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Behavioral disorders also known as conduct disorders are one of the most common forms of disability among children and young adults and is the most frequently cited reason for referral to mental health services. The appearance of behavioral disorders is increasing dramatically in our K-12 classrooms. As a result, their presence severely constrains the ability of the school systems to educate students effectively. The prevalence of behavioral problems among children and young adults is substantial. Many surveys indicate that behavioral disorders vary among young adults, ranging from 2 and 6 percent among K-12 students. This percentage translates into 1.3 to 3.8 million cases of behavioral disorders among the school and pre-college population.

Behavior disorders have also been referred to in a variety of different terminologies, including but not limited to:

1. Emotional and Behavior Disorders (EBD)

2. Emotional Conflict (EC)

3. Serious Emotional Disturbance (SED)

Behavioral disorders become apparent when the student displays a repetitive and impact persistent pattern of behavior that results in the significant disruption of other students. Such disturbances may cause significant impairments in academic, social, and or occupational functioning. Among the characteristics of a behavioral disorder among children and adolescents are:

General Strategies

Multidisciplinary educational teams, including parents, must design programs to meet the individual behavioral and academic needs of identified SED students. Most students can benefit from supportive treatments provided in general education programs. For others, at least temporary placements in special education classrooms, schools, or institutional programs may be appropriate.

Special education programs usually attempt to provide a structured environment where students experience a high degree of success; rules and routines are predictable; and students are consistently rewarded for appropriate behavior. Behavior management techniques, such as positive reinforcement, token economies, contracting, and time-out, which rely on direct measurement and monitoring of behavioral change, are commonly used in SED programs. The assessment and systematic teaching of social skills through modeling, discussion, and rehearsal are frequently used to help students increase control over their behavior and improve their relations with others. In addition, supportive therapies involving music, art, exercise, and relaxation techniques, as well as affective education, individual, and group counseling are sometimes employed to improve self-understanding, self-esteem, and self-control. The following are strategies that may be effective with students with EBD:

Teacher Presentation

Laboratory

Group Interaction and Discussion

1. Acknowledge the contributions of the student with an emotional disorder.

2. Call for responses and participation commensurate with the student's socialization skills.

3. As the student's comfort level rises and when a safe topic is available, encourage the student to be a group spokesperson.

4. Along with the student, devise a contingency plan in which inappropriate forms of response are replaced by appropriate ones.

5. Gradually increase the challenges in the student's participation in group exercises while providing increased positive reinforcement.

6. Help the student to feel as though he or she has something worthwhile to contribute to the discussion.

7. Some students may experience considerable strain in social adjustment in a group context. It may be necessary to work gradually toward group activities. One can devise a strategy of progressing from spectatorship to one-to-one instruction and eventually to small group discussion.

8. Should monitor carefully to ensure that the nondisabled students do not dominate the discussion or detract in any way from the successful performance of the student with the behavioral disorder.

Reading

1. It is necessary to target specific pro-social behaviors for appropriate instruction and assessment to occur such as:

1. Taking turns, working with partner, following directions.

2. Reading in group or with others.

3. Increasing positive relationships by means of awards when they read appropriately.

4. Demonstrating appropriate reading

2. Instructional strategies involving self-control, self-reinforcement, self-monitoring, self-management, problem solving, cognitive behavior modification, and metacognitive skills should be focused on teaching students reading skills

Research

1. Review and discuss with the student the steps involved in a research activity. Think about which step(s) may be difficult for the specific functional limitations of the student and jointly devise accommodations for that student.

2. Use appropriate laboratory and field strategies.

3. Depending on the site of the research check the previous two sections.

4. Show clear examples of what the students should expect as an outcome of their research.

Field Experiences

1. Use appropriate general strategies.

2. Consider alternate activities/exercises that can be utilized with less difficulty for the student, but has the same or similar learning objectives.

3. In field activities acknowledge the contributions and assistance of the student with an emotional disorder.

4. Help the student to feel as though he or she has something worthwhile to contribute to the field trip.

5. Use a buddy system.

6. Gradually increase the challenges in the student's participation in field exercises while providing increased positive reinforcement.

7. Group participation in field activities is highly desirable because it enhances social contacts.

8. Make the student with the behavioral disorder become one of the field trip leader of an activity which can often reduce their disorder.

9. Special efforts should be made to get students with behavioral disorders to interact with other students.

10. You should encourage students to practice field skills during their free hours.

11. Every effort should be made to arouse the interest of such students in activities, so they will learn to perform the activities with success and pleasure with appropriate behaviors.

Testing

1. Be sensitive to the student's reactions to the various aspects of assessment.

2. For each student, accumulate in his or her portfolio several examples of work (quizzes, assignments, projects) that demonstrate knowledge of the subject matter or the unit of study.

3. Make special arrangements for the student with an emotional disorder according to what their special needs are and that they do not compromise the integrity of the testing situation.

4. Stay on top of student progress through informal assessment, don't wait until it's too late to discover that there is a problem.

5. Provide private room/smaller group setting/alternative test site (with proctor present); alternatively screens to block out distractions.

Organizations

Council for Exceptional Children-Council for Children with Behavior Disorders (CCBD)
The Council for Children with Behavioral Disorders (CCBD) is dedicated to supporting the professional development and enhancing the expertise of those who work on behalf of children with challenging behavior and their families. It is a division of the Council for Exceptional Children (CEC).

CCBD Foundation
The CCBD Foundation was founded in 1997 by the Council for Children with Behavioral Disorders (CCBD), to support its mission of improving the education of children and youth with emotional or behavioral disorders (EBD).

Resources

Council for Exceptional Children (Behavior Disorders/Emotional Disturbance)
The Council for Exceptional Children (CEC) page on EBD. The Council for Exceptional Children (CEC) is the largest international professional organization dedicated to improving the educational success of individuals with disabilities and/or gifts and talents.

BehaviorDisorder.org
The site offers information on behavior disorders, conduct disorders, and other behavior problems.

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Behavioral disorders also known as conduct disorders are one of the most common forms of disability among children and young adults and is the most frequently cited reason for referral to mental health services. The appearance of behavioral disorders is increasing dramatically in our K-12 classrooms. As a result, their presence severely constrains the ability of the school systems to educate students effectively.

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A school counselor can be a great ally for children with anxiety and OCD - AnxietyTraining.com

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A School counselor is an important bridge between children with anxiety and OCD and the diagnosis and treatment that can help them get well.

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What do mental health professionals do in schools

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Centers for Disease Control and Prevention

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Being mentally healthy during childhood means reaching developmental and emotional milestones and learning healthy social skills and how to cope when there are problems. Mentally healthy children have a positive quality of life and can function well at home, in school, and in their communities.

Mental disorders among children are described as serious changes in the way children typically learn, behave, or handle their emotions, which cause distress and problems getting through the day. Many children occasionally experience fears and worries or display disruptive behaviors. If symptoms are serious and persistent and interfere with school, home, or play activities, the child may be diagnosed with a mental disorder.

Mental health is not simply the absence of a mental disorder. Children who don't have a mental disorder might differ in how well they are doing, and children who have the same diagnosed mental disorder might differ in their strengths and weaknesses in how they are developing and coping, and in their quality of life. Mental health as a continuum and the identification of specific mental disorders are both ways to understand how well children are doing.

What are common childhood mental disorders?

Among the more common mental disorders that can be diagnosed in childhood are attention-deficit/hyperactivity disorder (ADHD), anxiety (fears or worries), and behavior disorders.

Learn more about childhood mental disorders, symptoms, and treatment.

Other childhood disorders and concerns that affect how children learn, behave, or handle their emotions can include learning and developmental disabilities, autism, and risk factors like substance use and self-harm.

Read more about related conditions.

What are the symptoms of childhood mental disorders?

Symptoms of mental disorders change over time as a child grows, and may include difficulties with how a child plays, learns, speaks, and acts, or how the child handles their emotions. Symptoms often start in early childhood, although some disorders may develop during the teenage years. The diagnosis is often made in the school years and sometimes earlier; however, some children with a mental disorder may not be recognized or diagnosed as having one.

Can childhood mental disorders be treated?

Childhood mental disorders can be treated and managed. There are many treatment options based on the best and most current medical evidence. Parents and doctors should work closely with everyone involved in the child's treatment-teachers, coaches, therapists, and other family members. Taking advantage of all the resources available will help parents, health professionals, and educators guide the child towards success. Early diagnosis and appropriate services for children and their families can make a difference in the lives of children with mental disorders.

Get help finding treatment

If you have concerns about a child, you can use these resources to help you find a healthcare provider familiar with treatment options.

Who is affected?

Childhood mental disorders affect many children and families. Boys and girls of all ages and ethnic/racial backgrounds and living in all regions of the United States experience mental disorders. Based on the National Research Council and Institute of Medicine report, which gathered findings from previous studies, it is estimated that in 2007, 13-20% of children living in the United States (up to 1 out of 5 children) experienced a mental disorder in a given year, costing individuals, families, and society an estimated $247 billion per year.

What is the impact of mental disorders in children?

Mental health is important to overall health. Mental disorders are chronic health conditions-conditions that last a long time and often don't go away completely-that can continue through the lifespan. Without early diagnosis and treatment, children with mental disorders can have problems at home, in school, and in forming friendships. Mental disorders can also interfere with a child's healthy development, causing problems that can continue into adulthood.

Public health includes mental health

Supporting children's mental health also includes making sure children meet developmental milestones, understanding what to do when there is a concern, supporting positive parenting strategies, and improving access to care.

CDC works with partner agencies to better understand mental health and mental disorders and the impact they have on children.
Read more about research on children's mental health.
What you can do

Parents: You know your child best. Talk to your child's healthcare professional if you have concerns about the way your child behaves at home, in school, or with friends.

Youth: It is just as important to take care of your mental health as it is to take care of your physical health. If you are angry, worried or sad, don't be afraid to talk about your feelings and reach out to a trusted friend or adult.

Healthcare professionals: Early diagnosis and appropriate treatment based on updated guidelines are very important. There are resources available to help diagnose and treat children's mental disorders.

Teachers/school administrators: Early identification is important so that children can get the help they need. Work with families and healthcare professionals if you have concerns about the mental health of a child in your school.

Resources

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Learn more about mental health, mental disorders, treatments, prevention, and public health research on children's mental health.

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Finding the motivation to make positive lifestyle changes can be hard for anyone. For teenagers, it can be especially difficult when parents are the ones telling them to do it. But if they've fallen into unhealthy habits like vaping or alcohol abuse, change can be beneficial. Motivational interviewing is a form of therapy that creates a safe, non-judgmental environment for teens to establish their own goals and values and see how changing unhealthy behaviors can benefit them in the long run.

This series of articles comes from the Child Mind Institute, with most available in English and Spanish. Why might teens be resistant to therapy and how can parents and others to help them get the treatment they need? The articles explain how motivational interviewing can help teens gain the self-confidence to make important behavioral changes. To read more about motivational interviewing, and to connect with the articles in both English and Spanish, please visit CPIR's abstract.

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Center for Parent Information and Resources | Your Central Hub for Parent Centers Serving Families of Children With Disabilities

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Finding the motivation to make positive lifestyle changes can be hard for anyone. For teenagers, it can be especially difficult when parents are the ones telling them to do it. But if they've fallen into unhealthy habits like vaping or alcohol abuse, change can be beneficial.

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Emotional distress can happen before and after a disaster. Coping strategies include preparation, self-care, and identifying support systems.

People can experience a wide range of emotions before and after a disaster or traumatic event. There's no right or wrong way to feel. However, it's important to find healthy ways to cope when these events happen.

Take Care of Yourself and Your Loved Ones

Eating a healthy diet, avoiding the use of drugs and alcohol, and getting regular exercise can reduce stress and anxiety. Activities as simple as taking a walk, stretching, and deep breathing can help relieve stress.

Take care of yourself. Try to eat healthy, avoid using alcohol and drugs, and get some exercise when you can-even a walk around the block can make a difference.

Reach out to friends and family. Talk to someone you trust about how you are doing.

If you have children, talk to them. They may feel scared, angry, sad, worried, and confused. Let them know it's okay to talk about what's on their mind. Role model healthy coping.

Limit your consumption of news. We live in a society where the news is available to us 24 hours a day via television, radio, and the Internet. The constant replay of news stories about a disaster or traumatic event can increase stress and anxiety and make some people relive the event over and over. Reduce the amount of news you watch and/or listen to.

Get enough "good" sleep. Some people have difficulty falling asleep after a disaster, or wake up throughout the night. If you have trouble sleeping, only go to bed when you are ready to sleep, avoid using cell phones or laptops in bed, and avoid drinking caffeine or alcohol at least one hour before going to bed. If you wake up and can't fall back to sleep, try writing what's on your mind in a journal or on a sheet of paper.

Establish and maintain a routine. Try to eat meals at regular times and put yourself on a sleep schedule to ensure an adequate amount of rest. Include a positive or fun activity in your schedule that you can look forward to each day or week.

Avoid making major life decisions. Doing things like switching jobs or careers can already be stressful and are even harder to adjust to directly after a disaster.

Understand there will be changes. Disasters can destroy homes, schools, and places of business and worship and can disrupt the lives of people living in affected areas for a long time. Sometimes, people lose loved ones or experience injuries, both physical and mental, that may last a lifetime. Some people may also experience a temporary or permanent loss of employment. For children, attending a new or temporary school may result in being separated from peers, or after-school activities may be disrupted.

Take care of pets or get outside into nature when it's safe. Nature and animals can help us to feel better when we are down. See if you can volunteer at a local animal shelter-they may need help after a disaster. Once it's safe to return to public parks or natural areas, find a quiet spot to sit in or go for a hike.

Know when to ask for help. Signs of stress can be normal, short-term reactions to any of life's unexpected events-not only after surviving a disaster, but also after a death in the family, the loss of a job, or a breakup. It's important to pay attention to what's going on with you or with someone you care about, because what may seem like "everyday stress" can actually be: depression (including the thoughts of suicide), anxiety, or alcohol/drug abuse.

Those at Risk
Disasters have the potential to cause emotional distress.
Some are more at risk than others:

Survivors living or working in the impacted areas (youth & adults)

Loved ones of victims

First Responders, Rescue & Recovery Workers

Stress, anxiety, and depression are common reactions after a disaster.
Warning signs of distress may include:

Sleeping too much or too little

Stomachaches or headaches

Anger, feeling edgy or lashing out at others

Overwhelming sadness

Worrying a lot of the time; feeling guilty but not sure why

Feeling like you have to keep busy

Lack of energy or always feeling tired

Drinking alcohol, smoking or using tobacco more than usual; using illegal drugs

Eating too much or too little

Not connecting with others

Ask for Help

Warning signs of stress are normal, short-term reactions to life's unexpected challenges. However, it is important to recognize when you or others experience emotional distress that is persistent and becomes difficult to manage.

Find a local support group. In a group setting led by trained and experienced professionals, people who have shared a similar experience can exchange thoughts, feelings, and ideas on how to get through difficult times. Support groups provide a safe place for people to find comfort in knowing they are not alone.

Reach out to family and friends. Talking to someone you trust about your feelings without fear of judgment may offer some relief. Family and friends can be a great resource for support. Your family and friends may have also survived the disaster and understand the emotions you are experiencing. It's also a good idea to speak with friends who were not involved, because they can be objective and provide additional support.

Speak with a financial adviser. The loss of a home or job or being unable to work after a disaster can be an overwhelming financial burden people feel they have to struggle with alone. Financial advisers don't immediately come to mind as a resource after a disaster, but they should be among the first people you call when developing a strategy to rebuild your life. Seeking help from a financial adviser can ease the stress and point you in the direction of other helpful resources or programs tailored to your situation.

If you or your loved ones continue to have feelings of anxiety, fear, and anger for two weeks or more, with no improvement, it's best to seek professional help. Call or text the Disaster Distress Helpline to locate services and speak with trained crisis counselors who are ready to assist you.

References and Relevant Resources

General Disaster Response and Recovery Information

Incidents of Mass Violence: Specific Information

Resources for Disaster Responders

Traumatic Stress and Retraumatization Resources

National Child Traumatic Stress Network Resources (NCTSN)

The NCTSN has multiple resources to support children, youth, families and community response efforts:

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Coping Tips for Traumatic Events and Disasters

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Emotional distress can happen before and after a disaster. Coping strategies include preparation, self-care, and identifying support systems. People can experience a wide range of emotions before and after a disaster or traumatic event. There's no right or wrong way to feel. However, it's important to find healthy ways to cope when these events happen.

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Definition

Students with emotional disorders are a very heterogeneous group with a wide range of issues that are unique to each individual. However, there are some key characteristics that are used to define this disability category, mostly relating to issues of personal identity and emotional well-being. An emotional disorder may be present if a student responds to a situation with an inappropriate behavior or emotion, and particularly, if this emotion is depression or long term unhappiness. Students with emotional disorders typically have a very difficult time maintaining personal relationships with others, and these personal problems lead to physical symptoms in time. If the student has difficulty learning, but there is no intellectual or sensory cause of this difficulty, then an emotional disorder may be to blame. This disability category does include some mental illnesses such as schizophrenia.

It should be noted that one or more of the previously mentioned characteristics has to be present for an extended period of time, and must have a negative impact on the student's academic performance before being considered an emotional disorder. Signs of an emotional disorder need to be taken seriously, as they can lead to physical aggression and self-injurious behavior. However, care must also be taken to recognize the difference between emotional disturbance and general teenage angst. There are as many causes of emotional disturbance in children as there are children in this category, but they can generally be divided into either biological causes, environmental causes, or a combination of the two.

Prevalence

The U.S. Department of Education reports 5,971,495 students receiving special education services in the 2003-2004 school year. Of that number, roughly 7.7%, or 461,055 students, received special education services based on a classification of emotional disturbance. However, within this group of 461,055 students, there was a definite disproportionally between gender, race and socioeconomic background. African-American students were far more likely to be diagnosed as emotionally disturbed than white students, reflecting possible race bias in this category. Research has pointed to a direct correlation between low income status and emotional disorders, but the exact reasons for this correlation are unknown.

Characteristics

Each student with an emotional disturbance will have characteristics that are unique to that individual. However, these students will all share deficits in three specific areas, namely emotional development, behavioral development, and cognitive development.

These students may have specific emotional characteristics/conditions such as anxiety disorder, mood disorder, oppositional defiant disorder, conduct disorder, and schizophrenia. Not addressing any one of these disorders with the appropriate support system could have potentially tragic results. Behavioral characteristics of an emotional disorder include externalizing behavior and conversely internalizing behavior. The former can result in problem behavior and physical aggression while the latter results in depression and anxiety. Finally, students with emotional disorders have a number of academic issues as well, and each year half of the students in this category drop out of school entirely.

One intriguing possible contributing factor to emotional disturbance can be found in deficits in communication. An estimated 71% of students with emotional disorders also have expressive and receptive language disorders that impact their ability to understand and communicate with peers and adults.

Impact on Learning

Students with emotional disorders can be found at every level of cognitive functioning, but the majority of these students tend to have low average intelligence. Most achieve below grade level in academic achievement, with the greatest deficits in both math and spelling. Many have a coexisting learning disability of some type. Students that exhibit externalizing behaviors are at the greatest risk for continued deficits in academic functioning. Students with emotional disorders are less likely to attend post-secondary school than students in many other disability categories. An effective educational program for students with emotional disorders will provide emotional and behavioral supports that foster the replacement of problem behaviors with more appropriate behaviors. Positive behavior support systems are one especially effective strategy to achieve this goal, as are the implementation of wraparound services.

Teaching Strategies

Wraparound planning is a collaborative process that has shown great promise in supporting students with emotional disorders, both in research and in more practical application. This planning process brings all of the involved service providers (i.e., adult rehabilitation services, mental health services, guidance counselor) and individuals together to create a natural support system that is founded on the strengths of the individual student and the community in which that student lives. The family is an integral part of this process, and the overall goal is to devise a program that will capitalize on the strengths and interests of the student while utilizing community resources for placement and intervention.

Generally, academic achievement and problem behaviors often go hand-in-hand for students with emotional disorders. To put this another way, the more difficulty they have with a classroom task, the more likely that maladaptive behavior will result. Supporting the academic performance of these students will thus have the added benefit of decreasing externalizing and internalizing behaviors. Best practices for students with emotional disorders are often best practices for all students. A strategy such as allowing students to choose between classroom tasks, for example, is an effective way to decrease problem behaviors in general. Consistent and specific praise is also a great technique to utilize with all students in the classroom, but can be particularly effective with students with emotional disorders.

It is very important to not make assumptions about any family of a child with an emotional disorder. Many emotional disorders have an organic cause, and the parents of the child may well be loving and supportive in every way. However, some of these students have indeed been abused in some fashion in their young lives, and this too can be a cause of emotional or behavioral issues. Trust can be a very large issue for these children. Forming a relationship with these students that is built on empathy, trust, and mutual respect can often be the solution to many problem behaviors, and can have a lasting impact of the emotional development of the child.

Assistive Technology

Some modification in instruction will be necessary to allow a student with an emotional disorder to demonstrate mastery in a number of academic areas, and most especially in the area of writing. Word processing software can be an excellent supplementary aid for these students, allowing them to edit and revise their work as they produce it. These programs can strengthen spelling skills and writing cohesion simply by making the writing process easier overall. Of particular benefit are word processing programs that read the text as it is typed, providing an additional audio cue for the student.

Organizations

There are a number of excellent organizations that can help support classroom instruction for students with emotional and behavioral disabilities. The information presented in this module is intended as just a very brief description of emotional disorder and its impact on learning. Much more in-depth information and instructional strategies can be accessed through the following organizations:

American Academy of Child and Adolescent Psychiatry

The AACAP (American Academy of Child and Adolescent Psychiatry) is the leading national professional medical association dedicated to treating and improving the quality of life for children, adolescents, and families affected by these disorders. Composed of over 7,500 child and adolescent psychiatrists and other interested physicians, its members actively research, evaluate, diagnose, and treat psychiatric disorders and pride themselves on giving direction to and responding quickly to new developments in addressing the health care needs of children and their families.

Public Information Office
3615 Wisconsin Ave., NW
Washington, DC 20016-3007

Web: www.aacap.org

Center on Positive Behavioral Interventions and Supports

The OSEP-funded National Technical Assistance Center on Positive Behavior and Intervention Supports was established to address the behavioral and discipline systems needed for successful learning and social development of students. The Center provides capacity-building information and technical support about behavioral systems to assist states and districts in the design of effective schools.

5262 University of Oregon
Eugene, OR 97403-5262

Email: pbis@oregon.uregon.edu
Web: www.pbis.org

Center for Disability and Development

Dept. of Educational Psychology
4225 Texas A&M University
College Station, TX 77843-4225

Council for Exceptional Children

The Council for Exceptional Children (CEC) is the largest international professional organization dedicated to improving educational outcomes for individuals with exceptionalities, students with disabilities, and/or the gifted. CEC advocates for appropriate governmental policies, sets professional standards, provides continual professional development, advocates for newly and historically underserved individuals with exceptionalities, and helps professionals obtain conditions and resources necessary for effective professional practice.

1110 North Glebe Road, Suite 300
Arlington, VA 22201-5704

Federation of Families for Children's Mental Health

This organization is dedicated exclusively to helping children with mental health needs and their families achieve a better quality of life. They provide leadership to develop and sustain a nationwide network of family-run organizations; focus the passion and cultural diversity of our membership to be a potent force for changing how systems respond to children with mental health needs and their families; help policy-makers, agencies, and providers become more effective in delivering services and supports that foster healthy emotional development for all children.

1101 King Street, Suite 420
Alexandria, VA 22314

Email: ffcmh@ffcmh.org
Web: www.ffcmh.org

National Alliance for the Mentally Ill (NAMI)

NAMI is the National Alliance on Mental Illness, the nation's largest grassroots organization for people with mental illness and their families. NAMI is dedicated to the eradication of mental illnesses and to the improvement of the quality of life for persons of all ages who are affected by mental illnesses. NAMI members and friends work to fulfill our mission by providing support, education, and advocacy.

Colonial Place Three
2107 Wilson Boulevard, Suite 300
Arlington, VA 22203-3754

Web: www.nami.org

Mental Health America

Mental Health America is dedicated to helping ALL people live mentally healthier lives. They work to fulfill this mission by education the public about ways to preserve and strengthen mental health; advocating for access to effective care; fostering innovation in research, practice, services and policy; and providing support to individuals and families.

2001 N. Beauregard Street, 12th Floor
Alexandria, VA 22311

Web: www.nmha.org

National Mental Health Information Center

The National Mental Health Information Center was developed for users of mental health services and their families, the general public, policy makers, providers, and the media. They provide free information about mental health via a toll-free number, their website, and more than 600 publications.

P.O. Box 42557
Washington, DC 20015

Web: www.mentalhealth.org

References

Hunt, N., and Marshall, K. (2006). Exceptional children and youth. Boston, MA: Houghton Mifflin Company.

National Dissemination Center for Children with Disabilities (2004). Fact Sheet 5. Retrieved February 1, 2008 from www.nichcy.org/pubs/factshe/fs5txt.htm.

Turnbull, A., Turnbull, R. & Wehmeyer, M. L. (2007). Exceptional lives. Special education in today's schools. Upper Saddle River, NJ: Pearson Merrill Prentice Hall.

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Students with emotional disorders typically have a hard time maintaining relationships, and these personal problems may lead to physical symptoms in time.

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What is your favorite school counseling anxiety resource? Testing season aside, students are experiencing record rates of anxiety. School counselors are leaders in the building to help students and staff understand and effectively manage anxiety.

Staff Book Study

Last year, my building focused on learning more about anxiety and how to better support students emotionally. We used Anxiety and Depression in the Classroom: A Teacher's Guide to Fostering Self-Regulation in the Classroom for a book study, and it is incredible. Written by a clinical psychologist, it explains clearly anxiety disorders, and provides straightforward tools and activities for educators. It sparked amazing discussions, gave everyone another perspective on supporting children, and provided concrete suggestions that staff implemented immediately. A truly wonderful resource to build confidence in supporting the emotional wellbeing of students.

- Gretchen at Speckled Moose Counseling

Engaging Videos

GoZen is an incredible program to help students build skills to manage anxiety! The program has animated videos that teach students how to change the way they think about problems, challenge their negative thinking patterns, and avoid cognitive distortions (or Thought Holes, as the program calls them). The videos are really engaging and practical with short exercises that can be practiced daily to reinforce learning. There are programs for both schools and parents, so it's also a great resource to recommend to parents who are looking for ways to help their children manage anxiety at home.

- Keri from Counselor Keri

Informative Website

Anxiety BC is a wonderful resource to help students develop coping skills to manage their anxiety. This website has a ton of information on anxiety disorders (handouts and videos), suggested treatment strategies, and worksheets. It's simple to navigate and I like that I have resources readily available to send home with students to give directions on how to practice what we worked on in session at home, and to keep parents updated on the strategies their child has learned.

- The Sunny Sunshine Student Support Store

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Favorite School Counseling Anxiety Resource - Confident Counselors

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What is your favorite school counseling anxiety resource? Testing season aside, students are experiencing record rates of anxiety. School counselors are leaders in the building to help students and staff understand and effectively manage anxiety. Last year, my building focused on learning more about anxiety and how to better support students emotionally.

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Many professionals have seen a rise in the number of students who are exhibiting symptoms of anxiety in schools. As school counselors, we know that anxiety disorders can significantly impair children's social skills and academic success. Therefore, it is important that we educate teachers and staff about the signs to look for in students who may be experiencing anxiety related disorders.

Family relationships, grades, friends, health concerns and extracurricular performance are all things students may obsess over. Other signs may be a student needing constant reassurance, frequent nurse visits, physical complaints of stomachaches, headache and other physical symptoms without a known cause. Students may also do other avoiding behaviors and may appear inattentive, restless or irritable. Anxiety can also cause perfectionism. Kids need to know that a small amount of worry is normal, but that knowing how to be in control of your worries is essential to succeed at school.

Most school counselors focus on teaching coping skills instead of trying to be anxiety free. Students with anxiety may benefit greatly from small groups or short-term individual counseling to best learn helpful coping skills. School counselors can also implement school-wide anxiety reduction programs to teach all students coping skills and to reach the students with anxiety who have not been identified.

To help students with anxiety succeed in the classroom, 504 accommodations may be provided. Students may also need an Individualized Education Plan (IEP) to address another diagnosed disability that may affect their learning, and can then receive support for their anxiety as well. Some beneficial accommodations on 504s could be preferred seating, being allowed breaks, small group or separate location for testing, support for classroom presentations or participation, and pre-warning about fire drills or other drills.

Helping students change their mindset about their anxiety is crucial to their success. Helping students see their anxiety as a positive instead of a negative can empower them to learn about their anxiety, their triggers, and the best coping skills for them.

We experienced this with one student who was experiencing high anxiety in class and could never pinpoint a trigger. Over time, we were able to identify when she was experiencing an anxiety attack and the best methods for her to be able to return to class. She brought her own small "coping toolkit" to leave in the school counseling office for when she needed it. We developed a hand signal with her classroom teacher so the student could let her teacher know if she felt an anxiety attack coming on and needed to leave the room. Eventually, she was able to stay in the classroom and work through her anxiety without needing to leave and come to my office. It may take time for students to experience this type of success; however, the lifelong benefit is well worth it!

Kelli Conraads is WySCA president-elect and April Petty is WySCA treasurer and past president.

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How School Counselors Can Help with Anxiety - American School Counselor Association (ASCA)

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Many professionals have seen a rise in the number of students who are exhibiting symptoms of anxiety in schools. As school counselors, we know that anxiety disorders can significantly impair children’s social skills and academic success. Therefore, it is important that we educate teachers and staff…

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National Institute of Mental Health (NIMH)

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What is anxiety?

Occasional anxiety is a normal part of life. Many people worry about things such as health, money, or family problems. But anxiety disorders involve more than temporary worry or fear. For people with an anxiety disorder, the anxiety does not go away and can get worse over time. The symptoms can interfere with daily activities such as job performance, schoolwork, and relationships.

There are several types of anxiety disorders, including generalized anxiety disorder, panic disorder, social anxiety disorder, and various phobia-related disorders.

What are the signs and symptoms of anxiety?

What are the risk factors for anxiety?

How is anxiety treated?

How can I find a clinical trial for anxiety?

Where can I learn more about anxiety?

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Learn about anxiety disorders, including signs and symptoms, types, risk factors, and potential treatments and therapies.

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Individuals with Disabilities Education Act

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Individuals with Disabilities Education Act (IDEA)

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The U.S. Department of Education’s Individuals with Disabilities Education Act website brings together department and grantee IDEA information and resources. The IDEA makes available a free appropriate public education to and ensures special education and related services to eligible children with disabilities.

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Working to deliver a better special education service

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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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The difference between IEPs and 504 plans

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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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Home - ADDA - Attention Deficit Disorder Association

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Empowering adults with adhd to live their best lives A Different Brain Requires a Different Approach Whether you're newly diagnosed, wondering if you have ADHD, or simply ready to take charge of your life - we're here to help. Have ...

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Therapy for ODD, Oppositional and Defiant Disorder

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Oppositional defiant disorder (ODD) is a condition that generally appears in childhood. It is characterized by defiant, hostile behavior that is not developmentally appropriate. Parents and caregivers who are concerned about a child's disruptive behavior or defiance may wish to seek out a mental health professional, as therapy can often help treat ODD and may both prevent a child's behavior from worsening and reduce the risk that other mental health issues will develop.

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Thermoregulatory Fear of Harm Mood Disorder* is a legitimate psychiatric disorder with a known effective treatment.

Learn About This Groundbreaking New Diagnosis, How To Recognize It, And How To Treat It.

Help your patients and be a part of ushering in a new era in mental healthcare.

JBRF researchers have identified a biological marker for Fear of Harm

This is the first biomarker ever associated with a mental illness

Thermodysregulation results in both somatic and behavioral symptoms

Medications that treat the biological dysfunction resolves these symptoms

Diagnostic Criteria

1) Episodic and Abrupt Transitions in Mood States

2) Fear of Harm

3) Thermoregulatory Disturbance

4) Aggression

5) Sleep/Wake Disturbances

6) Symptoms Are Not Due to a General Medical Condition

7) A Family History of Recurrent Mood Disorder or Alcoholism

Learn More

The Fear of Harm Training Courses are custom designed for clinicians and prescribers. Each course teaches how to recognize, diagnose, and treat Fear of Harm whether you are a  professional counselor, social worker, psychologist, MD, APN, or CNP. These courses will support you as you help children and families get their lives back.

JBRF sponsored work has developed the world’s largest data set of symptoms experienced by children at risk for, or diagnosed with, bipolar disorder.

From this, investigators have defined a syndrome called Fear of Harm (FOH), a severe and often treatment-resistant illness.

1/3 of the children and adults diagnosed with bipolar disorder likely have Fear of Harm.

Investigators have been able to describe a neuroanatomical model of the illness and have determined that problems with body temperature regulation underlie the condition.

Studies are underway to explore the observed effectiveness of ketamine to reduce the symptoms of FOH.

Testing for Bipolar Disorder and Fear of Harm

Clinician's Pathway Program

Dr. Demitri Papolos, author of the best selling book The Bipolar Child, has developed an online tool to help diagnose juvenile onset bipolar disorder accurately.

Dr. Papolos’s private practice offers a diagnostic assessment program for juvenile bipolar disorder designed for use in clinical and research settings to screen for bipolar disorder in children from parent and child reports.

Click here to access an existing account or here to create a new account.

For any questions about account access, scoring, or fees, please direct all questions to Dr. Papolos’s administrator:

CPP@drpapolos.com

*Illustrated by Karl Gude, director of graphic design at Newsweek magazine

Through Dr. Papolos’s private practice parents can take the Child Bipolar Questionnaire, or children can take the Jeannie and Jeffrey Illustrated Interview for Children. These are the only diagnostic tools designed specifically for children with bipolar disorder.

Dr. Papolos’s private practice is responsible for all issues relating to account development, access, scoring, and scoring fees. Please direct all question to his administrator: CPP@drpapolos.com

The Professionals Training Program

Access the most up to date information uncovered by JBRF researchers as they learn more about Fear of Harm in clinical research studies.

Join supervision sessions led by a trained professional as you learn how to successfully diagnose and effectively treat Fear of Harm.

Develop the competency to add treatment of Fear of Harm to the menu of services you offer to your clients and patients.

To become a part of this program please contact us.

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Professionals - Juvenile Bipolar Research Foundation

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Thermoregulatory Fear of Harm Mood Disorder* is a legitimate psychiatric disorder with a known effective treatment. Learn About This Groundbreaking New Diagnosis, How To Recognize It, And How To Treat It. Help your patients and be a part of ushering in a new era in mental healthcare. JBRF researcher…

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What Teachers Should Know

Even the best-behaved students occasionally can be difficult. But kids and teens who display a continual pattern of tantrums, arguing, and angry or disruptive behavior toward teachers, parents, or other authority figures may have oppositional defiant disorder (ODD).

Students with ODD can be so uncooperative and combative that their behavior affects their ability to learn and get along with classmates and teachers. It can lead to poor school performance, anti-social behaviors, and poor impulse control.

ODD is more common in boys than girls. Signs of ODD generally develop during preschool years, and are almost always present before early teens.

Symptoms of ODD can be hard to distinguish from other mental health disorders. Children and teens with ODD may also have:

Behaviors associated with ODD can be mild, moderate, or severe and include:

negativity

being argumentative and defiant

disobedience

hostility toward authority figures

temper outbursts

angry and irritable mood

Students with ODD might need:

seating closer to the teacher to avoid disrupting other students

breaks from classroom activities when they feel overwhelmed

more time to complete assignments

to consult with a school counselor or psychologist

to visit the school nurse to take medication for coexisting conditions, such as ADHD

an individualized education program (IEP) if a learning disability is associated with their ODD

ODD treatment involves therapy, training to help build positive interactions, and sometimes medications to treat related mental health conditions.

What Teachers Can Do

It can be difficult to recognize the differences between a strong-willed or emotional student and one with ODD.

Post classroom rules and review them regularly. Have a plan in place to handle serious behavior problems. Students with ODD often are isolated and lack friends. They may be the targets of bullies or be seen as bullies.

Be sensitive to self-esteem issues. Provide feedback to your student with ODD in private, and avoid asking the student to perform difficult tasks in front of classmates. It can be helpful to praise positive behaviors, such as staying seated, not calling out, taking turns, and being respectful.

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Oppositional Defiant Disorder Factsheet (for Schools)

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Even the best-behaved students occasionally can be difficult. But kids and teens who display a continual pattern of tantrums, arguing, and angry or disruptive behavior toward teachers, parents, or other authority figures may have oppositional defiant disorder (ODD). Students with ODD can be so uncooperative and combative that their behavior affects their ability to learn and get along with classmates and teachers.

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Not all students who have disabilities require specialized instruction. For students with disabilities who do require specialized instruction in the United States, the IDEA controls the procedural requirements and an IEP is developed. "Special education" under IDEA means the child has been identified as having unique educational needs related to his/her disability and is entitled to an Individualized Education Program (IEP) to meet these needs.

The IDEA process is more involved than that of Section 504 of the Rehabilitation Act. The IDEA requires that measurable growth and progress towards written goals and objectives be documented.

For students with disabilities who do not require specialized instruction but need the assurance that they will receive equal access to public education and services, a document is created to outline their specific accessibility requirements. Section 504 is a federal civil rights law. The purpose of Section 504 is to protect persons with disabilities against discrimination for reasons related to their disabilities.

While students with a 504 plan do not require specialized instruction, and specific goals and objectives are not necessarily outlines nor is data tracked, the plan should be reviewed annually to ensure that the student is receiving the most effective accommodations for his/her specific circumstances.

Unlike IDEA, Section 504 does not guarantee that a child with a disability will receive an individualized educational program that is designed to meet the child's individual educational needs. Rather, it guarantees that accommodations will be made relative to their specific medical needs.

Eligibility for protections under Section 504 depends on the child in question having a physical or mental impairment which must substantially limit at least one major life activity. Major life activities include walking, seeing, hearing, speaking, breathing, learning, reading, writing, performing math calculations, working, caring for oneself, and performing manual tasks. Section 504 requires an evaluation that draws information from a variety of sources.

A child who receives Section 504 protections has fewer rights than the child who receives special education services under the IDEA. The child who receives special education services under the IDEA is automatically protected under Section 504.

Section 504 is designed to guarantee that children with disabilities will not be discriminated against. It is also important to understand that if your child does not qualify for special education services under IDEA, your child does not have the procedural protections that are available under the IDEA.

Under Section 504, the child with a disability may receive accommodations and modifications that are not available to children who are not disabled. These accommodations and modifications are also available under IDEA. For example; accommodations could include, but not be limited to, such things as:

Tests taken in a separate location with time limits waived or extended.

The use of a word processor due to fine motor, visual motor deficits.

Shortened assignments.

Standardized tests answers written directly in the test booklet and transferred onto answer sheet by teacher or assistant.

Class notes provided rather than having the student copy from the chalkboard or overhead.

Allowing the child to leave the classroom 2 to 3 minutes early to avoid crowded hallways.

Preferential seating in the classroom.

Provision of a daily assignment sheet to be filled out by the student and verified by the teacher for accuracy. The parent could then check to make sure that all the work is accomplished. This would assist with homework prioritizing and management.

Please note: These are simply examples. All or none of these may be suitable for your child.

Students with bipolar disorder may or may not have a need for specialized instruction provided within an IEP. For some students, simply being granted accommodations that make allowance for the side effects of medications, related anxiety issues, or results of mood changes is sufficient.

Students with bipolar disorder who are well-controlled on medication may or may not be plagued by racing thoughts, distracting thoughts, an inability to concentrate, decreased energy; all of which will require modifications in the teaching environment or instructional strategies.

For other students, the side effects of medications may be significant enough to require changes in instruction provided or curriculum modifications. Some of the common side effects of medications include: tremors (trembling of hands), blurred vision, loss of coordination, slurred speech, sedation, ataxia (unsteady movement), dizziness, seizures. Some students with bipolar disorder may also have one of a number of other disabilities that impacts their access to the general education curriculum; such as vision or hearing impairment, learning disability, processing problems, or other disability. The co-morbidity rates of ADHD, anxiety disorder, conduct disorder, oppositional-defiant disorder and learning disabilities in students with bipolar disorder tell us that we should explore all avenues available to meet the educational needs of our children.

The following accommodations are meant to serve as a resource for parents unsure of what possibilities exist:

Students on some medications may need:

increased access to water, unlimited access to restrooms (particularly students taking Lithium)

decreased reading assignments or having books on tape or computer screen-reading due to blurred vision

modified school arrival, shortened day, scheduling of core content during the student's most alert time, reducing homework and extending deadlines, providing notes, allowing longer or more frequent breaks, allowing exercise or other movement due to sleep impairment or to sedation of medications

provision of notes and listening guides, work monitoring, extended time on assignments, extra set of books for home use, breaking assignments into more manageable pieces, use of checklists, providing written instructions and/or other visual cues, use of word banks on fill-in types of tests and other modifications that aid retrieval/memory, testing in a separate room, or extended test time, use of multiple choice formats, use of oral exams rather than written demands, use of noise-canceling headsets, - all for impaired concentration, memory

reducing or discontinuing homework may be necessary for some students due to difficulties with concentration, sleep patterns, mood irritability. For these students it may be necessary to schedule a resource room period at the beginning of the day to get assignments ready for the day, or at the end of the day to complete assignments before leaving school

preferential seating can be used to help with vision, focus, reduce visual or auditory distraction, allow for discrete monitoring

and while a 504 plan will simply list the type of accommodation needed and the reasons for it/them, an IEP must contain objectives that are written with specific criteria; such as -Given a grade level reading assignment of 1 chapter with 4 comprehension questions, (name) will answer the questions with 60/70/80% accuracy. Or given an assignment containing 5 long division problems, (name) will complete 3/4/5 problems at 80% accuracy.

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Accommodations for Students with Bipolar Disorder and Related Disabilities - International Bipolar Foundation

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Obsessive-Compulsive Disorder In Children And Adolescents

No. 60; Updated October 2018

Obsessive-compulsive disorder (OCD) usually begins in adolescence or young adulthood and is seen in as many as 1 in 200 children and adolescents. OCD is characterized by recurrent intense obsessions and/or compulsions that cause severe discomfort and interfere with day-to-day functioning. Obsessions are recurrent and persistent thoughts, impulses, or images that are unwanted and cause marked anxiety or distress. Frequently, they are unrealistic or irrational. They are not simply excessive worries about real-life problems or preoccupations. Compulsions are repetitive behaviors or rituals (like hand washing, keeping things in order, checking something over and over) or mental acts (like counting, repeating words silently, avoiding). In OCD, the obsessions or compulsions must cause significant anxiety or distress, or interfere with the child's normal routine, academic functioning, social activities, or relationships.

The obsessive thoughts may vary with the age of the child and may change over time. A younger child with OCD may have persistent thoughts that harm will occur to himself or a family member, for example an intruder entering an unlocked door or window. The child may compulsively check all the doors and windows of his home after his parents are asleep in an attempt to relieve anxiety. The child may then fear that he may have accidentally unlocked a door or window while last checking and locking, and then must compulsively check over and over again.

An older child or a teenager with OCD may fear that he will become ill with germs, AIDS, or contaminated food. To cope with his/her feelings, a child may develop "rituals" (a behavior or activity that gets repeated). Sometimes the obsession and compulsion are linked; "I fear this bad thing will happen if I stop checking or hand washing, so I can't stop even if it doesn't make any sense."

Research shows that OCD is a brain disorder and tends to run in families, although this doesn't mean the child will definitely develop symptoms if a parent has the disorder. A child may also develop OCD with no previous family history.

Children and adolescents often feel shame and embarrassment about their OCD. Many fear it means they're crazy and are hesitant to talk about their thoughts and behaviors. Good communication between parents and children can increase understanding of the problem and help the parents appropriately support their child.

Most children with OCD can be treated effectively with a combination of psychotherapy (especially cognitive and behavioral techniques) and certain medications, for example, serotonin reuptake inhibitors (SSRIs). Family support and education are also central to the success of treatment. Seeking help from a child and adolescent psychiatrist is important both to better understand the complex issues created by OCD as well as to get treatment

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obsessive-compulsive disorder in children and adolescents ocd

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Obsessive-Compulsive Disorder In Children And Adolescents

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Obsessive-Compulsive Disorder In Children And Adolescents No. 60; Updated October 2018 Obsessive-compulsive disorder (OCD) usually begins in adolescence or young adulthood and is seen in as many as 1 in 200 children and adolescents. OCD is characterized by recurrent intense obsessions and/or compulsions that cause severe discomfort and interfere with day-to-day functioning.

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Child Mind Institute | Transforming Children’s Lives.

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The Child Mind Institute is an independent nonprofit dedicated to transforming the lives of children struggling with mental health and learning disorders.

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Definition

Students with emotional disorders are a very heterogeneous group with a wide range of issues that are unique to each individual. However, there are some key characteristics that are used to define this disability category, mostly relating to issues of personal identity and emotional well-being. An emotional disorder may be present if a student responds to a situation with an inappropriate behavior or emotion, and particularly, if this emotion is depression or long term unhappiness. Students with emotional disorders typically have a very difficult time maintaining personal relationships with others, and these personal problems lead to physical symptoms in time. If the student has difficulty learning, but there is no intellectual or sensory cause of this difficulty, then an emotional disorder may be to blame. This disability category does include some mental illnesses such as schizophrenia.

It should be noted that one or more of the previously mentioned characteristics has to be present for an extended period of time, and must have a negative impact on the student's academic performance before being considered an emotional disorder. Signs of an emotional disorder need to be taken seriously, as they can lead to physical aggression and self-injurious behavior. However, care must also be taken to recognize the difference between emotional disturbance and general teenage angst. There are as many causes of emotional disturbance in children as there are children in this category, but they can generally be divided into either biological causes, environmental causes, or a combination of the two.

Prevalence

The U.S. Department of Education reports 5,971,495 students receiving special education services in the 2003-2004 school year. Of that number, roughly 7.7%, or 461,055 students, received special education services based on a classification of emotional disturbance. However, within this group of 461,055 students, there was a definite disproportionally between gender, race and socioeconomic background. African-American students were far more likely to be diagnosed as emotionally disturbed than white students, reflecting possible race bias in this category. Research has pointed to a direct correlation between low income status and emotional disorders, but the exact reasons for this correlation are unknown.

Characteristics

Each student with an emotional disturbance will have characteristics that are unique to that individual. However, these students will all share deficits in three specific areas, namely emotional development, behavioral development, and cognitive development.

These students may have specific emotional characteristics/conditions such as anxiety disorder, mood disorder, oppositional defiant disorder, conduct disorder, and schizophrenia. Not addressing any one of these disorders with the appropriate support system could have potentially tragic results. Behavioral characteristics of an emotional disorder include externalizing behavior and conversely internalizing behavior. The former can result in problem behavior and physical aggression while the latter results in depression and anxiety. Finally, students with emotional disorders have a number of academic issues as well, and each year half of the students in this category drop out of school entirely.

One intriguing possible contributing factor to emotional disturbance can be found in deficits in communication. An estimated 71% of students with emotional disorders also have expressive and receptive language disorders that impact their ability to understand and communicate with peers and adults.

Impact on Learning

Students with emotional disorders can be found at every level of cognitive functioning, but the majority of these students tend to have low average intelligence. Most achieve below grade level in academic achievement, with the greatest deficits in both math and spelling. Many have a coexisting learning disability of some type. Students that exhibit externalizing behaviors are at the greatest risk for continued deficits in academic functioning. Students with emotional disorders are less likely to attend post-secondary school than students in many other disability categories. An effective educational program for students with emotional disorders will provide emotional and behavioral supports that foster the replacement of problem behaviors with more appropriate behaviors. Positive behavior support systems are one especially effective strategy to achieve this goal, as are the implementation of wraparound services.

Teaching Strategies

Wraparound planning is a collaborative process that has shown great promise in supporting students with emotional disorders, both in research and in more practical application. This planning process brings all of the involved service providers (i.e., adult rehabilitation services, mental health services, guidance counselor) and individuals together to create a natural support system that is founded on the strengths of the individual student and the community in which that student lives. The family is an integral part of this process, and the overall goal is to devise a program that will capitalize on the strengths and interests of the student while utilizing community resources for placement and intervention.

Generally, academic achievement and problem behaviors often go hand-in-hand for students with emotional disorders. To put this another way, the more difficulty they have with a classroom task, the more likely that maladaptive behavior will result. Supporting the academic performance of these students will thus have the added benefit of decreasing externalizing and internalizing behaviors. Best practices for students with emotional disorders are often best practices for all students. A strategy such as allowing students to choose between classroom tasks, for example, is an effective way to decrease problem behaviors in general. Consistent and specific praise is also a great technique to utilize with all students in the classroom, but can be particularly effective with students with emotional disorders.

It is very important to not make assumptions about any family of a child with an emotional disorder. Many emotional disorders have an organic cause, and the parents of the child may well be loving and supportive in every way. However, some of these students have indeed been abused in some fashion in their young lives, and this too can be a cause of emotional or behavioral issues. Trust can be a very large issue for these children. Forming a relationship with these students that is built on empathy, trust, and mutual respect can often be the solution to many problem behaviors, and can have a lasting impact of the emotional development of the child.

Assistive Technology

Some modification in instruction will be necessary to allow a student with an emotional disorder to demonstrate mastery in a number of academic areas, and most especially in the area of writing. Word processing software can be an excellent supplementary aid for these students, allowing them to edit and revise their work as they produce it. These programs can strengthen spelling skills and writing cohesion simply by making the writing process easier overall. Of particular benefit are word processing programs that read the text as it is typed, providing an additional audio cue for the student.

Organizations

There are a number of excellent organizations that can help support classroom instruction for students with emotional and behavioral disabilities. The information presented in this module is intended as just a very brief description of emotional disorder and its impact on learning. Much more in-depth information and instructional strategies can be accessed through the following organizations:

American Academy of Child and Adolescent Psychiatry

The AACAP (American Academy of Child and Adolescent Psychiatry) is the leading national professional medical association dedicated to treating and improving the quality of life for children, adolescents, and families affected by these disorders. Composed of over 7,500 child and adolescent psychiatrists and other interested physicians, its members actively research, evaluate, diagnose, and treat psychiatric disorders and pride themselves on giving direction to and responding quickly to new developments in addressing the health care needs of children and their families.

Public Information Office
3615 Wisconsin Ave., NW
Washington, DC 20016-3007

Web: www.aacap.org

Center on Positive Behavioral Interventions and Supports

The OSEP-funded National Technical Assistance Center on Positive Behavior and Intervention Supports was established to address the behavioral and discipline systems needed for successful learning and social development of students. The Center provides capacity-building information and technical support about behavioral systems to assist states and districts in the design of effective schools.

5262 University of Oregon
Eugene, OR 97403-5262

Email: pbis@oregon.uregon.edu
Web: www.pbis.org

Center for Disability and Development

Dept. of Educational Psychology
4225 Texas A&M University
College Station, TX 77843-4225

Council for Exceptional Children

The Council for Exceptional Children (CEC) is the largest international professional organization dedicated to improving educational outcomes for individuals with exceptionalities, students with disabilities, and/or the gifted. CEC advocates for appropriate governmental policies, sets professional standards, provides continual professional development, advocates for newly and historically underserved individuals with exceptionalities, and helps professionals obtain conditions and resources necessary for effective professional practice.

1110 North Glebe Road, Suite 300
Arlington, VA 22201-5704

Federation of Families for Children's Mental Health

This organization is dedicated exclusively to helping children with mental health needs and their families achieve a better quality of life. They provide leadership to develop and sustain a nationwide network of family-run organizations; focus the passion and cultural diversity of our membership to be a potent force for changing how systems respond to children with mental health needs and their families; help policy-makers, agencies, and providers become more effective in delivering services and supports that foster healthy emotional development for all children.

1101 King Street, Suite 420
Alexandria, VA 22314

Email: ffcmh@ffcmh.org
Web: www.ffcmh.org

National Alliance for the Mentally Ill (NAMI)

NAMI is the National Alliance on Mental Illness, the nation's largest grassroots organization for people with mental illness and their families. NAMI is dedicated to the eradication of mental illnesses and to the improvement of the quality of life for persons of all ages who are affected by mental illnesses. NAMI members and friends work to fulfill our mission by providing support, education, and advocacy.

Colonial Place Three
2107 Wilson Boulevard, Suite 300
Arlington, VA 22203-3754

Web: www.nami.org

Mental Health America

Mental Health America is dedicated to helping ALL people live mentally healthier lives. They work to fulfill this mission by education the public about ways to preserve and strengthen mental health; advocating for access to effective care; fostering innovation in research, practice, services and policy; and providing support to individuals and families.

2001 N. Beauregard Street, 12th Floor
Alexandria, VA 22311

Web: www.nmha.org

National Mental Health Information Center

The National Mental Health Information Center was developed for users of mental health services and their families, the general public, policy makers, providers, and the media. They provide free information about mental health via a toll-free number, their website, and more than 600 publications.

P.O. Box 42557
Washington, DC 20015

Web: www.mentalhealth.org

References

Hunt, N., and Marshall, K. (2006). Exceptional children and youth. Boston, MA: Houghton Mifflin Company.

National Dissemination Center for Children with Disabilities (2004). Fact Sheet 5. Retrieved February 1, 2008 from www.nichcy.org/pubs/factshe/fs5txt.htm.

Turnbull, A., Turnbull, R. & Wehmeyer, M. L. (2007). Exceptional lives. Special education in today's schools. Upper Saddle River, NJ: Pearson Merrill Prentice Hall.

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Students with emotional disorders typically have a hard time maintaining relationships, and these personal problems may lead to physical symptoms in time.

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Substance Abuse and Mental Health Services Administration

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Frequently Asked Questions - What is SAMHSA’s National Helpline?

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Each child is an individual with different social, emotional, and academic strengths and weaknesses. Therefore, their educational needs may vary from one season or school year to the next.

In the first section of our chapter, "School: A Child's World Beyond Home" we cover the legal evolution of the Individual with Disabilities Educational Act (IDEA 2004) and advise a parent how to initiate an Individual Education Plan (IEP), prepare for the IEP meeting (including rehearsal strategies), and locate educational consultants and attorneys.

But the more we talked to people in preparation for this chapter, the more we came to understand that both parents and educators were confused about the construction of an IEP for a student struggling with a bipolar disorder. A model IEP-one that specifically addresses the seasonal variations in mood, energy, attention, motivation, and behavior, as well as one that addresses the frequently co-occurring executive function deficits, needed to be developed.

Therefore, we asked special education advocate, Anne Marie Smith, M. Ed., from Agawam, Massachusetts, to construct an IEP that might provide guidelines for educating a middle school student throughout the school year.

With the hope that the following information is helpful to parents and educators alike, we excerpt the following from The Bipolar Child (pages 305-311.) Also see pages 295-303 in the book for a highly focused and very comprehensive list of accommodations, modifications, and special services that can be incorporated into an IEP.
From The Bipolar Child by Demitri Papolos, M.D. and Janice Papolos (Broadway Books, 2006). All rights reserved.

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Bipolar Children Individual Education Plan (IEP) Model

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Each child is an individual with different social, emotional, and academic strengths and weaknesses. Therefore, their educational needs may vary from one season or school year to the next.

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"We initially chose IRIS because of the past experiences and their credible research-based, high-quality modules that align with specific areas of growth and need to support a state-directed corrective action plan in our region."

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"We initially chose IRIS because of the past experiences and their credible research-based, high-quality modules that align with specific areas of growth and need to support a state-directed corrective action plan in our region."

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What Teachers Should Know

Bipolar disorder affects how the brain functions, causing shifts in a person's moods and energy levels. It's also called manic depression, manic-depressive disorder, manic-depressive illness, bipolar mood disorder, and bipolar affective disorder.

People with bipolar disorder go through episodes of low-energy depression and high-energy mania.

Depression episodes may include:

sadness or feelings of worthlessness or guilt

loss of interest in usual activities

sleeping too much or inability to sleep

inability to concentrate and a drop in academic performance

inability to experience pleasure

overeating or loss of appetite

thoughts of death or suicide

Mania episodes may include:

increased physical and mental activity

racing speech and thoughts

elevated mood and exaggerated optimism

inflated sense of self-importance

decreased need for sleep

difficulty concentrating

reckless or aggressive behavior

anger, excessive irritability, or impatience

poor judgment and making rash decisions

In adults, mania or depression episodes can last weeks or months. In kids and teens, episodes can be much briefer, going back and forth between mania and depression throughout a day.

Without treatment, bipolar disorder can worsen as children get older. But following a medication treatment plan and making a few lifestyle changes - like eating a nutritious diet, getting enough sleep, exercising regularly, and managing stress - can help kids and teens with bipolar disorder control the symptoms and lead normal lives.

Students with bipolar disorder may:

need seating near the front of the room to help avoid distractions

show drops in grades and changes in class participation

need additional time for tests and assignments or require modified schedules

miss class time due to appointments with health care professionals

need to visit the school nurse for medication

need to carry a water bottle and have unlimited access to restrooms (especially students taking lithium)

need to talk with a school counselor or psychologist periodically

be at a higher risk for suicide

What Teachers Can Do

Treatment for bipolar disorder usually involves the use of medications, such as mood stabilizers, and counseling or psychotherapy. Teachers need to watch for extreme behavioral changes or any signs of suicidal thoughts. Educators should take these signs seriously. The student's parents or guardians, psychologist, or other health care professionals can talk to school staff about how to respond to such situations.

Encourage your students with bipolar disorder to participate in all school-based activities as best they can, when they can.

Plan and agree on a "safe place" with your student - a place to go if he or she feels overwhelmed or just needs to relax. You also can agree on a "safe person" (possibly you) your student can talk to. When your student needs to go to the safe place or talk with the safe person, allow for a discreet exit without drawing his or her classmates' attention.

If the student does not have an individualized education plan (IEP) or a 504 education plan, consult with a school counselor, psychologist, or social worker to see if developing a plan with parents or guardians would help. If the student does have an IEP or 504, make sure to follow the plan's requirements.

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bipolar mood disorder and bipolar affective disorder

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Bipolar Disorder Factsheet (for Schools)

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Bipolar disorder affects how the brain functions, causing shifts in a person's moods and energy levels. It's also called manic depression, manic-depressive disorder, manic-depressive illness, bipolar mood disorder, and bipolar affective disorder. People with bipolar disorder go through episodes of low-energy depression and high-energy mania.

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By Laurie L. Hayes, Special to Counseling Today

As many as one in 10 children may have a conduct disorder, according to the U.S. Department of Health and Human Services. Conduct disorders are characterized by the repeated violation of personal or property rights of others and the basic expectations of society. It is among the more difficult behavior disorders to diagnose and even harder to treat.

Some signs of the disorder include aggressive behavior that harms or threatens other people or animals, destruction of property, lying and/or theft. Diagnosis is usually contingent on the exhibition of three or more of these behaviors over the past year and at least one in the six months prior to evaluation.

It is important to note that while "bullying" is common in children with conduct disorder, mental health experts stress that the condition goes far beyond self-assertive or antisocial behavior or isolated incidents of misconduct.

"We're talking about unusual and serious violations of rules," said Jeff Cochran, a counseling psychologist at Georgia Southern University. "A diagnosis of conduct disorder is not based on just a single incident. The behavior permeates the child's life"

Cochran said that children with conduct disorder rarely respond to punishment or any sort of rewards system for good behavior. In fact, he notes, the negative behaviours are likely to escalate along with the punishment.

Most childhood conduct disorders become apparent by age 10, Cochran said, although signs can begin to appear as early as five years of age. Conduct disorders are often seen in conjunction with other problems including hyperactivity, anxiety, depression, academic difficulties or problems with peer relationships. Teachers are usually the first to express concern about the behavior as the child begins to disrupt the school environment or engage their instructors in a power struggle.

This is not to say that the child is not acting out at home as well, Cochran noted. "Parents are slower to refer their children for help, because they often have feelings of guilt about the child's behavior," he said. "In the [upward] spiral of punishment, they may be concerned that they crossed the line of child abuse."

Contributing factors

Children with conduct disorders also are likely come from chaotic home environments. "If both parents are present in the home, there is frequently difficulty in the marriage, said Cochran. In addition, according to the HHS Center for Mental Health Services, children with conduct disorders often experience a lack of supervision or guidance, frequent changes in caregivers, poverty and neglect. They also may surround themselves with a delinquent peer group.

While the exact cause of conduct disorder remains a mystery, obviously all of these issues play a significant role in the onset of the disorder. Researchers continue to investigate several psychological, sociological and biological theories. Most experts do agree that successful treatment depends, in part, on an early diagnosis and the resolution of some or all of these contributing factors.

Effective treatment of conduct disorder is difficult, but necessary, as the problem will not go away without intervention, according to experts. Drugs are usually not effective; therapy can be problematic, but appears to be the most promising approach. Even Cochran, who has years of experience counseling children with conduct disorders, admits to the difficulty.

"These kids are very frustrating to work with," he said. "We're not talking about short-term treatment, especially if the child is living in a home environment that is less than ideal."

By nature, these youngsters are hard to reach and unless the treatment has been mandated by a school or court (which may make them even more uncooperative), they may not attend scheduled sessions. Cochran said it will take at least 10 sessions a year to build a helping relationship. And because of the inevitable stress involved, he recommends that the counselor have other professionals they can consult with without breaking their promise of confidentiality.

At the root of conduct disorder, Cochran believes, is a child's feeling that "no one will love me." This feeling leads to fear, loneliness and anxiety and as these emotions intensify the child begins to drive others away to avoid rejection, according to Cochran.

It is because of this thought process that early intervention is so important, Cochran said, because "you can help these children change their emotional and belief system before it solidifies and is entrenched in their life.

"Through a counseling relationship, you can help these children collect evidence that disputes this thought pattern and show them that they are able to be loved and accepted by the counselor," he continued. Once a counselor is able to challenge their belief system, the children may be ready for a group setting.

Parental involvement

Ideally, any counseling should be done in conjunction with the parent (s) or guardian(s). HHS recommends developing a "system of care" that is designed to improve the child's ability to function in all areas of his or her life - at home, in school and in the community. Whenever possible, children should be involved in the decisions about their care.

In situations where the parents are not available or choose not to participate, it is possible to treat conduct disorder without parental involvement, Cochran said. The child can be challenged to incorporate his or her new belief system into the existing home environment. While this is obviously not the ideal, he said, it can work.

Cochran also points out that a large percentage of a child's life is spent in school which can be a tremendous support system, especially if the school counselor is involved in the child's treatment. However, he notes that some school counselors are hesitant to take on the task of counseling children with conduct disorder because of the difficulty in dealing with their behaviors and the significant commitment of time and energy.

Cochran admits that the time crunch faced by many school counselors could make it difficult for them to accept every suspected case of conduct disorder, but he insists that it is "both possible and important" for them to become involved with the most troubling cases.

"School counselors have access to first hand knowledge of the child's behavior, while an agency has second hand information at best," he said. "They are also in a position to advise and consult with other adults who the child regularly comes in contact with. Most importantly, school counselors are there if a crisis erupts. They can be there to help the child realize what is happening and help them rethink their behavior."

Cochran stressed that dealing with children with conduct disorders requires a great amount of patience, but quickly added that the rewards can more than make up for the frustration. If you get through to them, you are, in essence, showing them how to be loved, he said.

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Counseling children with conduct disorder

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As many as one in 10 children may have a conduct disorder, according to the U.S. Department of Health and Human Services. Conduct disorders are characterized by the repeated violation of personal or property rights of others and the basic expectations of society.

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What comes to mind when you hear OCD? Do you picture TV detective Adrian Monk refusing to touch door handles because of germs? Or maybe super-nerd Sheldon Cooper, who absolutely has to use the bathroom at the same time each day? These characters often get played for laughs, but living with Obsessive-Compulsive Disorder, often called OCD, is no joke. The obsessions these people experience, and the compulsions they develop to deal with them, can keep them from leading satisfying lives. Students with OCD often struggle academically and socially. Here's how teachers can help.

What is OCD?

According to Child Mind, OCD is an anxiety condition that plagues a person with unwanted thoughts, images, or impulses called obsessions. The International OCD Foundation estimates that as many as 1 in 200 children have OCD. In an average elementary school, there are at least four or five kids with OCD and as many as 20 in a high school.

People with OCD have unreasonable fears that disrupt their daily lives. They might worry about contamination or fear that they'll suddenly become violent and hurt themselves or others. To cope with these anxieties, they develop repetitive and ritualized actions. These could include counting, locking and re-locking doors, lining up objects, hand-washing, or skin-picking. Those with OCD can get so involved in those behaviors that they're unable to focus on other tasks or function normally.

Children as young as five can develop OCD. It's most commonly diagnosed between the ages of 10 and 12 or between the late teens and early adulthood. To be diagnosed, someone must experience both obsessions and compulsions so strong that they disrupt normal life.

What does OCD look like in students?

For students with OCD, school can be a challenging and stressful place. They may appear to be daydreaming, distracted, uninterested, or lazy. In reality, they're hyper-focused on nagging urges and obsessive thoughts. Here's what that might look like specifically in your classroom. ( See a complete list here.)

Repetitive behaviors

This is one of the classic OCD behaviors. Those with OCD believe their behaviors are absolutely essential to their safety or the safety of others. They might believe that if they don't line up their pencils from smallest to largest, something terrible will happen to all their friends. They develop rituals like checking locks multiple times or reading a paragraph three times out loud before going on to the next one.

If a student with OCD has a bad thought when going through a door, for example, they may want to go back and "fix it." They will retrace steps and attempt to right the wrong of a bad thought or an item left in a room. Attempting to disrupt or deny these behaviors can lead to complete meltdowns.

Frequent bathroom breaks

The bathroom is a safe space for lots of students. Those with OCD may go there to be alone with their anxieties. If they have fears of contamination, they might be washing their hands or even school supplies obsessively. They might also retreat there to perform repetitive behaviors like skin-picking.

Focus on perfection

There's a difference between wanting to do your best and never feeling something is good enough. Students with OCD often focus on perfection. This leads them to spend an excessive amount of time on assignments and especially tests. They may also resist leaving a task unfinished and moving on to something else.

Compulsive erasing

Given that need for perfection, students with OCD especially struggle with writing. They may write and re-write something over and over, erasing it until there are holes in the page. Or, a minor error may cause them to scribble all over the page, trying to make the problem disappear.

Lack of focus

There are many reasons students can appear distracted. But those with OCD are usually dealing with intrusive and obsessive thoughts. For instance, they may be counting the number of red objects in the room, and fear if they miss one, a family member could die. Not surprisingly, those sorts of thoughts make it very hard to concentrate on schoolwork.

Fear of contamination

Many people with OCD have a severe fear of germs and dirt. This leads to compulsive hand-washing (sometimes to the point that their hands bleed). It also means kids might avoid doing things like sitting on the floor, touching books in the library, or even joining in on a messy art project.

Difficulty with transitions

For many kids, moving from one subject or class to the next is as easy as scooping up their stuff and moving on. For kids with OCD, it's not that simple. Their items may need to be arranged just so. They might not want to leave unfinished work behind. And when they start the next subject or class, everything has to be arranged exactly right all over again.

Need for constant reassurance

To quell their anxieties, students with OCD seek constant assurance that everything is okay. They might ask the same question about how to complete an assignment over and over again, interrupting the teacher when everyone else has moved on. They'll straighten their books, check their backpack again and again to make sure everything is there, or apologize profusely for breaking a very small rule.

How can teachers support students with OCD?

Understanding OCD and its behaviors is a good first step. Students who are diagnosed with OCD often undergo cognitive behavioral therapy (CBT). An IEP/504 plan developed with their therapist may outline specific actions for schools and teachers to take.

Tip: Remember, accommodations aren't treatment. Sometimes you may be asked to do something that seems to be allowing behavior that you feel ought to be stopped. But that's up to a student and their doctor or therapist. As a teacher, you want to focus on how they can succeed in your classroom. Some of these actions might help. ( See more ideas here.)

Choose their place in the classroom carefully

Finding the right place for a student with OCD can be tricky. They might need to sit facing away from an object that causes obsessive thoughts. Eliminating distractions like noise or movement might help. Many students need a safe space to fidget, rock, or perform another calming behavior (unless they're actively working to overcome that action).

Make assignments manageable

Students with OCD see any assignment as a chance to make endless mistakes, and longer assignments are even worse. Help younger students by breaking assignments into shorter tasks (read just one paragraph or page at a time, or give them just one math problem rather than a whole worksheet). Teach older students to do the same for themselves.

Reduce test-taking anxiety

Tests are enough to raise anxiety in any kid, but they're a disaster for those seeking perfection. Ensure the test focuses on what you need to assess, and eliminate unnecessary distractions. If a student takes too long to write, let them type their answers. Some students with OCD have trouble with bubble sheets, feeling the need to fill in each circle perfectly. Is there another way to take the test? Can an aide fill in the sheet for them, allowing them to focus on the questions themselves?

Provide separate supplies

For students with fears about germs and contamination, shared supplies are a nightmare. Even when schools make special efforts to keep things clean, a person with OCD may not trust or believe. Give them their own set of supplies when possible. Hand them their worksheet first, so they know other students haven't touched it, and make sure they have books marked for their own particular use.

Give alternatives to writing

When writing isn't the focus, don't make it necessary for success. Let them provide information orally or use a computer to type their answers. Whenever possible, don't grade work on neatness or nitpick about items that don't apply to the learning at hand. (For instance, don't correct spelling on a science paper if it really doesn't make much of a difference.)

Consider audiobooks

When reading proficiency isn't the goal, audiobooks can be an excellent tool for students with OCD. Reading often takes them longer, as they obsessively go back over a paragraph again and again, so they don't miss anything. Audiobooks continue on their own, providing information at a more regular pace.

Set limits

Compulsive behaviors can continue on and on. Let a student know that you'll be limiting what's acceptable. Do they often disappear to the bathroom to perform a repetitive behavior? Limit their visits to a certain number per day, with a set number of allowed minutes. (Of course, you can make exceptions for illness, etc.) For students who ask questions repeatedly, give them a maximum number of times (say, 3) that you'll answer. When a student feels the need to check their supplies obsessively or wash their hands again and again, try limiting that to certain times of day. Communicate these limits clearly, and stick to them.

Acknowledge their fears

You might feel the need to attempt to reassure students their fears aren't really a problem. After all, you know perfectly well that the student won't get into a car accident on the way home if they accidentally step on a line in the tile floor. But that doesn't really help students with OCD. It's okay to acknowledge and validate their feelings, without agreeing that their fears are true. Knowing that you understand and accept them can make a big difference.

Don't use "OCD" lightly

It's become common for us to joke about being "so OCD" about something, like wanting desks to be lined up straight or grading with your favorite pen. But OCD is no joke to the people who have it. Consider your words carefully when you speak.

How can I connect with students with OCD?

Kids with OCD want to succeed and can get very frustrated that their own behavior is getting in the way. According to Denise Egan Stack, a behavioral therapist from the International OCD Foundation, building a relationship is the key to a successful learning experience. Some students with OCD seek teachers out for approval and reassurance. Others, though, may hide because they feel ashamed or don't want to cause trouble. In that case, a teacher may need to be the one to reach out.

Egan Stack notes that these students do well with set check-ins. Set aside time to meet and talk about how things are going. This can help students cross the barrier when they're tempted to hide and avoid dealing with their OCD. Instead, you can work together to make plans.

Build a team to support the student and make them a part of regular meetings as well. This team could include parents, school counselors, the student's therapist, and, of course, the student themselves.

OCD Resources for Teachers

The more you understand about OCD, the more you can help and support your students affected by it. Try these resources for more information.

Online

Books

How do you support students with OCD in your classroom? Come share your thoughts and ask for advice on the WeAreTeachers HELPLINE group on Facebook.

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How To Support Students With OCD (Obsessive-Compulsive Disorder)

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What comes to mind when you hear OCD? Do you picture TV detective Adrian Monk refusing to touch door handles because of germs? Or maybe super-nerd Sheldon Cooper, who absolutely has to use the bathroom at the same time each day? These characters often get played for laughs, but living with Obsessive-Compulsive Disorder, often called OCD, is no joke.

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eLearning Hub

This resource center is designed to equip you with knowledge, resources, and a sense of hope for the future - for yourself or someone else you care about.

Check out our eLearning Hub to learn more about common behavioral health conditions.

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Find Resources or a Provider | You're Not Alone | Mental Health Texas

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Mental Health Texas provides learning and treatment opportunities for those coping with mental health conditions and those who support them.

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School-Based Interventions for Students with Depressive Disorders

Professional School Counseling

Vol. 8, No. 4 (APRIL 2005), pp. 344-352 (9 pages)

Published By: Sage Publications, Inc.

https://www. jstor .org/stable/42732629

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School-Based Interventions for Students with Depressive Disorders on JSTOR

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Richard W. Auger, School-Based Interventions for Students with Depressive Disorders, Professional School Counseling, Vol. 8, No. 4 (APRIL 2005), pp. 344-352

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Feeding and Eating Disorders- Staff Presentation (1)

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Mental Health Support, Resources & Information | HealthyPlace

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Learn more about mental health disorders and treatments from a trusted source. Find support in our online community of HealthyPlace forums and blogs.

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"With good mental health literacy, we learn how to take better care of ourselves, our loved ones and our communities. We are empowered and provided with the skills that we need to help us build better lives, better systems of care and a better society." ~ Wei & Kutcher 2018
GET LITERATE The Elementary Mental Health Literacy Resource (EMHLR) is a classroom-ready resource designed to support multiple school environments, including in-person, online and hybrid instruction. With character-driven and developmentally-informed materials, the EMHLR engages students to:
build and maintain positive mental health
decrease stigma surrounding mental illness
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improve help-seeking skills LEARN MORE The Mental Health and High School Curriculum Guide provides a complete set of evidence-based, online modular resources proven to increase the understanding of mental health and mental disorders, decrease the stigma of mental illness and enhance help-seeking efficacy among both students and teachers. LEARN MORE The first publication of its kind, providing
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What are Mental Disorders? What is Brain Injury? What is Stigma? We need to know as much about our minds as we do our bodies. Check out our videos on our YouTube channel to learn more.

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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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Lo sentimos, la página que usted busca no se ha podido encontrar. Puede intentar su búsqueda de nuevo o visitar la lista de temas populares. 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.

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Eating disorders are complex illnesses that affect adolescents with increasing frequency. They rank as the third most common chronic illness in adolescent females ( 1), with an incidence of up to 5% ( 2, 3), a rate that has increased dramatically over the past three decades. Two major subgroups of the disorders are recognized: a restrictive form, in which food intake is severely limited (anorexia nervosa), and a bulimic form, in which binge eating episodes are followed by attempts to minimize the effects of overeating via vomiting, catharsis, exercise or fasting (bulimia nervosa). Both anorexia nervosa and bulimia nervosa can be associated with serious biological, psychological and sociological morbidity, and significant mortality.

Although eating disorders occur most frequently in adolescents, reports in the scientific literature often combine findings from adolescents with those from adults or report exclusively on adult samples. Unique features of adolescents and the developmental process of adolescence are often critical considerations in determining the diagnosis, treatment or outcome of eating disorders. Consequently, adolescents need to be considered separately and differentiated from adult patients with eating disorders. This position statement addresses the key issues distilled from the scientific literature and represents a consensus of numerous specialists in adolescent medicine regarding the diagnosis and management of adolescents with eating disorders.

DIAGNOSIS

Diagnostic criteria for eating disorders such as described in DSM-IV ( 4) may not be entirely applicable to adolescents. The wide variability in the rate, timing and magnitude of both height and weight gain during normal puberty; the absence of menstrual periods in early puberty along with the unpredictability of menses soon after menarche; and the lack of psychological awareness regarding abstract concepts (such as self-concept, motivation to lose weight or affective states) owing to normative cognitive development limit the application of those formal diagnostic criteria to adolescents. In addition, clinical features such as pubertal delay, growth retardation or the impairment of bone mineral acquisition may occur at subclinical levels of eating disorders ( 5, 6). The use of strict criteria may preclude the recognition of eating disorders in their early stages and subclinical form (a prerequisite for primary or secondary prevention), and may exclude some adolescents with significantly abnormal eating attitudes and behaviours, such as those who vomit or take laxatives regularly but do not binge ( 7- 9). Finally, abnormal eating habits may result in significant impairment in health ( 10), even in the absence of fulfilment of formal criteria for an eating disorder. For all of these reasons, it is essential to diagnose eating disorders in adolescents in the context of the multiple and varied aspects of normal pubertal growth, adolescent development and the eventual attainment of a healthy adulthood rather than by merely applying formalized criteria.

Position: In clinical practice, the diagnosis of an eating disorder should be considered in an adolescent patient who engages in potentially unhealthy weight control practices and/or demonstrates obsessive thinking about food, weight, shape or exercise and not only in one who meets established diagnostic criteria. In such adolescents, an eating disorder should be considered if the teenager fails to attain or maintain a healthy weight, height, body composition or stage of sexual maturation for sex and age.

MEDICAL COMPLICATIONS

No organ system is spared the effects of eating disorders ( 11- 15). Although the physical signs and symptoms occurring in a patient are primarily related to the weight control behaviours practised, the health care professional must consider their frequency, intensity and duration, as well as the biological vulnerability conferred by the sexual maturity of the patient. The majority of physical complications in adolescents with an eating disorder appear to improve with nutritional rehabilitation and recovery from the eating disorder, but some may be potentially irreversible. The long term consequences are still to be elucidated.

Medical complications in adolescents that are potentially irreversible include growth retardation if the disorder occurs before closure of the epiphyses ( 15- 18); pubertal delay or arrest ( 6, 16, 17); and impaired acquisition of peak bone mass during the second decade of life ( 6, 20, 21), increasing the risk of osteoporosis in adulthood. These features emphasize the importance of medical management and ongoing monitoring by physicians who understand normal adolescent growth and development.

Just as we endorse early recognition of eating disorders through the use of broad developmentally appropriate criteria, we also endorse early intervention to prevent, limit or ameliorate medical complications, some of which are life-threatening. Adolescents who restrict food intake, vomit, purge or binge in any combination, with or without severe weight loss, require treatment even if they do not meet strict criteria for an eating disorder.

Position: Because of the potentially irreversible effects of an eating disorder on physical and emotional growth and development in adolescents, because of the risk of death and because of evidence suggesting improved outcome with early treatment, the threshold for intervention in adolescents should be lower than in adults. Ongoing medical monitoring should continue until the adolescent has demonstrated a return to both medical and psychological health.

NUTRITIONAL DISTURBANCES

Nutritional disturbances are a hallmark of eating disorders and are related to the severity and duration of dysfunctional dietary habits. Although abnormalities of minerals, vitamins and trace elements can occur, they generally are not clinically recognized ( 22). Deprivation of energy (calories) and protein on the other hand are especially important to identify because these elements are crucial to growth ( 23). Moreover, there is evidence that adolescents with eating disorders may be losing critical tissue components, such as muscle mass, body fat and bone mineral ( 5, 21, 24), during a phase of growth when dramatic increases in these elements should be occurring. Complete and ongoing assessment of nutritional status is the basis of management of nutritional disturbances in adolescents with eating disorders.

Position: The evaluation and ongoing management of nutritional disturbances in adolescents with eating disorders should take into account the specific nutritional requirements of patients in the context of pubertal development and activity level.

PSYCHOSOCIAL DISTURBANCES

Eating disorders that develop during adolescence interfere with adjustment to pubertal development ( 25) and the accomplishment of the developmental tasks necessary to become a healthy functioning adult. Social isolation and family conflicts arise at a time when families and peers ought to provide a milieu to support development ( 1, 26). Issues related to self-concept, self-esteem, autonomy, separation from the family, the capacity for intimacy, affective disorders (eg, depression and anxiety) and substance abuse should be addressed in a developmentally appropriate manner ( 27).

All patients should be evaluated for co-morbid psychiatric illness, including disorders of anxiety, depression, dissociation and behaviour. Because adolescents usually live at home or interact with their families on a daily basis, the role of the family should be explored during both evaluation and treatment.

Position: All adolescents with an eating disorder should be evaluated for co-morbid psychiatric illness. Mental health intervention for adolescents with eating disorders should address not only the psychopathology characteristics of eating disorders, but also the accomplishment of the developmental tasks of adolescence and the specific psychosocial issues central to this age group. For most adolescents, family therapy should be considered as an important part of treatment.

TREATMENT GUIDELINES

Because of the complex biopsychosocial aspects of eating disorders in adolescents, the assessment and ongoing management of these conditions appear to be optimal with an interdisciplinary team consisting of professionals from medical, nursing, nutritional and mental health disciplines ( 27). Physical and occupational therapy may be useful adjuncts to treatment. Health care providers should have specific experience in treating eating disorders as well as expertise in working with adolescents and their families. They should be knowledgeable about normal adolescent physical and emotional development.

Both in-patient and out-patient treatments need to be available to adolescents with eating disorders ( 27, 28). Factors that would justify in-patient treatment include significant malnutrition, physiological or physical evidence of medical compromise (such as vital sign instability, dehydration or electrolyte disturbances) even in the absence of significant weight loss, arrested growth and development, failure of out-patient treatment, acute food refusal, uncontrollable binging, vomiting or purging, family dysfunction that prevents effective treatment, and acute medical or psychiatric emergencies ( 28). The goals of treatment are the same in a medical or psychiatric in-patient unit, a day program or out-patient setting: to help the adolescent achieve and maintain both physical and psychological health.

The expertise and dedication of the members of a treatment team who work specifically with adolescents and their families are more important than the particular setting. In fact, traditional settings such as a general psychiatric ward may be less appropriate than an adolescent medical unit, if one of the latter is available ( 18, 28- 30). Some evidence suggests that the outcome for patients treated in adolescent medicine units (both out-patient and in-patient) may be better than that of those treated in traditional psychiatric settings with adult patients ( 28- 30). Smooth transition from in-patient to out-patient care can be facilitated by an interdisciplinary team that provides continuity of care in a comprehensive, coordinated, developmentally oriented manner. Health care specialists with an interest in adolescents are familiar with working not only with the patient, but also with the family, school, coaches and other agencies or individuals who are important influences on healthy adolescent development. Given the evidence that eating disorders can be associated with relapse, recurrence, crossover and the later development of other psychiatric disorders, treatment should be of sufficient frequency, intensity and duration to provide effective intervention.

Position: Adolescents with eating disorders require evaluation and treatment focused on biological, psychological and social features of these complex, chronic health conditions. Assessment and ongoing management should be interdisciplinary and is best accomplished by a team consisting of medical, nursing, nutritional and mental health disciplines. Treatment should be provided by health care providers who have expertise in managing adolescent patients with eating disorders and are knowledgeable about normal adolescent physical and psychological development. Hospitalization of an adolescent with an eating disorder is necessary in the presence of malnutrition, clinical evidence of medical or psychiatric decompensation or failure of out-patient treatment. Ongoing treatment should be delivered with appropriate frequency, intensity and duration.

BARRIERS TO CARE

Interdisciplinary treatment of eating disorders can be time-consuming, relatively prolonged and extremely costly. Lack of access to appropriate interdisciplinary teams or insufficient treatment can result in chronicity, social or psychiatric morbidity, and even death. Some provincial plans limit access to private care resources such as nutrition visits or mental health visits. Absent or low reimbursement rates for psychosocial services results in fewer qualified persons being willing to care for teenagers and young adults with eating disorders.

Some older adolescents are no longer eligible for treatment or coverage because of provincial medical insurance rules. Thus, withdrawal from treatment can occur at an age when leaving home, unemployment or temporary employment is the norm. Some institutions have age limit policies that negatively affect treatment and limit access to care during the transition from paediatric to adult care.

Legislation should provide reimbursement for intervention by multiple disciplines for adolescents with eating disorders. Coverage should ensure that for adolescents, treatment should be dictated by the severity and range of the clinical situation. The promotion of size acceptance and healthy lifestyles, introduction of prevention programs for high risk adolescents, and strategies for early diagnosis and intervention should be encouraged.

Position: Health care reforms should include provisions that address the needs of adolescents with eating disorders and ensure that they not be denied access to care because of absent or inadequate health care coverage.

This position paper was adapted by the CPS Adolescent Medicine Committee from a paper by the Society for Adolescent Medicine. It represents a modification of the version published in the Journal of Adolescent Health (1995;16:476-480). We appreciate the permission of the authors, the Journal of Adolescent Health and the Society for Adolescent Medicine to adapt the manuscript to the Canadian context.

The Society for Adolescent Medicine position paper was prepared by Richard E Kreipe, Neville H Golden, Debra K Katzman, Martin Fisher, Jane Rees, Roger S Tonkin, Tomas J Silber, Garry Sigman, Janet Schebendach, Seth Ammerman and Harry M Hoberman.

Footnotes
ADOLESCENT MEDICINE COMMITTEE
Members: Drs Lionel Dibden, Edmonton, Alberta; Eudice Goldberg, The Hospital for Sick Children, Toronto, Ontario; Karen Mary Leslie, The Hospital for Sick Children, Toronto, Ontario; Andrew Lynk (director responsible), Sydney, Nova Scotia; Roger Tonkin (chair), Gabriola Island, British Columbia; Michael Westwood, Dorval, Quebec

Consultants: Drs Delores Doherty, St John's, Newfoundland; Jean-Yves Frappier, Hôpital Ste-Justine, Montréal, Québec; Miriam Kaufman, The Hospital for Sick Children, Toronto, Ontario; Larry Pancer, Markham, Ontario; Diane Sacks, Toronto, Ontario

The recommendations in this Clinical Practice Guideline do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate.

REFERENCES

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Eating disorders in adolescents: Principles of diagnosis and treatment

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Eating disorders are complex illnesses that affect adolescents with increasing frequency. They rank as the third most common chronic illness in adolescent females ( 1), with an incidence of up to 5% ( 2, 3), a rate that has increased dramatically over the past three decades.

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My Health My Resources of Tarrant County - We change lives

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My Health My Resources of Tarrant County

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Suggestions for Eating Disorder Education in Schools

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A group of Canadian researchers offer practical suggestions for preventing eating disorders in schools, and how to identify and work with at-risk students. Issues with current eating disorder educations Researchers suggest that the current eating disorder efforts in schools pay undue attention to the signs and symptoms of eating disorders, whereas more attention is needed to cultivate healthy attitude and behaviors among students.

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The adjective "schizophrenic" needs to be removed from counselors' vocabulary, says Elizabeth Prosek, a counselor and assistant professor at the University of North Texas (UNT).

Schizophrenia has a great deal of stigma and negative connotations associated with it, and referring to clients in the first person can lessen these, she says.

"I encourage counselors to advocate for what clients with schizophrenia can do rather than [focusing on] the limitations of experiencing psychosis," says Prosek, who has counseled clients with severe mental health disorders and served on a support team for individuals with schizophrenia living independently. "I once heard someone discuss the 'aggressive nature' of those diagnosed with schizophrenia. I could not help but wonder where that perception evolved. In my experience, clients did not demonstrate aggressive behavior or language."

Counselors, as part of a multidisciplinary treatment team of helping professionals, can play a critical role in the lives of people diagnosed with schizophrenia, say Prosek and Kara Hurt, a licensed professional counselor who works with clients with schizophrenia at an inpatient psychiatric hospital.

Prosek and Hurt, who is also a doctoral student at UNT, recently collaborated to write a practice brief on schizophrenia for the American Counseling Association's Center for Counseling Practice, Policy and Research (see sidebar below).

In the brief, the duo describes schizophrenia as a lifelong illness characterized by negative symptoms, including "delusions, hallucinations (most commonly auditory), disorganized thinking or speech and disorganized or abnormal motor behavior." The estimated prevalence rate for schizophrenia is 1 percent of the population in Western, developed countries.

For counselors, empathy should play a big part in therapy - from knowing the many side effects of schizophrenia medications to fully understanding what it is like to live with hallucinations and psychosis, say Prosek and Hurt. Special training and workshops can help counselors understand the nuances of the disorder, as can materials from mental health agencies (see "for more information" below).

Prosek once attended a seminar at which participants sat through the experience - virtually - of living with hallucinations, experiencing paranoia and hearing voices intertwined with the dialogue of another person.

Prosek and Hurt led a course this past year in which they showed videos of clients with schizophrenia explaining their own experiences.

"When the students in the class debriefed after the video, many confirmed that hearing firsthand from a client decreased their misperceptions about the disorder," says Prosek. "Watching a video of a client with schizophrenia who was articulate and successful in a career reduced stigma of the disorder. Also, I noticed that when person-first language is used when discussing clients with schizophrenia [as opposed to using the term "schizophrenic"], negative connotations are immediately lessened."
What do counselors need to know about schizophrenia?
Elizabeth Prosek: Living with psychosis can be scary and challenging. When working with those diagnosed with schizophrenia, demonstrating empathic concern is essential to build a therapeutic relationship. In my experience, clients appreciated my willingness to embrace their perspective of psychosis. I think all of the clients I worked with experienced their psychosis uniquely, and it was imperative that I understood their lived experience.

Kara Hurt: Schizophrenia affects the client's support system, not just the client. In my experience, it is just as important to provide counseling and support to family members and loved ones of people diagnosed with schizophrenia as it is to provide support and counseling to clients with schizophrenia. All of us counselors can help provide services in some way that help clients diagnosed with schizophrenia and those that love them.

EP: Counselors may provide family members and friends with psychoeducation on the symptoms and treatment options for schizophrenia. Furthermore, counselors may assist family members and friends to build empathy for the experiences of those diagnosed with schizophrenia. There are support groups for family members through the National Alliance on Mental Illness (NAMI). Find a local NAMI support group through nami.org.

For those clients who do not have a familial support system, encouraging the development of a community support network may be essential for the social and emotional well-being of clients diagnosed with schizophrenia. Regardless of diagnosis, humans in general seek "belongingness" in their community, and those diagnosed with schizophrenia are no different.
What advice would you give about working with clients diagnosed with schizophrenia?
EP: Recognizing strengths can be a great first step to creating an appropriate treatment plan. Several of the clients I counseled had creative interests, such as art and music, and we developed interventions to promote participation in those activities.

Also, I recommend communication with all professionals working with the client. In my experience, collaborating with the client's psychiatrist and case manager allowed for a holistic approach when addressing current therapeutic needs. Having a multidisciplinary team also allows for clients to more easily transition in and out of inpatient psychiatric hospitalization when necessary. With the appropriate releases of information, all professionals involved can be aware of how the client's psychosis presented, any medication changes and any changes in treatment recommendations after an inpatient hospitalization stay.

It did not take long after beginning my work with clients diagnosed with schizophrenia for me to recognize the need for socialization. Several of my clients lived in isolation but longed for social relationships. In collaboration with case managers, I organized social outings for clients, which allowed for a more genuine community-living experience. There are several community resources for clients diagnosed with serious mental health disorders, such as supported-work programs. Having knowledge of such programs in the community will serve as great referral sources for clients diagnosed with schizophrenia.
With what other types of issues can clients diagnosed with schizophrenia present?
KH: One of the presenting issues that I had not expected when I started working with clients diagnosed with schizophrenia was substance abuse. One client in particular stands out in my mind because of the extent of his illicit drug use, which worsened his paranoia and other delusions. When working with clients with schizophrenia, you may need to reconsider your assumptions to appreciate that these clients have many of the same kinds of problems as other clients.

EP: I agree. Substance misuse was prevalent among the clients diagnosed with schizophrenia that I worked with as well. I also observed many secondary diagnoses, including anxiety and depression. I connect the anxiety and depressive symptoms back to the potential isolation clients experienced. Furthermore, it seems to me hearing voices and feeling out of touch from reality would lead to feelings of anxiety. Helping my clients accurately explain symptoms to their psychiatrists allowed for more precise medication prescriptions.
What are some common misperceptions about schizophrenia?
EP: One of the common misperceptions I hear frequently when describing a client with schizophrenia is the term "medication noncompliance." I advocate for this phrase to be removed from counselor language. From my observations, when clients did not take medications regularly or as prescribed, it was not with intentional noncompliance, but rather there was confusion when medication regimens became complex or changed with frequency. Moreover, several antipsychotic medications have uncomfortable side effects. On a bad day, when a client is not feeling well, he or she might not feel inclined to perpetuate the experience by taking medications that may worsen physical symptoms. In counseling sessions, taking time to hear clients' concerns or complaints about side effects may help clients feel validated in their experience.

What challenges do counselors face in this area?

EP: I think there may be a perception that clients with schizophrenia only need a case manager and psychiatrist. From my perspective, counselors can play a vital role in the treatment team. Never underestimate the power of a space in which a client's experience is heard and valued.

KH: I think it is absolutely critical to have good supervision when working with a client diagnosed with schizophrenia. I have felt frustrated with my perceptions of clients' lack of progress or insight, but with supportive supervision, I have been able to be more flexible with my therapeutic expectations and shift my perspective to be a better counselor for my clients. I cannot underestimate the value of good supervision. It can help you gain awareness of potential burnout and the need for regular self-care.

EP: Supervision is helpful. I often felt frustrated with the mental health care system and how clients with schizophrenia became victims of gaps in continuity of care. I agree with Kara that there is a greater potential for burnout when working with clients in and out of crisis.

Another challenge for counselors might be understanding the differences in antipsychotic medications most commonly prescribed for clients with schizophrenia. Actually, Kara introduced me to an app (named Epocrates) that provides names, descriptions and side effects for medications. I remember when I first started working with this population, I had a hard time differentiating the medications the clients were prescribed. There are several research studies published outlining effectiveness and common side effects of antipsychotic medications which may be helpful to read.

Going back to one of Kara's original statements about the importance of family supports, it may be challenging to help family understand the experience of schizophrenia. Counselors can serve as a good source of information to help educate and support family members. Consequently, family members can better support the client diagnosed with schizophrenia.

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For more information
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ACA Center for Counseling Practice, Policy and Research practice briefs
Prosek and Hurt's information sheet on schizophrenia is one of 30 practice briefs available to American Counseling Association members through the Center for Counseling Practice, Policy and Research.

The briefs, which range from working with victims of domestic violence to animal-assisted therapy to posttraumatic stress disorder, are written by ACA members who are experts on that particular topic. New practice briefs are being added regularly.

The practice briefs are designed to be practical, evidence-based resources for ACA members, says Victoria Kress, executive editor of the ACA center's practice briefs project and a professor at Youngstown State University in Ohio.

Counselors can use the practice briefs as a refresher on topics they may not encounter very often, such as schizophrenia, or as a jumping-off point for further research. Each brief contains links to in-depth sources and data on a topic, as well as therapy models and other tools.

Kress says each practice brief is written and edited to be practical and succinct, with focused bursts of information on topics that counselors in all works settings may encounter, from divorce and autism to perfectionism and suicide prevention.

The plan is to post 15 to 20 new briefs each year, Kress says, including on each of the new disorders added to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

Kress began soliciting practice briefs from ACA members, then editing and posting the briefs on the ACA website, close to two years ago. The idea grew out of ACA past president Bradley Erford's focus on counselor use of evidence-based practices, Kress says.

"Counselors don't always have access to, or the time to read, journal articles," she says. "We wanted to provide an outlet for ACA members to sit down and get a quick overview. ... It was really born out of this idea that counselors should be using evidence-based practices. We know that counselors are busy and have competing demands. ... The ultimate idea is that it will improve their practice. It's better for their clients and the profession."

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday

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What counselors need to know about schizophrenia - Counseling Today

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The adjective "schizophrenic" needs to be removed from counselors' vocabulary, says Elizabeth Prosek, a counselor and assistant professor at the University of North Texas (UNT). Schizophrenia has a great deal of stigma and negative connotations associated with it, and referring to clients in the first person can lessen these, she says.

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Support is a word constantly used in the mental health world. We are told to "make sure you have a support network in place" and to "reach out for support during difficult times." While this advice is truly essential, it does not define what "support" really means. Is it asking someone to help with grocery shopping or seeking advice from a mental health professional?

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Support is a word constantly used in the mental health world. We are told to "make sure you have a support network in place" and to "reach out for support during difficult times." While this advice is truly essential, it does not define what "support" really means.

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Archives of Disease in Childhood

Abstract

Obsessive-compulsive disorder (OCD) in childhood and adolescence is an impairing condition, associated with a specific set of distressing symptoms incorporating repetitive, intrusive thoughts (obsessions) and distressing, time-consuming rituals (compulsions). This review considers current knowledge of causes and mechanisms underlying OCD, as well as assessment and treatment. Issues relating to differential diagnosis are summarised, including the challenges of distinguishing OCD from autism spectrum disorders and tic disorders in youth. The recommended treatments, namely cognitive behaviour therapy and serotonin reuptake inhibiting/selective serotonin reuptake inhibitor medications, are outlined along with the existing evidence-based and factors associated with treatment resistance. Finally, novel clinical developments that are emerging in the field and future directions for research are discussed.

Keywords: Child Psychiatry, Child Psychology, Psychology, Outcomes research

Epidemiology

Obsessive-compulsive disorder (OCD) is a psychiatric condition characterised by persistent and unwanted intrusive thoughts, images and urges (obsessions) and repetitive behaviours or mental acts (compulsions) (see table 1 ). Once considered to be rare in youth, epidemiological studies have found an estimated prevalence of 0.25%-4% among children and adolescents. 1-3 Left untreated symptoms may wax and wane but typically follow a chronic course 4 5 and cause marked functional impairment across multiple domains, including at home, school and socially. 6 Furthermore, paediatric OCD is associated with increased risk of other psychiatric disorders in adulthood. 7 8

Aetiology

The aetiology of paediatric OCD remains relatively poorly understood, despite considerable research to date. Data from twin, family and segregation studies strongly support a genetic component. 9 Twin studies have shown that genetic factors explain 45%-65% of the variance of OCD in children, 10 pointing to a higher heritability in OCD relative to most other anxiety disorders and depression in youth. 11 Interestingly, the heritability of OCD appears to be greater in paediatric compared with adult cohorts, 10 supporting the notion of early-onset OCD as a putative developmental subtype of the disorder. The results of genome-wide association studies 12 13 and meta-analyses of candidate gene studies 14 suggest that the genetic influence on OCD is polygenic, with many genes involved which individually exert a relatively small effect on the phenotype. In particular, genes within the serotonergic, dopaminergic and glutamatergic system appear to influence OCD. 15

Neuropsychological models of OCD propose that OCD arises from alterations to frontostriatal circuitry. Hyperactivation of the orbitofrontal cortex has been proposed to mediate persistent thoughts about threat and harm (ie, obsessions), which in turn lead to attempts to neutralise the perceived threat (ie, compulsions). There is robust evidence from functional neuroimaging studies of increased activation in the lateral and medial orbitofrontal cortex in both children and adults with OCD. 15 Interestingly, orbitofrontal brain dysfunction has also been found in unaffected relatives of patients with OCD, who are at genetic risk of OCD. 16 Importantly, treatment studies have demonstrated reduced activation in the orbitofrontal cortex following cognitive behaviour therapy (CBT) for OCD, 15 demonstrating some degree of plasticity.

While genetic factors clearly influence the expression of OCD, environmental factors also play a significant role, but remarkably little is known about these effects. Few prospective studies have been conducted, and results have been inconsistent. For example, one longitudinal study found that social isolation, physical abuse and negative emotionality were specific predictors of an adult OCD diagnosis. 17 In contrast, a recent retrospective study found no evidence for an association between adverse childhood experiences and OCD, although such experiences were related to certain comorbidities, including depression. 18

There has been emerging clinical evidence over the past 10-15 years of a subgroup of children who experience sudden onset OCD and/or tics after streptococcal infection. This group of children was originally given the acronym PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcus), 19 but more recently the term PANS (paediatric acute-onset neuropsychiatric syndrome) has been used in preference, as it is felt to capture both the sudden onset and the uncertainty about aetiology. 20 These children tend to have more widespread neuropsychiatric difficulties than other children with OCD, including enuresis, deterioration in handwriting and impulsivity. The exact mechanism of sudden onset neuropsychiatric disorder is unknown, but there has been interest in delivering therapies that target immune and infectious causes. However, other small studies suggest that OCD in this population responds as well to standard treatments, and effectiveness of prophylactic antibiotics has been inconsistent.

Diagnostic criteria and classification

The diagnosis of OCD in young people is broadly similar to adults (see box 1 for the International Classification of Diseases (ICD) diagnostic criteria). However, it has been noted that children are less likely to have insight into the irrationality of their obsessions and compulsions, 21 presumably due to underdeveloped meta-cognitive skills. Furthermore, in children, it is important to differentiate true compulsions from normal routines or ritualised behaviours, which are typically transient and no cause for concern. For example, many children display specific routines at bedtime such as saying goodnight in a particular way to their parents and/or toys. 22 In order to be considered a compulsion, a behaviour must be distressing and/or impairing.

Box 1

1. Either obsessions or compulsions or both present on most days for a period of 2 weeks.

2. Obsessions (unwanted ideas, images or impulses that repeatedly enter a person's mind) and compulsions (repetitive stereotyped behaviours or mental acts driven by rules that must be applied rigidly) share the following features:

Patient is aware that these originate from their own mind.

They are repetitive, unpleasant and distressing to the patient. At least one is perceived as excessive or unreasonable ('egodystonic').

At least one is resisted unsuccessfully, even though others may be present that the sufferer no longer resists.

Thought of carrying out the obsession or compulsion is not intrinsically pleasurable (simple relief of tension momentarily on completion of the thought/act is not regarded as pleasure in this sense).

3. The symptoms must be disabling. Even young children will have some insight into the senselessness of the thoughts and behaviours.

Historically OCD has been considered to be an anxiety disorder. Indeed, OCD is listed as a 'neurotic, stress-related and somatoform disorder' along with anxiety disorders in ICD-10, and similarly it was classified as an anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III, DSM-III-R and DSM-IV. However, in light of accumulating evidence for key differences in the phenomenology and aetiology of OCD compared with other anxiety disorders, 23 its classification has changed within DSM-5 and it now falls within the new 'OCD and related disorders' section. This section also includes a number of other disorders that are characterised by repetitive thinking and repetitive behaviour, such as body dysmorphic disorder, hoarding disorder and trichotillomania.

Assessment and diagnosis

OCD typically goes undetected for many years before an accurate diagnosis is made. 24 Delays in detection in young people may reflect embarrassment and attempts to conceal symptoms, poor insight and/or difficulty differentiating true OCD from normative rituals during development. 25 Furthermore, while OCD is often associated with a characteristic set of symptoms (eg, excessive washing, repeated checking), the disorder is strikingly heterogeneous; two individuals with OCD may present with entirely non-overlapping symptom profiles, which can present a diagnostic challenge. Nevertheless, the majority of paediatric OCD cases be identified using a six-question screening instrument, the Short OCD Screener (SOCS), recommended by the National Institute for Health and Clinical Excellence (see box 2). 26 The SOCS has been found to have a sensitivity of 97% (95% CI 0.91 to 0.98) in detecting OCD. As it is not a diagnostic instrument, further assessment is required in individuals who screen positive including taking a detailed history of obsessions and compulsions, a developmental history and a separate interview with the young person. 27 The latter is particularly important given that 'taboo' obsessions, such as sexual obsessions, are common and the young person may be reluctant to disclose them in front of relatives. 28

Box 2

1. Do you wash or clean a lot?

2. Do you check things a lot?

3. Is there any thought that keeps bothering you that you would like to get rid of but cannot?

4. Do your daily activities take a long time to finish? (eg, getting ready for school)

5. Are you concerned about putting things in a special order or are you very upset by mess?

6. Do these problems trouble you?

Differential diagnosis

Differential diagnosis can be challenging, particularly in paediatric populations; three of the most complex differential diagnoses are outlined below.

Restricted interests and stereotyped behaviours are a core feature of autism spectrum disorders (ASDs) and may result in both cognitive preoccupations and repetitive behaviours. Stereotyped behaviours can manifest as a phenocopy of compulsions (eg, ordering and arranging toys) and it is crucial to delineate ASD-related behaviours from true compulsions in order to inform treatment. In contrast to autism-related stereotyped behaviours, compulsions are usually (a) preceded by an obsession, (b) associated with relief in anxiety and (c) egodystonic (ie, unwanted and inconsistent with the individual's fundamental values) and the behaviour itself is not experienced as being intrinsically pleasurable. Of course, a young person may present with both ASD and OCD, and indeed prevalence rates of OCD are significantly elevated among individuals with ASD. 29 Detecting and treating OCD in the context of ASD can significantly improve functioning and quality of life. 30

Another common differential diagnosis is OCD and tic disorders. Up to 59% of children and adolescents with OCD meet criteria for a diagnosis of a tic disorder at some point during their lifetime. 31 Individuals with comorbid tic disorders may display an earlier age of onset of OCD and a different symptom profile compared with those without tic disorders. 32 Complex tics, in particular, can be difficult to differentiate from compulsions: as with autism-related stereotyped behaviours, the behaviour itself can appear identical to a compulsion (eg, touching and tapping). However, while tics are largely involuntary, compulsions are performed deliberately to relieve anxiety. The level of complexity of the behaviour may also help to differentiate tics from compulsions; even complex tics are relatively straightforward behaviours (eg, a brief tapping action), whereas compulsions are often more elaborate and performed according to a rule (eg, tapping four times with the left hand and four times with the right hand). Differentiating an OCD component is important, as OCD treatments are effective in children with tics and OCD, and OCD can be the most impairing aspect of their condition. 33

A third differential diagnosis that can be challenging is psychosis and OCD. The bizarre nature of obsessional thoughts can often raise queries of psychotic phenomena, especially in cases where the young person has limited insight into the irrationality of their obsessions. For example, a proportion of young people with OCD present with 'transformation obsessions', which refers to a fear of turning into someone or something else or acquiring unwanted characteristics. 34 These unusual symptoms can easily be confused with delusions, leading to inappropriate treatment. 34 Similarly, aggressive obsessions such as a fear of being harmed can appear similar to paranoia. In cases of OCD, the individual may have some insight into the irrationality of their fears; the obsessional thought is unlikely to be part of a broader delusional set of beliefs (eg, a plot of how and why others would want to harm them); and other symptoms of OCD are likely to be present upon questioning whereas other symptoms of psychosis (such as hallucinations and thought-disorder) are absent.

Treatment

There are two treatments with an established evidence base in the treatment of paediatric OCD, namely CBT incorporating exposure with response prevention (E/RP) and selective serotonin reuptake inhibitors (SSRIs). 35 CBT for paediatric OCD is a relatively short-term treatment, usually consisting of 12-20 weekly sessions. The main therapeutic strategy is E/RP, which involves the young person gradually confronting their feared situations (eg, touching dirty door handles) and refraining from carrying out compulsions (eg, handwashing) in an attempt to neutralise their anxiety or feared outcome. Instead, the young person is encouraged to wait until their anxiety comes down naturally, and then to repeatedly practice the same E/RP task until their anxiety extinguishes altogether (ie, habituation). E/RP tasks are set up in graded way, as guided by a hierarchy, and are carried out in sessions with the therapist and in between sessions as homework.

Randomised controlled trials (RCTs) have demonstrated that CBT is an efficacious treatment for paediatric OCD. The treatment is associated with a 40%-65% reduction in symptoms 36 and can be effective for children as young as 3 years when delivered in a developmentally appropriate format. 37 Gains appear to be relatively enduring and have been shown to be maintained up to 18-month follow-up. 38 Encouragingly, similar outcomes have been observed in community clinics (ie, non-research settings), suggesting that CBT protocols are effective in routine clinical practice. 39 40

In line with the robust evidence base, there is international consensus that CBT should be offered to all young people with OCD and should be the first-line treatment in mild to moderate cases of OCD. 35 41 In more severe cases or where young people fail to respond to CBT, medication should be considered in addition to CBT. RCTs have shown a range of SSRIs (fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram) to be effective in the treatment of paediatric OCD; they are associated with a 29%-44% reduction in symptoms and appear to be well tolerated and safe. 36 Few comparative treatment trials of different SSRIs have been undertaken, so there is little or no evidence to suggest that any one SSRI is more effective than another. However, in the UK, currently only sertraline and fluvoxamine are licensed for use in children, with sertraline recommended because of its favourable side effect profile.

Only one study to date has directly compared the efficacy of CBT versus SSRI medication in paediatric OCD. 42 This study found that CBT and sertraline were associated with comparable levels of symptom reduction, but that combined CBT and SSRI treatment was associated with superior outcomes. More recently, the same group has investigated the extent to which CBT improves outcomes among young people receiving SRIs for OCD. 43 They found that the individuals who received CBT compared with medication management alone had better outcomes, indicating that the combination of CBT and medication is superior to medication as a monotherapy in paediatric OCD. Interestingly, young people who received brief CBT instructions did not show any better response than those who received medication alone, suggesting that a truncated form of CBT is not effective in this population.

Treatment-resistant OCD

A proportion of young people with OCD do not respond to CBT or SSRIs, and an even larger proportion make gains but are left with clinically significant residual symptoms. A number of studies have attempted to identify predictors of treatment response in an attempt to understand the mechanisms underlying treatment resistance. Perhaps, most attention has been given to the impact of comorbidity on treatment response. Comorbidity is common in paediatric OCD, with up to 80% meeting diagnostic criteria for an additional psychiatric disorder. 42 Although some comorbidities, such as depression and anxiety disorders, do not appear to affect response to CBT or SSRIs, others may have an impact. For example, individuals with comorbid tic disorders tend to have a poorer response to SSRIs but respond equally well to CBT compared with those without tics. 44 Externalising disorders (oppositional defiant disorder and conduct disorder) have been shown to predict a worse response to SSRIs and CBT, 44 and there is some suggestion that individuals presenting with this dual diagnosis would benefit from modified treatment approaches, such as CBT combined with parent management training. 45 Similarly, it has been suggested that individuals with ASDs respond less well to CBT for OCD, highlighting the need for modified CBT protocols in this group. 46

Children with OCD who fail to respond to a course of CBT and an initial SSRI administered for at least 12 weeks at the maximum tolerated dose should usually have additional trials of at least one other SSRI. The tricyclic drug clomipramine (a non-SSRI) may be a useful medication to trial in resistant cases where two or more SSRIs have failed, although it is less well tolerated than SSRIs. There is also some RCT evidence in adults, and emerging evidence in children that augmentation of SSRI medication with a low dose of a dopamine antagonist can improve response rate, with up to 50% of previous non-responders showing improvement. 47 However, studies have variable outcomes, and a recent RCT in adults who had been non-responsive to SSRIs demonstrated that delivering high-quality exposure-based CBT was more efficacious than risperidone augmentation. 48 The key message again for treatment in children with OCD is that they should have access to exposure-based CBT and that risperidone augmentation is a less-favourable option.

Future directions

A major clinical challenge is the dissemination of good quality CBT to young people with OCD. Unfortunately, the vast majority of OCD sufferers fail to access CBT due to geographical barriers and/or a shortage of appropriately trained therapists. 49 In recent years, research has begun to focus on developing evidence-based methods for increasing the availability of, and access to, CBT. Novel approaches that have shown promise include CBT delivered via telephone 50 or web-camera 51 and internet CBT with minimal therapist input. 52 While further validation is required, these methods have the potential to transform service delivery for this population.

In addition to efforts to disseminate current evidence-based treatments for paediatric OCD, recent research has also focused on ways of enhancing CBT in order to improve outcomes, particularly for the significant minority who do not benefit from existing CBT protocols. For example, family conflict and parental blame have been shown to be associated with poorer CBT outcome in young people with OCD 53 and pilot data suggest that family therapy specifically aimed at targeting these dynamics is an effective adjunct to CBT in families that present with these difficulties. 54 With respect to pharmacological developments, in recent years there has been increasing interest in the use of d-cycloserine (DCS) as a potential augmentation strategy for CBT for OCD. DCS is a partial N-methyl-D-aspartate receptor agonist and animal studies have shown that DCS enhances extinction learning, which has raised the question of whether DCS could augment exposure-based therapies for anxiety disorders. However, findings remain mixed with some studies demonstrating an augmentation effect of DCS on CBT for OCD, 55 but not others. 56 These discrepancies may reflect methodological differences between studies, and further research is needed to establish the possible value of DCS in treating OCD in youth.

Conclusions

OCD commonly starts in childhood, and in addition to causing significant distress and impairment in children, it can persist into adult life where the WHO ranks it as one of the most impairing illnesses. 57 National guidelines exist for the assessment and treatment of OCD, and children should be offered interventions according to guidelines incorporating these evidence-based treatments. A substantial proportion of children and adolescents will respond with full or partial remission to CBT, which may be combined with an SRI/SSRI. Unfortunately, inadequate provision of CBT means limitations in access to treatments, and current research aims to establish more accessible and economic formats of CBT. Ongoing research into the genetic and biological basis of OCD and its relationship with infections/autoimmunity may also in time increase understanding of mechanisms and offer new treatment possibilities.

Acknowledgments

GK receives salary support from the National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Footnotes

Contributors: GK and IH contributed equally to the writing of this article.

Competing interests: None.

Provenance and peer review: Commissioned; externally peer reviewed.

References

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# data[].attributes.attachment_link.title
Obsessive-compulsive disorder in children and adolescents

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Archives of Disease in Childhood Obsessive-compulsive disorder (OCD) in childhood and adolescence is an impairing condition, associated with a specific set of distressing symptoms incorporating repetitive, intrusive thoughts (obsessions) and distressing, time-consuming rituals (compulsions). This review considers current knowledge of causes and mechanisms underlying OCD, as well as assessment and treatment.

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INTRODUCTION

The most common time of onset for psychotic disorders is adolescence and early adulthood []. The onset of psychotic disorders is usually preceded by a prodromal period characterized by non-specific psychiatric and attenuated psychotic symptoms accompanied by functional decline []. "Ultra-high risk" (UHR) for psychosis is defined by the presence of attenuated positive psychotic symptoms without full impairment of reality testing. Recently, the UHR concept was included in "attenuated psychosis syndrome" (APS), a new diagnosis contained in Section 3 of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the section reserved for conditions requiring further research []. Among adolescents who reported psychotic-like experiences, those of 80% remitted, and the symptoms of 20% persisted []. The early detection and treatment of people at risk for psychosis is currently regarded as a promising strategy for preventing the devastating consequences of full-blown psychosis [].

As children and adolescents spend a large portion of their time at school, mental health problems are commonly identified in this setting. School-based detection of those at UHR for psychosis has the benefit of improving access to mental health treatment for students who have psychotic-like experiences. In Korea, mandatory school based mental health screening test for mental health problems of students has been conducted every year. Due to limited school mental health resources, school counselors perform non-counseling related activities beyond their training such as clinical expertise regarding to assessment and referral of clinical high risk students.

Given increasing recognition of the need to identify individuals with UHR risk status, school counselors are facing the challenge of how to understand and deal with these symptoms. Indeed, in view of the essential contribution of the identification of symptoms to the provision of effective mental health services, it is essential to recognize the potential role played by school counselors.

Thus, the current study examined how school counselors diagnose and define the appropriate treatment for those at UHR for psychosis. We assessed respondents' recognition of UHR for psychosis based their responses to a brief vignette depicting a hypothetical student reporting relevant symptoms.

METHODS

Participants

The sample for this anonymous cross-sectional survey, which was conducted in October 2015, consisted of school counselors. In total, 132 school counselors from 125 (81.7%) of the 153 schools and all of three Wee centers in Gwangju metropolitan city participated in the survey and completed the questionnaire. Data on sociodemographic characteristics were collected. The survey was approved by the the Chonnam National University Hospital Institutional Review Board (CNUH-2015-171).

Vignette

The vignette used in this study was developed by the corresponding author (KSW) () based on the vignette developed by Jacobs et al. [] and the manual of Personal Assessment and Crisis Evaluation (PACE) clinic of Orygen Youth Health in Melbourne, Australia []. The vignette described a fictional individual at UHR for psychosis according to the Comprehensive Assessment of At-Risk Mental States (CAARMS) criteria [,]. The protagonist in the vignette met criteria for subthreshold non-bizarre ideation and perceptual abnormality with functional decline. She also met criteria of the DSM-5 criteria for APS. Two authors (LJY and CYC) with extensive experience in this area discussed and further revised the vignette.

First, we asked participants whether the vignette depicted a psychiatric disorder (yes/no/don't know). Participants were asked to identify the most appropriate diagnosis for the hypothetical student from a list of 10 diagnoses. We also asked participants to recommend an appropriate referral and treatment approach for the student by asking them to rate 11 treatment options on the following scale: first choice, second-or-later choice, would not recommend, and no opinion. Participants who diagnosed the protagonist with schizophrenia, delusional disorder, or at UHR for psychosis were considered the "schizophrenia spectrum disorders group," and others were considered the "non-psychotic disorders group."

Statistical analyses

Basic demographic differences among respondents according to the diagnosis chosen were analyzed using the chi-square test. The percentage of respondents choosing each answer was calculated and is presented. SPSS for Windows software (ver. 21.0; IBM Corp., Armonk, NY, USA) was used to perform the statistical tests. All statistical tests were two-tailed, and p-values <0.05 were deemed to indicate statistical significance.

RESULTS

Demographic characteristics of participants

The sample consisted primarily of females (94.7%), and there were no significant differences in the demographic characteristics of respondents according to the diagnosis they selected ().

Diagnosis

In total, 123 (94.6%) respondents recognized that the vignette depicted someone with a mental disorder. The data regarding diagnoses are summarized in , which shows the percentage of respondents choosing each diagnosis. The most common diagnosis was schizophrenia (n=34, 28.1%), followed by delusional disorder (n=32, 26.4%), and depressive disorder (n=23, 19.0%). The diagnosis of UHR for psychosis was selected by 15 (12.4%) subjects.

Referral and treatment

shows the referral recommendations according to the diagnosis chosen by the school counselors. Most participants who diagnosed the protagonist with schizophrenia spectrum disorder selected psychiatric clinics as the optimal referral. Additionally, an average of 58.1% of respondents would refer to Wee center, which is school counseling services, and an average of 37.2% would refer to a private counseling center.

shows treatment preferences according to the diagnosis chosen by school counselors. School counselors who diagnosed the student depicted in the vignette with schizophrenia were likely to recommend antipsychotics (35.3%) and family therapy (35.3%) as the first-line treatment. School counselors who diagnosed the protagonist as being at UHR for psychosis were also likely to prefer family therapy (46.7%). In terms of the medication options for those at UHR for psychosis, antipsychotics were the most frequently chosen.

DISCUSSION

This is the first study to explore the recognition of Korean school counselors regarding students at UHR for psychosis. Participants were presented with a vignette depicting the case of a student who initially presents with recent-onset subsyndromal psychotic symptoms with functional decline. We found that most participants believed that the student was suffering from a psychiatric disorder. However, only 12.4% of the respondents correctly diagnosed her as at UHR for psychosis, whereas over half of respondents described her as suffering from a full-blown psychotic disorder. This reflects the fact that school counselors may be unfamiliar with the concept of high risk for psychosis, and lack confidence in treating this concept as a potential precursor of psychotic symptoms.

About 40% of school counselors did not consider the protagonist in the vignette to be suffering from schizophrenia spectrum disorder but, instead, believed she was dealing with a less severe condition, including depressive disorder (19.0%). Although the vignette did not portray severe depression, many school counselors nonetheless identified the problem in question as depressive disorder, which is a common psychiatric disorder among students. While most school counselors recommended psychiatric treatment for the protagonist in the vignette, a majority also considered a counseling center, which might not offer psychiatric services and might not operate according to the medical model, as would be appropriate for the treatment of a psychotic disorder. Early detection and intervention have an important role in reducing the duration of untreated psychosis (DUP) and ameliorating the presenting symptoms of UHR subjects [,]. However, appropriate psychiatric intervention is commonly delayed within mental health services, including school counseling systems [,]. Therefore, early referral and the timely delivery of transfer information by school counselors may play an important role in improving the diagnostic and treatment approach of subsequent practitioners.

Our findings reflected great variability in the treatment recommendations offered for the protagonist of the vignette. In particular, school counselors who diagnosed her with schizophrenia or at UHR for psychosis recommended both antipsychotics and family therapy. These results may be attributable to recognition on the part of school counselors that antipsychotics have been established as a standard treatment for persons with psychotic symptoms. Additionally, as school counselors are more frequently exposed to information related to familial and environmental problems, they may consider family therapy to be an important resource for treatment. Although low doses of antipsychotics appear to be effective for reducing the severity of the presenting symptoms of UHR subjects, premature recommendations for medication by school counselors may exacerbate a student's experience of being odd and stigmatized, especially if they are adolescents []. Furthermore, there is growing evidence that psychological interventions, such as cognitive-behavioral therapy, and newly emerging treatments, such as omega-3 fatty acids, may be effective in reducing the severity of the symptoms experienced by individuals at UHR for psychosis [⁻]. These results suggest that Korean school counselors were not familiar with preventive approaches to the development of psychotic disorders or with the importance of early intervention. Thus, we should develop educational materials to raise the awareness of school-based gatekeepers of access to mental health treatment regarding psychosis prevention and help school counselors expand their knowledge about treatment options for those at UHR.

This study has several limitations. First, the use of only one vignette to assess school counselors' recognition of UHR for psychosis may have led to difficulties in distinguishing this condition from other psychotic disorders. Second, we asked only two categorical questions regarding the diagnosis of, and treatment for, individuals at UHR for psychosis; that is, we did not assess such additional factors as respondents' experiences with, goals for, and opinions regarding treatment. Future research may benefit from adding vignettes that depict different levels of psychotic symptoms and elicit more information from respondents. Moreover, as there is no "golden standard" treatment for UHR, the range of recommended treatments in our study should be tested for relevance in futures.

In conclusion, this study suggests that Korean school counselors are not sufficiently familiar with the condition known as UHR for psychosis, although they generally recognize the vignette has mental health problems and needs help. To prevent delays in the implementation of appropriate school-based interventions for attenuated psychotic symptoms, school counselors should be provided with proper education and training.

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School Counselors' Recognition of the Ultra-High Risk for Psychosis

# data[].attributes.attachment_link.description
The most common time of onset for psychotic disorders is adolescence and early adulthood []. The onset of psychotic disorders is usually preceded by a prodromal period characterized by non-specific psychiatric and attenuated psychotic symptoms accompanied by functional decline [].