expanded in the face of atypical presentations or when cases are refractory to standard treatments.

Table 2

Infections

Creutzfeldt-Jakob disease

Herpes encephalitis

Human immunodeficiency virus infection

Lyme disease

Subacute bacterial endocarditis

Sydenham's chorea

Metabolic disturbances

Adrenocortical insufficiency

Cushing's disease

Hypercalcemia or hypocalcemia

Hypermagnesemia or hypomagnesemia

Hypernatremia or hyponatremia

Hyperthyroidism

Hypoglycemia

Hypokalemia

Hypophosphatemia

Lactic acidosis

Panhypopituitarism

Parathyroid disease

Thyroid storm

Neurologic

Cerebral neoplasms

Cerebrovascular disease

Cerebral lipidoses

Complex partial auras or seizures

Creutzfeldt-Jakob disease

Encephalitis (including anti- N-methyl-d-aspartate receptor encephalitis)

Focal lesions of temporal and parietal lobe

Generalized seizures

Hepatic encephalopathy

Herpes encephalitis

Multiple sclerosis

Normal pressure hydrocephalus

Temporal arteritis

Postnoxic encephalopathy

Posttraumatic encephalopathy

Fragile X syndrome

Klinfelter's syndrome

Metachromic leukodystrophy

Prader-Willi syndrome

Velocardiofacial syndrome

Wilson's disease

Vitamin deficiencies

Folate deficiency

Niacin deficiency

Vitamin B ₁₂ deficiency

Vitamin D insufficiency

Medications

Drug classes that can cause hallucinations or delusions

Amphetamine-like drugs

Anabolic steroids

Angiotensin-converting enzyme inhibitors

Anticholinergics

Antidepressants (both tricyclic antidepressants and selective serotonin reuptake inhibitors)

Antiepileptics

Barbiturates

Benzodiazepines

β-adrenergic blockers

Calcium channel blockers

Cephalosporins

Corticosteroids (prednisone, cortisone, adrenocorticotropic hormone, others)

Dopamine receptor agonists

Fluoroquinolone antibiotics

Nonsteroidal antiinflammatory drugs

Procaine derivatives (procainamide, procaine, penicillin G)

Salicylates

Sulfonamides

Alcohol toxicity/withdrawal

Illicit use of drugs (including prescribed medications)

Amphetamines

Glue sniffing/ingestion

Lysergic acid diethylamide

Methamphetamine (crystal meth)

Phencyclidine hydrochloride (PCP)

Psilocybin (mushrooms)

Toxicologic causes

Carbon monoxide poisoning

Heavy metal poisoning (eg, mercury, lead)

Key tests in the pediatric population () may include drug screens (to rule out medication or substance-related psychosis), laboratory studies (to rule out infections, metabolic disturbances, certain genetic conditions, or vitamin deficiencies), an electroencephalogram (EEG), and structural neuroimaging (eg, magnetic resonance imaging [MRI] or computed axial tomography [CT] scanning). The clinical relevance of a given EEG tracing can be difficult to discern, as almost half of the patients with new-onset psychosis will have EEG abnormalities of unclear significance. Furthermore, EEGs read as "normal" may not capture an interictal psychosis. Likewise, incidental and non-clinically meaningful MRI findings are found in approximately 20% of the non-psychiatrically ill population. Recent guidelines suggest that structural neuroimaging should not be obtained routinely during an evaluation for a first episode of psychosis. Despite the low yield of neuroimaging, counter arguments supporting its judicious use emphasize that patients and families feel reassured by negative scans. Conversely, neuroimaging can rule out rare etiologies for psychosis (eg, brain tumors) and help patients and families understand and accept the psychotic symptoms as manifestations of a psychiatric disorder.

Table 3

Electroencephalogram

Imaging studies (eg, magnetic resonance imaging or computed tomography of the brain) in select patients based on clinical suspicion

Laboratory studies

Antinuclear antibodies

Blood urea nitrogen/creatinine

Calcium and phosphorus

Ceruloplasmin (for Wilson's disease)

Complete blood count

Electrolytes

Erythrocyte sedimentation rate

FTA-Abs (for syphilis)-preferred over rapid plasma reagin

Human immunodeficiency virus screening

Liver function tests

Thyroid-stimulating hormone

Urinalysis

Urine (and/or serum) drug screen

HOW SHOULD PSYCHOSIS DUE TO AN UNDERLYING MEDICAL CONDITION BE TREATED?

The optimal treatment for secondary psychosis is treatment of the underlying medical or neurologic condition. Concomitant treatment of the secondary psychosis (usually with an antipsychotic agent) can protect both the patient and the treatment team while medical treatment is administered. Notably, most guidelines for dosing antipsychotics are based on the treatment of patients with schizophrenia and bipolar disorder. Patients treated for psychosis related to medical causes are often antipsychotic naive and sensitive to the sedating properties of lower-potency antipsychotics and to the extrapyramidal effects of higher-potency antipsychotics.

WHAT DOES THE FIRST EPISODE OF PSYCHOSIS INVOLVE?

Once functionally impairing psychotic symptoms develop-defined in terms of symptom severity and duration-a patient is no longer considered to be in the prodromal phase of illness, but instead diagnosed with an episode of psychosis. Clinically, the demarcation between prodromal (or "attenuated") symptoms and frank psychosis is rarely clear-cut, particularly in a patient with brief or intermittent bouts of mild psychotic symptoms. Moreover, few patients receive emergency treatment for psychosis. The median duration of untreated psychosis refers to the lag between the development of symptoms and the initiation of treatment. This lag time can range from 4 to 50 weeks in first episodes, and can extend longer when mood symptoms or illicit drug use cloud the diagnostic picture. The availability of mental health resources, socioeconomic factors, and cultural attitudes toward mental illness can also affect the time to treatment. Most studies show that a longer duration of untreated psychosis is associated with worse clinical outcomes. This observation has spurred increased research interest into interventions that target the period prior to, or immediately after, the development of a psychotic disorder. The hope is that these targeted interventions might forestall the onset of psychosis or improve long-term outcomes.

WHAT PSYCHOSOCIAL TREATMENTS ARE AVAILABLE FOR YOUTH WITH PSYCHOSIS OR SCHIZOPHRENIA?

Cognitive-behavioral techniques that evaluate evidence for beliefs or thinking through explanations surrounding a patient's perceptions can help to alter dysfunctional behaviors. A consistent framework with similar words/techniques used at home, at school, and with friends may allow the patient to employ a standardized approach to events across settings and to diminish misperceptions of daily events and interactions.

Research data supporting psychosocial treatments in pediatric psychotic disorders are scant. There is a controlled study comparing cognitive-behavioral therapy (CBT) with no antipsychotic to a monitoring program in prodromal patients. CBT was associated with less progression to psychosis; however, the results of this study were limited by methodological flaws. The PACE (Personal Assessment and Crisis Evaluation) trial randomly assigned prodromal patients (aged 14-28 years) to risperidone plus CBT versus a needs-based intervention of supportive therapy and psychotropics other than antipsychotics. At 6 months, 3 of 31 patients in the risperidone plus CBT group converted to psychosis, whereas 10 of 28 patients in the supportive therapy and nonneuroleptic pharmacotherapy group converted to psychosis. Since the average risperidone dose used in this study was relatively low (1.3 mg/d), there is a suggestion that CBT was a vital ingredient to the protective effects seen in this study.

WHAT DOES THE PHARMACOTHERAPY OF SCHIZOPHRENIA IN YOUTH INVOLVE?

Pharmacologic treatment for schizophrenia in youth remains an area of active research, with several large multisite trials completed within the past few years. Six, 6-week, randomized, placebo-controlled studies of second-generation antipsychotics for early onset schizophrenia have been completed thus far. They showed that aripiprazole, olanzapine, paliperidone, quetiapine, and risperidone-but not ziprasidone-were superior to placebo. In these controlled studies, aripiprazole, olanzapine, paliperidone, quetiapine, and risperidone, were superior to placebo with regard to improvement in the Positive and Negative Syndrome Scale (PANSS) total score.

In terms of atypical antipsychotic dosing, typically, these medications are initiated at a low dose and gradually titrated upward to achieve efficacy. Risperidone, for example, is generally started at 0.25 mg twice a day and can be increased every 1 to 2 days in association with close observation. In general, olanzapine and quetiapine are more sedating; their dosing is usually started at 2.5 to 5 mg/d and 25 to 50 mg/d, respectively. As most antipsychotic medications have a relatively long half-life, they typically do not need be administered more than twice daily. For patients maintained on antipsychotics, clinicians should monitor weight, vital signs, and relevant laboratory results (eg, triglycerides, cholesterol, fasting glucose, and prolactin levels).

Newer atypical antipsychotics (eg, asenapine, iloperidone, lurasidone) may eventually have a role in the treatment of patients with childhood-onset or early onset schizophrenia and in patients deemed at-risk of developing schizophrenia due to genetic and/or environmental factors. However, at present, there is little evidence to support the safety, tolerability, or efficacy of these agents in the pediatric population.

In sum, current pharmacologic research for early-onset and childhood-onset schizophrenia focuses on the identification of antipsychotic agents that will provide optimal efficacy without also causing undue adverse events. Many typical and atypical antipsychotics have been shown (based on open trials, randomized clinical trials, and head-to-head comparisons) to be efficacious in the treatment of early-onset and childhood-onset schizophrenia; however, they are well known to cause side effects such as weight gain, extrapyramidal symptoms, and metabolic abnormalities.

WHAT IS THE ROLE OF LONG-ACTING (INJECTABLE) ANTIPSYCHOTICS IN CHILDHOOD-ONSET SCHIZOPHRENIA?

In the near future, as many as 4 new atypical antipsychotic long-acting therapy formulations may become available. In clinical situations wherein adherence with oral preparations has proven difficult, it is reasonable-especially in older adolescents-to consider using a long-acting medication. Risperidone long-acting therapy has been shown to be efficacious and well tolerated in the treatment of schizophrenia, including those with newly diagnosed schizophrenia. Short-term and long-term studies found that risperidone long-acting therapy was associated with low rates of discontinuation related to adverse events and few reports of pain from injections. Evidence for newer long-acting injectables (eg, olanzapine, paliperidone) remains limited. The available evidence suggests that long-acting injectable antipsychotics can be used safely and effectively in early stages of the illness and that they may be associated with better outcomes than with oral medications. However, this is largely supported by evidence from naturalistic cohort studies and by a small number of controlled trials of risperidone long-acting injection. Given the paucity of data of long-acting therapy in the adolescent population, the use of these preparations in adolescents remains empiric. provides the side effect risk profiles of common second-generation antipsychotic medications used in children and adolescents.,

Table 4

Second-Generation Antipsychotics
(trade name)

Anticholinergic

Diabetes

Hyperlipidemia

Hyperprolactinemia

Hypotension

Sedation

Tardive Dyskinesia

Weight
Gain

WHAT ARE THE ADVERSE EFFECTS OF ANTIPSYCHOTICS?

In reviewing the available randomized, controlled studies and head-to-head comparisons of antipsychotics, Schimmelmann and colleagues noted, "Antipsychotics are efficacious in the treatment of early-onset schizophrenia. The lack of evidence for efficacy differences between various antipsychotics (except for clozapine for treatment-refractory early-onset schizophrenia) suggests that a primum non nocere principle should be applied when choosing and antipsychotic."(p228) Therefore, the side effect profile of the antipsychotics often dictates the choice of pharmacologic agent for young people with psychotic symptoms. Antipsychotic therapy has been linked to a bevy of metabolic changes (eg, dyslipidemia, weight gain, plasma prolactin increases), sedation, extrapyramidal symptoms, and dyskinesias (see ). With the exception of tardive dyskinesia, young people with schizophrenia seem more likely to experience these side effects from atypical neuroleptics compared with their adult counterparts. Children and adolescents may gain weight, even when treated with antipsychotics that are considered "weight-neutral" in adults. Similarly, there are reports of prolactin elevations in youth treated with prolactin-sparing agents such as quetiapine.

Other common adverse effects of antipsychotics include drowsiness and anticholinergic effects (eg, dry mouth, nasal congestion, blurred vision), particularly with the low-potency phenothiazines. Caregivers can usually manage the short-term adverse effects of antipsychotics with adjustments of dose and timing of administration. One can avoid undue sedation by using less sedating agents and by prescribing most of the daily dose at bedtime. One should not confuse drowsiness with impaired cognition; drowsiness can usually be corrected by adjusting the dose and the timing of administration. Furthermore, there is no evidence that antipsychotics adversely affect cognition when used in low doses. One can minimize anticholinergic effects by choosing a medium-potency or high-potency antipsychotic.

Extrapyramidal Side Effects

Extrapyramidal side effects such as acute dystonia, akathisia (motor restlessness), and parkinsonism (bradykinesia, tremor, and lack of facial expressions) are more commonly seen with use of high-potency agents (eg, butyrophenones, thioxanthenes) and have been reported in up to 75% of children receiving these agents. The extent to which antiparkinsonian agents (eg, anticholinergic drugs such as benztropine, trihexyphenidyl, antihistamines, and the antiviral agent amantadine) should be used prophylactically when antipsychotics are introduced is controversial, although coadministration has been shown to reduce the incidence of extrapyramidal side effects by a factor of 7.

Other Movement Disorders

Abrupt cessation of antipsychotic drugs can cause withdrawal dyskinesias (typically benign, but occasionally more pronounced) and a syndrome of deteriorating behavior. As with adults, the long-term administration of antipsychotic drugs can produce tardive dyskinesia. Although children appear generally less likely to develop tardive dyskinesia than adults, the fact that tardive dyskinesia is potentially irreversible prompts caregivers to evaluate the benefits of such medications, including documenting a clear indication and identifying target symptoms; to periodically discontinue the drug to assess continued need; and to monitor closely to ensure early detection. Current practice parameters recommend monitoring neurologic side effects with standardized scales (eg, Abnormal Involuntary Movement Scale or Simpson Angus Scale) at baseline and periodically during any treatment regimen requiring antipsychotic agents.

Akathisia

Akathisia is a movement disorder characterized by anxiety and an inability to sit still; it can be a side effect of either antipsychotics or antidepressants. Akathisia may be particularly problematic in young patients because of underrecognition or misdiagnosis as ADHD or agitation. Caregivers should consider akathisia in the differential when a child or adolescent starts an antipsychotic and becomes acutely agitated with an associated inability to sit still (and/or with aggressive outbursts).

Treatment of akathisia involves reduction of the offending agent to the lowest effective dose and then using either a benzodiazepine (eg, lorazepam, 0.5 to 1 mg 3 times per day) or a β-blocker. Although all β-blockers are likely to be effective, propranolol, initiated at 10 mg 2 or 3 times per day with an increase every few days until the desired effect is achieved, is a good choice. Alternately, betaxolol hydrochloride, a long-acting β ₁-selective adrenergic antagonist with few medication interactions, may be useful.

Neuroleptic Malignant Syndrome

Little is known about the potentially lethal neuroleptic malignant syndrome in children and adolescents; however, preliminary evidence indicates that its presentation is similar to that in adults. This syndrome may be difficult to distinguish from primary central nervous system pathology, concurrent infection, anti-NMDA receptor encephalitis, or other, more benign, side effects of antipsychotic treatment, including extrapyramidal side effects or anticholinergic toxicity. Neuroleptic syndrome is a life-threatening medical emergency; treatment is largely supportive but can include dopamine reuptake inhibitors like amantadine, similar to strategies used in adults.

WHAT STRATEGIES ARE HELPFUL FOR NONRESPONDERS?

A unique head-to-head randomized controlled trial of olanzapine and clozapine in the treatment of patients with childhood-onset schizophrenia showed that clozapine led to a statistically significant reduction in all outcome measures (particularly negative symptoms of schizophrenia) even when compared to another atypical agent.

WHAT STRATEGIES ARE AVAILABLE FOR EARLY INTERVENTION AND PREVENTION OF CHILDHOOD-ONSET SCHIZOPHRENIA?

The notion of early intervention and perhaps even prevention of schizophrenia remains at the forefront of early-onset psychosis research. Further research in this area is ongoing. However, at present, the literature does not support clear treatment guidelines for these vulnerable patients.

CONCLUSION

Clinicians should be vigilant and consider psychotic illnesses when evaluating children and adolescents with emotional and behavioral disturbances. Given the high developmental, financial, and functional toll associated with chronic psychotic illness, clinicians should employ a variety of diagnostic and treatment modalities to mitigate the risks associated with this illness. These modalities may include performing careful psychiatric and physical examinations, relevant laboratory testing, neuropsychological testing, and employing relevant cognitive therapies, as well as the use of antipsychotic and other pharmacologic interventions. Advances in the understanding of childhood-onset and early-onset schizophrenia, as well as the elucidation of prodromal psychotic symptomatology, will benefit both children and adults.

Footnotes
LESSONS LEARNED AT THE INTERFACE OF MEDICINE AND PSYCHIATRY
The Psychiatric Consultation Service at Massachusetts General Hospital (MGH) sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

Dr Stevens is physician-in-charge at Westpark (Dearborn), Henry Ford Health Systems, Dearborn, Michigan, and clinical assistant professor at Wayne State University, Detroit, Michigan. Dr Prince is director of child psychiatry at North Shore Medical Center in Salem, Massachusetts, and an instructor in psychiatry at Harvard Medical School, Boston, Massachusetts. Dr Prager is director of the Child Psychiatry Emergency Service at Massachusetts General Hospital, Boston, and assistant professor of psychiatry (child psychiatry) at Harvard Medical School, Boston, Massachusetts. Dr Stern is chief of the Avery D. Weisman Psychiatry Consultation Service at Massachusetts General Hospital, Boston, and the Ned H. Cassem professor of psychiatry in the field of psychosomatic medicine/consultation at Harvard Medical School, Boston, Massachusetts.

Dr Prince has received honoraria from the American Physician Institute and has provided expert legal reviews in malpractice cases. Dr Stern is an employee of the Academy of Psychosomatic Medicine, has served on the speaker's board of Reed Elsevier, is a stock shareholder in WiFiMD (Tablet PC), and has received royalties from Mosby/Elsevier and McGraw Hill. Drs Stevens and Prager report no conflicts of interest related to the subject of this article.

References

1. Freudenreich O. Psychotic Disorders: A Practical Guide. Philadelphia, PA: Lippincott Williams and Wilkens; 2008.

20. McDonell M, McClellan J. Early-onset schizophrenia. In: Mash E, Barkley R, editors. Assessment of Childhood Disorders. 4th ed. New York, NY: Guilford Press; 2007. pp. 526-550.

26. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Washington, DC: American Psychiatric Press; 2013.

28. Kodish I, McClellan J. In: Handbook of Psychological Assessment, Case Conceptualization, and Treatment: Vol. 2, Children and Adolescents. Hersen M, Reitman D, editors. Hoboken, NJ: John Wiley & Sons; 2008. pp. 405-443.

42. Millichap JJ, Goldstein JL, Laux LC, et al. Ictal asystole and anti- N-methyl-d-aspartate receptor antibody encephalitis. Pediatrics. 2011;127(3):e781-e786.

49. Freudenreich O, Goff DC. Psychotic patients. In: Stern TA, Fricchione GH, editors. Massachusetts General Hospital Handbook of General Hospital Psychiatry. Amsterdam, The Netherlands: Elsevier Science Publishers; 2010.

52. Structural neuroimaging in first-episode psychosis. London (UK): National Institute for Health and Clinical Excellence (NICE); 2008 Feb. 24 p. (technology appraisal guidance; no. 136) http://www.guideline.gov/content.aspx?id=12284. Accessed December 4, 2013.

54. Marshall M, Rathbone J. Early intervention for psychosis. Cochrane Database Syst Rev. 2011;(6):CD004718. [ PMC free article]

60. Xia J, Merinder LB, Belgamwar MR. Psychoeducation for schizophrenia. Cochrane Database Syst Rev. 2011;(6):CD002831. [ PMC free article]

61. Jones C, Cormac I, Silveira da Mota Neto JI, et al. Cognitive behaviour therapy for schizophrenia. Cochrane Database Syst Rev. 2004;(4)(CD000524)

71. Yan J. FDA advisors back additional antipsychotics for use in teens. Psychiatr News. 2009;44(13):1-29.

80. Celano CM, Beach SR, Huffman JC, et al. Side effects profiles of psychotropic medications from cardiovascular and other side effects of psychotropic medications. In: Stern TA, Herman JB, Gorrindo T, editors. The Massachusetts General Hospital Psychiatry Update and Board Preparation. 3rd ed. Boston, MA: MGH Psychiatry Academy Publishing; 2012.

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Psychotic Disorders in Children and Adolescents: A Primer on Contemporary Evaluation and Management

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■ Hallucinatory experiences and delusions are more common in our patients than we may realize and occur frequently in the pediatric population. While not a benign occurrence, psychotic symptoms do not necessarily portend the future development of schizophrenia.

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What is ODD? ODD meaning and Oppositional Defiant Disorder DSM 5  diagnosis

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Understanding & Identifying OCD in the Classroom 

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Understanding & Identifying OCD in the Classroom 

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Today's blog post comes to us from one of our Family-Endorsed Providers, Carla Kenney, LMHC. She writes on the importance of both educators and family members noticing the possible signs of OCD in children. Thank you, Carla, for sharing your expertise with us at rtor.org. -Veronique Hoebeke, Associate Editor
Children say and do unusual things on occasion, or even quite often, but how do we know that it isn't just a quirky behavior or something more serious? How do we know if a child is struggling? If you are a teacher or school personnel, how would you know that those unusual behaviors you observe in your student may be something more, something that needs to be explored and possibly addressed?

Scenario:

Jonny is a 10-year-old boy attending the 5th grade. His academic performance is below average. He arrives tardy to school on most days and his parents report that he is "slow moving" and "not a morning person." Jonny's teachers notice that he asks the same questions over and over about his assignments as if he didn't understand and he spends a lot of time on his classwork. Sometimes his teachers see him erasing things repeatedly and starting over. He is often the last student to finish his work and he is falling behind academically. The other kids in class notice these behaviors too and sometimes make fun of him by calling him "slow poke." This makes Jonny more anxious and he gets more stuck on his school assignments. In addition, Jonny asks to use the bathroom multiple times each day. His visits to the bathroom are lengthy and when he leaves the bathroom his hands and wrists are visibly wet and red. The teacher is also noticing she is replenishing the soap and paper towels more frequently than usual in her classroom.

The above scenario describes a child struggling with Obsessive Compulsive Disorder (OCD) in the classroom environment. Many of these behaviors could be observed by onlookers as part of this child's character or disposition rather than something more serious, which could lead to an untreated illness that worsens and becomes more debilitating over time.

Understanding OCD

Before we can identify how OCD can manifest in the classroom we first need to understand it. According to statistics at least 1 in 100 children are diagnosed with OCD. This means that roughly about 8-10 kids in an average sized elementary school struggle with this illness. Research indicates that OCD is one of the most common psychiatric illnesses affecting children and adolescents.

OCD is an anxiety disorder that consists of obsessions and compulsions. Obsessions are unwanted thoughts, images, and urges that cause prominent distress. Compulsions are behaviors that are performed to help decrease the distress that the obsession has caused. Compulsions can be visible behaviors but they can also be mental acts that are not seen by others. These obsessions and compulsions are excessive and cause significant distress to the child and will often lead to avoidance behaviors. OCD is not pleasant and often a person who has OCD describes the illness as torturous and disabling.

Teachers and other school personnel spend a lot of time with children - often they see things that may go unnoticed at home therefore, it is important that they are aware of the many kinds of OCD symptoms. Sometimes OCD symptoms may mimic other illnesses.

How OCD Manifests Itself

While everyone experiences fears once in a while it is important to remember that these fears, worries and behaviors are excessive and cause significant and debilitating distress. Below are common obsessions and compulsions.

Common Obsessions

Contamination Obsessions: fear of dirt, germs, diseases, bodily wastes, sticky substances, chemicals, animals, insects and environmental contamination

Ordering Obsessions: need for symmetry, exactness, order, and perfectionism

Religious Obsessions & Morality Obsessions: fear of having bad thoughts and being punished for them, not following rules of religion or family values, losing control and doing bad things against religion, values, or society

Health Obsessions: fear about having a bad illness despite medical exams finding no evidence of an illness or having worries about being responsible for the well being of others

Aggressive Obsessions: fear of losing control and harming self or others

Sexual Obsessions: fear of losing control and acting out sexually, sexually harming others and thoughts about being homosexual, heterosexual, bisexual or other

Other kinds of obsessions

The need to know, seek out, confess, remember information that is useless

Fear of saying something wrong, not saying it a certain way, leaving out details

Worrying about losing things, making errors, forgetting information

Fear of saying certain words because something bad might happen

Fear of certain numbers, colors, objects, places

Common Compulsions

Cleaning and Washing Compulsions: hand washing, showering, bathing, teeth brushing, grooming, dressing, cleaning of house, space and objects

Checking Compulsions: checking to make sure no harm was done to self or others, that nothing terrible happened, that no mistakes were made

Repeating, Counting, and Ordering Compulsions: rereading, rewriting, repeating certain behaviors, doing things a certain number of times, counting items, counting while doing activities, arranging things a certain way

Health Compulsions: checking of the body to look for illness or injury, seeking out nurses, doctors and other medical professionals reassurance that everything is ok, seeking out medical tests, spending excessive amounts of time on the internet looking up medical information

Other kinds of compulsions

Mental rituals such as praying, counting, saying certain phrases

Excessive need to seek out reassurance from others

Excessive confessing about behaviors that are trivial

The need to touch, tap, rub items or people

Eating in a ritualistic way

As you can see, OCD symptoms can vary greatly. Not only can a person have multiple symptoms but symptoms can wax and wane over time in intensity as well as change altogether. For example, someone can have excessive worries about fears of getting sick and perform multiple washing compulsions and then these symptoms can lighten and a new obsession and set of new compulsions take center stage. These behaviors are often labeled as "odd" and much too often, a child will be misdiagnosed. As a result, they may end up getting ineffective treatment that only make their symptoms worse.

How OCD Is Missed

OCD symptoms can go unnoticed for several reasons. Teachers are not clinicians and have not had in-depth training on mental health illnesses and how they can present in the school environment. Also, many clinicians are not fully aware of the various faces of OCD and these "odd" behaviors are often dismissed as a phase the child may be going through. Children may also have trouble articulating what they are feeling or thinking or simply may lack self-awareness. Other children may be insightful about their thoughts and behaviors but choose to conceal their symptoms to ensure better social acceptance.

Some common manifestations of OCD in the classroom

Tardiness and/or absences from school

Disruptive behavior, meltdowns, tantrums and rage-like episodes

Asking questions repeatedly or having difficulty with completing work

Seeking reassurance

Rereading, rewriting, excessive erasing or throwing paper out

Inability to complete work, procrastination

Frequent trips to use the bathroom or nurse

Avoidance of certain places, people, situations, objects

Red, raw, and chapped looking hands and arms

Adjusting desk, contents of desk, locker or backpack, other items in the classroom

Repeatedly doing things (by number or by a "just right" feeling)

Difficulty transitioning from tasks, including entering or exiting rooms

Wearing the same clothing

Eating rituals

It is important that these behaviors be addressed as they can interfere with learning and affect a child's ability to concentrate, think and process information.

How OCD Affects the Student

Attention can be limited because the student is focused on their obsessions. This can be very exhausting for the child and can affect sleep. These behaviors in school can also take a heavy toll on social interactions with peers and may result in bullying by other students and isolation. Both can lead to depression.

Any teacher or school personnel who have concerns about a student having OCD should communicate it to the appropriate person and continue to monitor and document behaviors. In most cases the person to report these observations to are school psychologists, therapists/clinicians, adjustment counselors, or guidance counselors. Usually these professionals have in-depth training about mental illness and can investigate more by talking with the child, the child's teachers, and his or her parents. If a diagnosis of OCD is likely, then a referral to a treatment provider who specializes in the treatment of OCD should be made. It is important that if there is a diagnosis of OCD then communication between the outside treatment provider and school personnel should take place to help determine the best actions to help the student while in the school environment.

Teachers and school personnel who are educated about OCD can play an important role in the identification of this often-debilitating illness. Early detection is possible and can lead to effective treatment before symptoms worsen. This can help the child avoid years of unnecessary suffering. Understanding OCD and other related disorders can provide support that is crucial for a child's ability to function successfully in the classroom.

There are many online resources about OCD. The International OCD Foundation has specific information for educators and school personnel to provide guidance and support. In addition, there are a few books that are also very helpful. Please visit iocdf.org for a list of books that are recommended.
Carla Kenney, LMHC
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Children who have obsessive-compulsive disorder (OCD) are plagued with unwanted thoughts, images or impulses that are difficult to suppress, causing them great stress and worry. These are called obsessions. To alleviate the anxiety caused by their obsessive thoughts, they perform repetitive, ritualized actions called compulsions. A child with OCD might need to line things up, touch things in a certain order when leaving the room or wash his hands repeatedly.

Obsessions Common in Kids With OCD

Contamination: Kids with this obsession are sometimes called "germaphobes." In schools, this plays out with kids worrying about other kids sneezing and coughing, touching things that might be dirty or getting sick in many different ways. This is the most common obsession seen in children.

Magical thinking: This is a kind of superstition, like "step on a crack, break your mother's back," taken to extremes. For example, kids might worry that their thoughts can cause someone to get hurt, or get sick. A child might think, "Unless my things are lined up in a certain way, mom will get in a car accident."

Catastrophizing: Some kids easily jump to the conclusion that something terrible has happened. For example, if her parents are five minutes late picking her up, a girl who is catastrophizing might tell herself that they've decided to abandon her.

Scrupulosity: This is when kids have obsessive worries about offending God or being blasphemous in some way.

What ifs: Kids may be plagued by a lot of different kinds of thoughts about bad things they could do. "What if I hurt someone? What if I stab someone? What if I kill someone?"

The "just right feeling": When OCD first develops, from about 6 to 9 years of age, kids may not know why they are doing something, but just that they need to do it until they get what we call the "just right feeling." So: "I'll line these things up until it just kind of feels right, and then I'll stop." And then over time - in the 9- to 12-year-old range - it evolves into magical thinking and becomes more superstitious in nature.

Behaviors You Might See in Students With OCD

Frequent requests to go to the bathroom: This could be to wash hands, if someone near the child was coughing or sneezing, or if she touched something that she perceives as contaminated. She could be washing items-pens, pencils, backpacks, books. It could also be an excuse to get out the classroom and just be away from everyone, and have some respite.

Constant reassurance-seeking: This takes the form of repetitive questions. "Are you sure that's the answer? Could you tell me again? Did you hear what I said?" Checking doors, windows, lockers, desks. Over and over and over again.

Getting stuck on tasks: Sometimes kids with OCD will need to finish something to completion, or understand it to completion, before they're able to move on. So if a child is working out what he did wrong on a math test, and the teacher says, "Now let's open the textbook and start a new chapter," he's not going to be able to shift gears.

Retracing: If a child leaves the classroom and worries that she left a pencil behind, she'll go back into the classroom and go to her desk and check. If she had a bad thought as she went through the doorway, she might have to "fix it" by going back through the doorway again saying a good word. If she had a bad thought when she went down a flight of stairs on the way to class, she might need to go back up that same stairway at the end of the period, even if it means being late to her next class.

Obsessive erasing: A child could be erasing a lot because the letters have to look perfect. Or he could have used a word that disturbs him. For example, if he has a fear of vomiting and he's written the word vomit, he might not be able to stand seeing that word, so he erases it. Kids start having erasers worn down to the metal. Teachers start to see holes in the paper. Words will be drawn over on the back of the page. A lot of different areas of writing become problematic.

Behaviors Often Confused With Another Disorder

Some behaviors associated with OCD are easy to confuse with ADHD, learning problems or being oppositional.

Distraction: If a child is busy thinking that if she doesn't turn the pen cap and count to four the right way then her mom is going to get sick, she's not going to be paying attention in class. And if her teacher calls on her to answer a question, her distraction might look like ADHD, but it isn't.

Slowness on exams, papers and tasks: Sometimes when kids take a long time, they're struggling with the perfectionism of needing to do things the right way. This could look like learning problems, or inattention, but it isn't.

Avoidance: Teachers might see a child who doesn't want to sit on the floor, or pick things up that touched the floor, or get his hands dirty in art class. He may avoid a lot of playground activities - kids with germ fears will view the playground the way some adults view the subway: it's gross. Why touch anything there?

Tapping and touching symmetrically: If a child sits down at her desk and she accidentally kicks the chair of the kid next to her with her right foot, she's going to have to then kick it with her left foot. That might look like somebody who's being oppositional, or somebody who's got too much energy, but actually it's OCD.

Complaints of anxiety and fatigue: There's one interesting theory that kids with OCD are smarter than other kids. And if you consider how much thinking they're doing, they're really using their brain more frequently than a lot of other kids are. But when that's coupled with a lot of anxiety, you can have a lot of fatigue. So it's common for kids with OCD to want to come home and take a nap after school.

How to Help Students With OCD

For children struggling with OCD, functioning in school can be complicated and very difficult. Here are some things you can do to help them, and the class as a whole, focus on learning:

Seating arrangement: If the school has noisy hallways, you might not want to have a child with OCD sit by the door. You might have her sit in the front, where she's less able to hear the noise and can stay more focused on her work. On the other hand, a child who has very observable symptoms, and doesn't want other kids to see her fidgeting with her hands, rocking or getting up a lot, might be better off closer to the door, toward the back of the room.

Extended time for tests and papers: If writing is a problem for a child who needs to find the perfect way to say something, he's going to need more time to finish those essay questions or papers.

Laptops for writing: If writing and rewriting/erasing is really problematic for a child, consider letting her use a laptop for taking notes, and having all assignments be typed instead of handwritten.

Private testing rooms: Research is quite clear that kids with OCD do better, are less overwhelmed and are more in control of their thoughts and their reactions if they're in a quiet place away from the other kids.

Skip reading out loud: Kids who feel they need to read perfectly may have to go back and reread sentences or whole paragraphs over and over to make sure they've got them right. So reading becomes a very laborious task, and reading in front of the class can become a nightmare. So if we know doing this is a problem for children, we can spare them.

Books on tape: If kids get so hung up reading that it takes forever, listening to the books can be a solution.

Break homework into chunks: If looking at a whole page of math makes kids feel overwhelmed and anxious - think of the potential for mistakes! - the problems can be broken up over four pages. It helps kids stay focused on doing the problems instead of worrying.

How to Minimize Behavioral Problems

Plan an escape route: Try working out a communication system so that if the student feels symptoms coming on, she can signal to you and leave the classroom, or go to a protected place in the classroom, without interrupting the class. It can prevent an embarrassing and disruptive blowup of symptoms in the classroom, and the other kids picking on or bullying her about it.

Be aware of triggering events: It's very important for teachers to know what kind of things might trigger the symptoms. Fatigue is a huge piece of OCD, and it can be exacerbated by medication. So it's important to know that if a child is drowsy in class, and maybe he's putting his head down, it's not because he's being oppositional or disrespectful, but because he's overwhelmed with fatigue.

Advance notice: Irritability and frustration are two of the longer-lasting things that kids with OCD are feeling on a daily basis. Changes in schedule can be very disruptive for a child with OCD, so it can be helpful for teachers to give advance notice of things. Kids who know what to expect are less likely to be thrown by the change.

Children with OCD are often teased and bullied because of their symptoms. Kids feel very uncomfortable about their rituals, knowing that they're being watched. It can be helpful to educate the whole class about what's going on, especially if a child is going to be in the same school for a number of years, and it can inspire a surprising amount of support from other children.

Peer understanding program: A peer understanding program includes a presentation in the classroom that explains (with the child participating) what OCD is. The child might say, "Listen, I have OCD. It's an anxiety disorder. It makes me think that my hands are dirty and I have to wash my hands a lot, so if you see me getting up and going to the sink to wash my hands, that's why." Psychologists can role-play with the teacher and child ahead of time, to anticipate questions his classmates might ask, and how to answer them.

A buddy system: A buddy is like a peer coach who sits next to the child and prompts him to keep up with note taking and staying on task. It can be great for the buddy, to foster a sense of confidence and pride and to be able to help someone in need, and great for fostering friendship.

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When parents start googling behavior issues, one phrase tends to jump out: oppositional defiant disorder. It's easy to see why. "The words 'oppositional' and 'defiant' show up in parents' vocabulary fairly frequently," says Dr. David Anderson, director of the ADHD and Behavior Disorders Center at the Child Mind Institute. "It's one of the more aptly named diagnoses that exists."

Whether your child has oppositional defiant disorder (or ODD) or not, learning about the disorder can be helpful. That's because the behavior management strategies used in treatment are evidence-based techniques that all parents will benefit from knowing.

What is oppositional defiant disorder?

It is normal for children to be oppositional and defiant at least some of the time. In fact, it's a sign of healthy development. So when does a child have oppositional defiant disorder? The diagnosis should not be given, for example, to a toddler who has just discovered that her new favorite word is "no."

ODD is typically diagnosed around early elementary school ages and stops being diagnosed around adolescence. Kids who have ODD have a well-established pattern of behavior problems. Symptoms include:

Being unusually angry and irritable

Frequently losing their temper

Being easily annoyed

Arguing with authority figures

Refusing to follow rules

Deliberately annoying people

Blaming others for mistakes

Being vindictive

All children can have these symptoms from time to time. What distinguishes ODD from normal oppositional behavior is how severe it is, and how long it has been going on for. A child with ODD will have had extreme behavior issues for at least six months.

Another hallmark of ODD is the toll it takes on family relationships. Regular daily frustrations - ignored commands, arguments, explosive outbursts - build up over time, and these negative interactions damage the parent-child bond and reinforce hostile patterns of behavior.

Parenting under fire

"Kids who have behavioral issues push parents towards the extremes," says Dr. Anderson. "They push parents to become permissive and they push parents to become hyper-coercive in the hope that a larger amount of control will get the kid to listen."

Neither of these extremes make for ideal parenting. It is never a parent's intention to reinforce bad behavior, and we often don't realize when we're doing it. Here are two common scenarios:

1. You tell your child to stop playing a game and get ready for bed. He ignores your first two requests. By the third time you ask, you're so mad that you yell.

2. You tell your child to stop playing a game and get ready for bed. He throws a tantrum because he wants to keep playing. You don't want him to be so worked up before bedtime, so you back down and say he can play for another ten minutes - but then he has to go to bed.

In the first scenario, your child learns that yelling is an acceptable way to get a message across. More subtly, he might also be learning that he can continue ignoring those first few requests - when you escalate the situation is when he knows you're serious.

In the second scenario, your child has learned that throwing a tantrum might give him something that he wants, so he'll be more likely to do it again in the future.

Both of these scenarios can set families up for future conflicts, and the more they are repeated the more they become familiar patterns of behavior that are harder to break out of. Your child doesn't have to have ODD for these scenarios to happen, but repeated negative interactions like these make diagnosing a behavior disorder much more likely.

And just like parents aren't necessarily to blame, neither are the kids, says Dr. Anderson. "Through no conscious effort of the child, he learns through hundreds of trials that this is a way to continue getting what he wants."

This also explains why kids who have ODD might act out more at home. Dr. Anderson notes, "Kids who have ODD are likely to be more oppositional with people they know well, partly because the pathways are so well worn. Whereas in a place like school, where a kid has less control in general over their environment, the types of behaviors that are common to ODD may not pay off as much."

ADHD and other risk factors

There is a very high overlap in kids who have ADHD who are also diagnosed with ODD. Depending on the study, the overlap could be 30 to 50 percent of kids with ADHD also have ODD.

Dr. Anderson explains the connection like this: "Kids with ADHD are biologically loaded to be distractible, to be impulsive, to have difficulty staying in one place for a little while. So kids with ADHD start off doing things that parents perceive as off limits. And then when those kids get negative feedback they start to become even more negatively oriented towards adults." These repeated patterns of negative interactions can lead to developing ODD.

But another pathway into developing ODD has more to do with a child's temperament and might be apparent early on. Children who had a lot of difficulty soothing themselves as toddlers and continue to struggle with an age-appropriate ability to control their emotions in the face of disappointment or frustration can sometimes develop ODD. The adults in their environment might be more inclined to accommodate their demands in order to keep the family functioning as harmoniously as possible.

Kids who have experienced a lot of life stress and trauma are also more likely to develop ODD.

Why treatment is important

It's important to get treatment to improve the parent-child relationship, which is crucial to the health and happiness of the entire household. It is also important for your child's future. Some children will grow out of oppositional defiant disorder, but others will continue to have behavior issues, which could lead to peer rejection and difficulty forming healthy relationships, not to mention continued family discord.

They'll also be less likely to achieve their potential. If something doesn't go their way, they might think it's anyone's fault but theirs. Dr. Anderson says they might also "retreat to the places where they know they can get what they want. That might mean that they try even less, push even more on the people who are closest to them, who they actually care about the most, causing even more frayed relationships."

A small percentage of kids with ODD go on to develop something called conduct disorder, which is a more severe behavior disorder that includes criminal acts like stealing, setting fires and hurting people. Getting treatment sooner rather than later improves a child's trajectory.

What treatment for ODD looks like

Parents play a key role in treatment for oppositional defiant disorder. This might be surprising, since children are the ones given the diagnosis, but in ODD the parent-child relationship needs to be repaired, which means both parties need to make changes to get back on track.

All programs have certain goals in common, like helping parents find the middle ground between being too authoritative and too permissive. A behavioral therapist helps parents learn how to train their child's behavior through setting clear expectations, praising kids when they follow through and using effective consequences when they don't. Parents also learn to use these strategies consistently - one reason why behavior management strategies sometimes don't work is because parents try different, conflicting techniques, or don't stick to one program long enough to see gains. Parents and children will also learn problem solving skills they can rely on when they run into issues.

Parent training programs might include sessions with parents and children working together, or just parents alone. Some different programs include:

Parent-Child Interaction Therapy (PCIT)

Parent Management Training (PMT)

Defiant Teens

Positive Parenting Program (Triple P)

The Incredible Years

Clinicians might also recommend social skills training to help improve your child's peer relationships or cognitive behavioral therapy if she is struggling with anxiety or depression.

There is no FDA-approved medication for ODD, but medications are sometimes used as an adjunct to behavioral therapy. Anti-psychotic medications like Abilify (aripiprazole) and Risperdal (risperidone), which have been shown to reduce aggression and irritability, are frequently used in cases where a child is at risk of being removed from the school or home. Stimulant medication may be used if a child has excessive impulsivity, including those who have an ADHD diagnosis. Antidepressants (SSRIs) may be helpful if a child has underlying depression or anxiety.

Regardless of the treatment plan your therapist recommends, parents will need to provide a lot of encouragement. "Make no mistake, kids do not often just suddenly wake up with the insight that they wish their behavior was better and then ask all the adults in their life how they can change," warns Dr. Anderson. "They'll stick with whatever behavior is working for them, even if it's not working that well."

But once the family dynamic begins to change, and kids (and parents) begin to feel more confident in their ability to get along, everyone will be a lot happier.

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When parents start googling behavior issues, one phrase tends to jump out: oppositional defiant disorder. It's easy to see why. "The words 'oppositional' and 'defiant' show up in parents' vocabulary fairly frequently," says Dr. David Anderson, director of the ADHD and Behavior Disorders Center at the Child Mind Institute.

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