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Lee, A. (n.d.). The 13 disability categories under IDEA. Understood.

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Lee, A. (n.d.). The 13 disability categories under IDEA. Understood.

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At a glance

The Individuals with Disabilities Education Act (IDEA) requires public schools to provide special education services to eligible students.

IDEA covers 13 disability categories.

Not every student who struggles in school qualifies.

The Individuals with Disabilities Education Act (IDEA) requires public schools to provide special education and related services to eligible students. But not every child who struggles in school qualifies. To be covered, a child's school performance must be "adversely affected" by a disability in one of the 13 categories below.

1. Specific learning disability (SLD)

The "specific learning disability" (SLD) category covers a specific group of learning challenges. These conditions affect a child's ability to read, write, listen, speak, reason, or do math. Here are some examples of what could fall into this category:

SLD is the most common category under IDEA. In the 2018-19 school year, around 33 percent of students who qualified did so under this category.

2. Other health impairment

The "other health impairment" category covers conditions that limit a child's strength, energy, or alertness. One example is ADHD, which impacts attention and executive function.

3. Autism spectrum disorder (ASD)

ASD is a developmental disability. It involves a wide range of symptoms, but it mainly affects a child's social and communication skills. It can also impact behavior.

Various mental health issues can fall under the "emotional disturbance" category. They may include anxiety disorder, schizophrenia, bipolar disorder, obsessive-compulsive disorder, and depression. (Some of these may also be covered under "other health impairment.")

5. Speech or language impairment

This category covers difficulties with speech or language. A common example is stuttering. Other examples are trouble pronouncing words or making sounds with the voice. It also covers language problems that make it hard for kids to understand words or express themselves.

6. Visual impairment, including blindness

A child who has eyesight problems is considered to have a visual impairment. This category includes both partial sight and blindness. If eyewear can correct a vision problem, then it doesn't qualify.

Kids with a diagnosis of deafness fall under this category. These are kids who can't hear most or all sounds, even with a hearing aid.

The term "hearing impairment" refers to a hearing loss not covered by the definition of deafness. This type of loss can change over time. Being hard of hearing is not the same thing as having trouble with auditory or language processing.

Kids with a diagnosis of deaf-blindness have both severe hearing and vision loss. Their communication and other needs are so unique that programs for just the deaf or blind can't meet them.

10. Orthopedic impairment

An orthopedic impairment is when kids lack function or ability in their bodies. An example is cerebral palsy.

11. Intellectual disability

Kids with this type of disability have below-average intellectual ability. They may also have poor communication, self-care, and social skills. Down syndrome is one example of a condition that involves an intellectual disability.

12. Traumatic brain injury

This is a brain injury caused by an accident or some kind of physical force.

13. Multiple disabilities

A child with multiple disabilities has more than one condition covered by IDEA. Having multiple issues creates educational needs that can't be met in a program designed for any one disability.

Having a disability is not enough to qualify for special education. The disability has to have an "adverse effect" on a child's education.

Key takeaways

Each of the 13 disability categories in IDEA can cover a range of difficulties.

Dyslexia, dyscalculia, and written expression disorder fall under the "specific learning disability" category.

"Other health impairment" can cover ADHD.

About the author

About the author

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

Reviewed by

Reviewed by

Rayma Griffin, MA, MEd has spent 40 years working with children with learning and thinking differences in the classroom and as an administrator.

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The Individuals with Disabilities Education Act (IDEA) requires public schools to provide special education services to eligible students. IDEA covers 13 disability categories. Not every student who struggles in school qualifies. The Individuals with Disabilities Education Act (IDEA) requires public schools to provide special education and related services to eligible students.

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Bryant, J. and Strabavy, D. (2015). Section 504 considerations for students with internalizing disorders experiencing academic difficulties. 

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Bryant, J. and Strabavy, D. (2015). Section 504 considerations for students with internalizing disorders experiencing academic difficulties. 

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Carson, C. (2020, August 19). 3 Types of school supports to help students with mental health conditions. National Alliance on Mental Illness.

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Carson, C. (2020, August 19). 3 Types of school supports to help students with mental health conditions. National Alliance on Mental Illness.

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3 Types of School Supports to Help Students with Mental Health Conditions

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There is hope for students with mental health needs as there are several ways to secure academic and behavioral support.

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Wertlieb, E. (n.d.). Obsessive compulsive disorder and the school counselor. 

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Wertlieb, E. (n.d.). Obsessive compulsive disorder and the school counselor. 

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Obsessive Compulsive Foundation of Metropolitan Chicago. (n.d.). How to help your child: A parent's guide to OCD. 

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Obsessive Compulsive Foundation of Metropolitan Chicago. (n.d.). How to help your child: A parent's guide to OCD. 

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Child Mind Institute. (2021). Treatment for OCD. 

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Child Mind Institute. (2021). Treatment for OCD. 

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The first step in treatment is helping children understand how OCD works. It often helps to put OCD in a context that children can understand. For example, a clinician might explain that OCD functions like a bully. If a bully asks for your lunch money and you give in because you're afraid, then the bully will be happy and go away. But the next day the bully will come back for more, because he knows you are afraid. The more you give in to a bully the more he will ask for. OCD functions the same way. The goal of treatment is to help a child learn how to stand up to his bully.

The gold-standard treatment for OCD is a kind of cognitive behavioral therapy called exposure and response prevention, or ERP. ERP works by helping children face the things that trigger their anxiety in structured, incremental steps, and in a safe environment. This allows children to experience anxiety and distress without resorting to compulsions, with the support of the therapist. Through facing their triggers children learn to tolerate their anxiety and, over time, they discover that their anxiety has actually decreased.

For example, a child with fears about germs and contamination would create a "fear hierarchy" with his therapist. They would work together to identify all of the contamination situations he fears, rate them on a scale of 0-10, and then tackle them one at a time until his fear subsides. The child would start with a low-level trigger, such as touching clean towels, and build to more difficult triggers, such as holding something from the trash.

Because children often have symptoms that are specific to settings outside the clinical office, at home or in restaurants, for instance, it is important for treatment to move outside the office as needed. Your clinician should provide ERP in real world locations where your child experiences anxiety, and make sure that caregivers know how to reinforce ERP skills outside of treatment, too.

For most cases of mild to moderate OCD, treatment once a week for 12-15 weeks is usually enough to get strong results.

Working with parents

Parents spend the most time with their children, so it is essential for family to be involved in treatment. You should expect your child's clinician to work closely with you, explaining how treatment works and giving you and your child homework to practice the skills your child is learning in therapy.

Because children often come to parents looking for reassurance or to help with an obsession or compulsion, it is also important for parents to learn the best way to respond to their child without reinforcing her OCD. When a parent gives reassurance, it makes the child feel better in the moment, but that relief is fleeting and can actually reinforce the child's anxiety in the long run. It also doesn't help her learn any coping skills to help herself - only that asking mom or dad will help.

Similarly, if your child has an aversion to a certain word, your family might have learned to avoid saying that word and apologize if someone accidentally uses it. However inadvertent, this also reinforces the OCD because it doesn't give the child a chance to overcome her anxiety. Your child's clinician should work with you on finding ways to respond to requests for reassurance that are supportive without reinforcing OCD symptoms.

Intensive CBT and hospitalization

For children with severe symptoms, weekly or even twice-weekly therapy sessions might not be effective enough. If your child's symptoms are seriously interfering with school performance, family life and friendships, and if typical treatment isn't helping, you may want to consider a treatment program that is more intensive.

Some institutions that specialize in OCD, like the Child Mind Institute, offer intensive treatment programs that allow children to be seen several times a week, compressing treatment and helping children make more gains faster. These programs can have a transformative effect on children struggling with severe OCD, and can many times prevent hospitalization.

An inpatient hospitalization program is another option for children with severe OCD who are not getting the help they need from traditional outpatient treatment. After an inpatient OCD hospitalization, a child may be recommended to participate in an intensive outpatient program to help ease his transition away from being in a clinical environment and to help him maintain the gains he has made.

Medication treatment for OCD

While the primary treatment for OCD is cognitive behavioral therapy, children with more severe cases are often treated with a combination of CBT and medication. A class of antidepressant medication called SSRIs, or selective serotonin reuptake inhibitors, can be used to help reduce a child's anxiety, which in turn allows the child to be more responsive to therapy. Medication can be decreased or discontinued as the child learns skills to help her overcome her anxiety on her own.

Sometimes other types of medicines can be prescribed to control excessive irritability or anger that may be complicating treatment.

Related:
Kids and OCD: The Parents' Role in Treatment Intensive Treatment for OCD and Anxiety

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What Is the Best Treatment for OCD? | Child Mind Institute

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The first step in treatment is helping children understand how OCD works. It often helps to put OCD in a context that children can understand. For example, a clinician might explain that OCD functions like a bully. If a bully asks for your lunch money and you give in because you're afraid, then the bully will be happy and go away.

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Burbrick, J. (2021). How teachers can help kids with OCD. Child Mind Institute. 

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Burbrick, J. (2021). How teachers can help kids with OCD. Child Mind Institute. 

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If a child in your classroom is struggling with OCD, he may be distracted, frustrated in completing his work, and even disruptive to other students. Here are some things we can do to help him, and the class as a whole, focus on learning:

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.

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, to be able to help someone in need, and great for fostering friendship.

Private testing rooms: Research is quite clear that kids with OCD and OC spectrum disorders do better, are less overwhelmed, and are more in control of their thoughts and of 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 reading 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.

Plan an escape route: Try working out a communication system so that if the student feels OCD 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.

Related: The Pain of Hiding OCD

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 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.

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 them sit in the front, where they're less able to hear the noise, and stay more focused on their work. On the other hand, a child who has very observable symptoms, and doesn't want other kids to see them fidgeting with their hands, or rocking, or getting up a lot, might be better off closer to the door, toward the back of the room.

Peer understanding program: Finally, children oftentimes are teased and bullied because of their OCD symptoms. Kids feel very uncomfortable about their obsessive rituals, knowing that they're being watched. During a peer understanding program we have 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. This is a good way to educate the whole class about what's going on. It can be a very effective if a child is going to be in the same school for a number of years, and can inspire a surprising amount of support from other children.

Read More:

What Does OCD Look Like in the Classroom?
What Teachers Should Know About OCD
OCD and Internal Compulsions

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How Teachers Can Help Someone with OCD | OCD in Classroom | Child Mind Institute

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If a child in your classroom is struggling with OCD, he may be distracted, frustrated in completing his work, and even disruptive to other students.

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Kids Health. (2021). Obsessive-compulsive disorder factsheet (for schools). 

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Kids Health. (2021). Obsessive-compulsive disorder factsheet (for schools). 

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What Teachers Should Know

Students with obsessive-compulsive disorder (OCD) have upsetting or scary thoughts or images (called obsessions) pop into their minds that are hard to shake. Common obsessions include contamination, safety, and need for symmetry. Unwanted and intrusive thoughts can be of an aggressive or sexual nature.

People with OCD feel strong urges to repeatedly do certain things - called rituals or compulsions - to banish the scary and intrusive thoughts; ward off things they dread; or make sure that things are safe, clean, or right in some way. Common compulsions include cleaning, checking, counting, repeating, arranging, touching, seeking reassurance.

Doctors consider obsessive thinking and rituals to be OCD when they do one or more of the following:

take up more than 1 hour each day

cause distress

interfere with daily activities

OCD in kids is usually diagnosed between age 7 and 12. Since these are the years when kids naturally feel concerned about fitting in with peers, the discomfort and stress brought on by OCD can make them feel scared, out of control, and alone. Stressful events (such as starting school or a loved one's death, for example) can trigger or worsen OCD.

Students with OCD may:

miss class time to talk to a school counselor or other mental health specialist

need extra time to complete assignments because they reread and rewrite assignments

need to take medicine

have rituals and preoccupations that seem odd to other students, which may make them a target for bullies

benefit from special education services, such as individualized education programs (IEPs) or 504 education plans

What Teachers Can Do

Because OCD symptoms can interfere with learning, some students with the disorder require instructional accommodations, including extra time with assignments or learning breaks if they're feeling anxious.

Teachers need to understand that a student's ritualistic behaviors are part of the disorder. Talking with a school counselor and the student's parents or guardians to learn about the student can help. You might be asked to help the student redirect the behavior or ignore the behavior instead of correcting it or issuing a consequence.

OCD is treatable, but overcoming it isn't a quick or easy process. Students with OCD usually need to work with a therapist and take medicines to help manage their behaviors and the accompanying thoughts and feelings.

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Students with obsessive-compulsive disorder (OCD) have upsetting or scary thoughts or images (called obsessions) pop into their minds that are hard to shake. Common obsessions include contamination, safety, and need for symmetry. Unwanted and intrusive thoughts can be of an aggressive or sexual nature.

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ADAA. (n.d.). OCD at school. Anxiety and Depression Association of America. 

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ADAA. (n.d.). OCD at school. Anxiety and Depression Association of America. 

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OCD is like an unwelcome guest with bad manners. It moves into a mind - and it doesn't want to leave.
Students with OCD may appear to be daydreaming, distracted, disinterested, or even lazy. They may seem unfocused and unable to concentrate. But they are really very busy focusing on their nagging urges or confusing, stressful, and sometimes terrifying OCD thoughts and images. They may also be focused on completing rituals, either overtly or covertly, to relieve their distress.

While frustrating to educators, OCD may be torture for the students who have it. This disorder may be difficult to identify because its observable symptoms are similar to other conditions and mental disorders, and mental rituals cannot be observed. Symptoms in children and adolescents can change over time, and they tend to wax and wane for no apparent reason. School personnel who have a good understanding of the variety of behaviors that may signal OCD are better equipped to initiate a plan to assist the student.

The Effect of OCD on Academic Performance

Even very bright and motivated students can struggle with OCD. Although students with OCD typically have average to above-average intelligence levels, they may be unable to learn the same way others do because their focus is frequently on their obsessions or compulsions. Depending on the severity of the symptoms, some students find it difficult to learn and, for some, it's almost impossible to concentrate on and complete schoolwork.

Although they want to pay attention, participate in discussions or presentations, study, and complete homework, they feel compelled to respond to their obsessions or urges.

Students who have untreated OCD re likely to have a very difficult time concentrating in the classroom and completing homework assignments. They may experience overwhelming anxiety or strong urges, possibly describing the feeling of mounting anxiety or intensifying urges as if they were a rising volcano or a tea kettle about to boil - and relief comes when the pressure is released. Unfortunately, the release is usually a compulsive behavior that may be disruptive to learning and possibly to the classroom.

It may not be long before the student who has OCD falls behind and sees a drop in grades. In some cases, academic performance deteriorates abruptly and dramatically. And it may be nearly impossible to catch up unless a student can learn to manage the symptoms. For these reasons, it's important that school personnel take OCD seriously and work with the student and the family to provide support.

What Does OCD Look Like at School?

A student may enter a classroom at the beginning of the school year with a diagnosis of OCD, or the disorder may develop later. Whenever a student begins to falter - academically, socially, or emotionally - educators need to intervene. A proactive approach can make an impressive difference in a student's coping ability, academic performance, and interpersonal capabilities.

The first step is being aware of the behaviors that can signal OCD. The disorder includes a wide variety of symptoms in children and adolescents, which are not always obvious. It is important to keep in mind that OCD symptoms can look like other disorders, so it is critical that a mental health specialist trained in OCD and related disorders conduct a diagnostic assessment OCD can be confused for symptoms of ADHD and anxiety disorders, as well as acting out" or misbehavior not associated with a neurobiological disorder. Also, OCD changes in nature or scope from one set of obsessions and compulsions to another, with differing behaviors, and symptoms can worsen and or seem to disappear, often for no obvious reason.

Common Symptoms of OCD at School

Below are common OCD symptoms of children and adolescents in school.

Obsession: Fears of germs or contamination
Compulsions
* Repeatedly washing hands, using antibacterial wipes or hand-sanitizer
* Protecting what is perceived as clean space -- personal desk, locker, or other property
* Avoiding touching surfaces that others may have touched, such as doorknobs, desks, shared supplies, lab tables or equipment, computer keyboards, paints, paste, soap, cafeteria trays, etc.
* Avoiding contact play or sports either because of a fear of catching a disease or fear of contaminating another student
* Avoiding the use of bathrooms
* Seeking reassurance that they or others are not sick or dirty
* Refusing to share items or supplies with others
* Refusing to eat in the cafeteria
* Avoiding certain products because they may contain poison, such as substances used in chemistry

Obsession: Fears that harm, illness, or death, will befall oneself or others; fear of causing harm to oneself or others, including violent or aggressive obsessions (Note: People with OCD who have violent or aggressive thoughts do not have a history of violence or act upon these urges or ideas.)
Compulsions
* Checking behavior, such as making sure doors or windows are locked or turning light switches on and off repeatedly
* Reading a paragraph over and over again to prevent harm from coming to a loved one, another person, or a pet.
* Asking the teacher for reassurance that the student is safe
* Avoiding leaving a perceived safe zone (classroom); avoiding going into unsafe zones (lunch or recess areas) or open spaces such as a gymnasium
* Unreasonable avoidance of peers, teachers, for fear of causing them harm

Obsession: Fears that harm, illness, or death, will befall oneself or others; fear of causing harm to oneself or others, including violent or aggressive obsessions ( Note: People with OCD who have violent or aggressive thoughts do not act upon these urges or ideas OR have a history of violence.)
Compulsions
* Checking behavior, such as making sure doors or windows are locked or turning light switches on and off repeatedly
* Reading a paragraph over and over again to prevent harm from coming to a loved one, another person, or a pet.
* Asking the teacher for reassurance that the student is "safe"
* Avoiding leaving a perceived "safe" zone (classroom); avoiding going into "unsafe" zones (lunch or recess areas) or open spaces such as a gymnasium
* Unreasonable avoidance of peers, teachers, for fear of causing them harm

Obsession: Fears, feelings, or urges related to numbers
Compulsions
* Counting, touching, or saying words a certain number of times due to believing in a magical significance to certain numbers or using those numbers to keep harm away; counting the number of steps between locations and having to start over if interrupted
* Touching objects a certain number of times; not being able to move on unless this touching has been accomplished
* Reading words or pages a certain number of times
* Going back and forth through doorways a certain number of times before it's OK to enter the room
* Avoiding using certain numbers that are perceived as unlucky or not safe; only using numbers that are perceived as safe or lucky. (math problems may be answered improperly, pages may not be read or pages may be numbered out of sequence )

Obsession: Fears, feelings, or urges related to discarding items because something bad will happen; feelings of incompleteness if something is discarded or the need document and preserve all life experiences; fears of contamination; need to buy items in multiples of a particular number; not discarding objects to avoid repetitive rituals such as washing or checking. (Note: This form of hoarding is related to the obsessions and compulsions of OCD and is distinct from hoarding disorder.)
Compulsions
* Saving scraps of paper, candy wrappers, bottle caps, broken items, or other useless items; inability to part with unneeded things
* Keeping books, toys, food, school papers, clothing, or other items for fear that they might be needed sometime in the future
* Buying every item in a store that one has touched (and therefore contaminated) to prevent others from being contaminated
* Accumulating items or objects in a particular area (desk drawer) because they are contaminated and cannot be touched
* Buying multiples of the same item (buying three of everything because it's a magic number)

Obsession: Scrupulosity, or the excessive fear of violating religious or moral rules
Compulsions
* Apologizing or confessing that something is wrong, such as breaking religious, classroom, or school rules
* Constantly seeking reassurance that a task has been completed right or perfectly; seeking affirmation that a mistake was not made
* Saying prayers a certain number of times; excessive praying to atone for being bad; repeatedly confessing perceived sins or bad behavior
* Repetitive praying, confessing to neutralize or undo bad thoughts, intrusive sexual thoughts, or visions of cursing or blaspheming in school or church
* Avoiding answering questions for fear of telling a lie

Obsession: Fears, feelings, or urges related to symmetry or order
Compulsions
* Constantly evening up books or other items on a shelf or desk; aligning edges to be even
* Rearranging items to be in a certain order, such as by color or alphabetical order
* Avoiding a room with square tiles because seeing the tiles would require tracing each of the edges visually
* Fears, feelings, or urges related to sexual content
* Seeking reassurance that one is not gay or lesbian, despite being heterosexual
* Excessive praying to atone for having inappropriate sexual thoughts or images
* Avoiding magazines, books, DVDs, websites, or other media for fear of seeing sexual content

Obsession: Excessive doubting or dread of uncertainty
Compulsions
* Constantly rechecking to see that everything is in a backpack or book bag
* Asking to leave the classroom to recheck a locker or its contents
* Avoiding a school locker to prevent checking the lock over and over again

Obsession: Fears, feelings, or urges related to having something just right or perfect
Compulsions
* Getting up and sitting down repeatedly at a desk, until feeling just right
* Repeatedly revising the way letters, words, or numbers are written to make them look just right; getting stuck rewriting the same letter or word
* Repeatedly filling in circles on answer sheets; getting stuck on one or two questions because too much time is spent carefully filling in the circles, erasing, refilling until it looks perfect
* Erasing and rewriting words over and over
* Extreme slowness with activities or school work until everything is just right
* Repeating various actions for no apparent reason
* Avoiding a hallway until walking in it until it feels just right

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OCD is like an unwelcome guest with bad manners. It moves into a mind - and it doesn't want to leave. Students with OCD may appear to be daydreaming, distracted, disinterested, or even lazy. They may seem unfocused and unable to concentrate.

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American School Counselor Association. (2021). The school counselor and discipline. 

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American School Counselor Association. (2021). The school counselor and discipline. 

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Disruptive student behavior is one of the most serious, ongoing problems confronting school systems today (Diliberti, Jackson, & Kemp, 2017). Research suggests such behavior negatively affects classroom learning and school climate (Kremer, Flower, Huang & Vaughn, 2018).

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Cholewa, B. (n.d.). Evidence-based programs for school counselors. 

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Cholewa, B. (n.d.). Evidence-based programs for school counselors. 

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Children's Mental Health. (n.d.). Behavior or conduct problems in children. 

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Children's Mental Health. (n.d.). Behavior or conduct problems in children. 

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Centers for Disease Control and Prevention

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Children sometimes argue, are aggressive, or act angry or defiant around adults. A behavior disorder may be diagnosed when these disruptive behaviors are uncommon for the child's age at the time, persist over time, or are severe. Because disruptive behavior disorders involve acting out and showing unwanted behavior towards others they are sometimes called externalizing disorders.

Oppositional Defiant Disorder

When children act out persistently so that it causes serious problems at home, in school, or with peers, they may be diagnosed with Oppositional Defiant Disorder (ODD). ODD usually starts before 8 years of age, but no later than by about 12 years of age. Children with ODD are more likely to act oppositional or defiant around people they know well, such as family members, a regular care provider, or a teacher. Children with ODD show these behaviors more often than other children their age.

Examples of ODD behaviors include

Often being angry or losing one's temper

Often arguing with adults or refusing to comply with adults' rules or requests

Often resentful or spiteful

Deliberately annoying others or becoming annoyed with others

Often blaming other people for one's own mistakes or misbehavior

Learn more about ODD
Conduct Disorder

Conduct Disorder (CD) is diagnosed when children show an ongoing pattern of aggression toward others, and serious violations of rules and social norms at home, in school, and with peers. These rule violations may involve breaking the law and result in arrest. Children with CD are more likely to get injured and may have difficulties getting along with peers.

Examples of CD behaviors include

Breaking serious rules, such as running away, staying out at night when told not to, or skipping school

Being aggressive in a way that causes harm, such as bullying, fighting, or being cruel to animals

Lying, stealing, or damaging other people's property on purpose

Learn more about CD
Treatment for disruptive behavior disorders

Starting treatment early is important. Treatment is most effective if it fits the needs of the specific child and family. The first step to treatment is to talk with a healthcare provider. A comprehensive evaluation by a mental health professional may be needed to get the right diagnosis. Some of the signs of behavior problems, such as not following rules in school, could be related to learning problems which may need additional intervention. For younger children, the treatment with the strongest evidence is behavior therapy training for parents, where a therapist helps the parent learn effective ways to strengthen the parent-child relationship and respond to the child's behavior. For school-age children and teens, an often-used effective treatment is a combination of training and therapy that includes the child, the family, and the school.

Get help finding treatment

Here are tools to find a healthcare provider familiar with treatment options:

Managing Symptoms: Staying Healthy

Being healthy is important for all children and can be especially important for children with behavior or conduct problems. In addition to behavioral therapy and medication, practicing certain healthy lifestyle behaviors may reduce challenging and disruptive behaviors your child might experience. Here are some healthy behaviors that may help:

Engaging in regular physical activity, including aerobic and vigorous exercise

Eating a healthful diet centered on fruits, vegetables, whole grains, legumes (for example, beans, peas, and lentils), lean protein sources, and nuts and seeds

Getting the recommended amount of sleep each night based on age

Strengthening relationships with family members

Prevention of disruptive behavior disorders

It is not known exactly why some children develop disruptive behavior disorders. Many factors may play a role, including biological and social factors. It is known that children are at greater risk when they are exposed to other types of violence and criminal behavior, when they experience maltreatment or harsh or inconsistent parenting, or when their parents have mental health conditions like substance use disorders, depression, or attention-deficit/hyperactivity disorder (ADHD). The quality of early childhood care also can impact whether a child develops behavior problems.

Although these factors appear to increase the risk for disruptive behavior disorders, there are ways to decrease the chance that children experience them. Learn about public health approaches to prevent these risks:

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Behavior or Conduct Problems in Children | CDC

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Children sometimes argue, are aggressive, or act angry or defiant around adults. A behavior disorder may be diagnosed when these disruptive behaviors are uncommon for the child's age at the time, persist over time, or are severe. Learn about behavior or conduct problems in children.

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U.S. Department of Health and Human Services. (n.d.). Evidence-based and promising practices. 

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U.S. Department of Health and Human Services. (n.d.). Evidence-based and promising practices. 

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CHADD. (2021). Disruptive behavior disorders. 

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CHADD. (2021). Disruptive behavior disorders. 

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Having ADHD along with a coexisting disruptive behavior disorder (ODD/CD) can complicate diagnosis and treatment and also worsen the prognosis. Even though many children with ADHD ultimately adjust, some (especially those with an associated conduct or oppositional defiant disorder) are more likely to drop out of school, have fewer years of overall education, have less job satisfaction and fare less well as adults. Early diagnosis and treatment of these conditions is by far the best defense against these poorer outcomes.

What are the types of disruptive behavior disorders?

Disruptive behavior disorders include two similar disorders: oppositional defiant disorder (ODD) and conduct disorder (CD). Common symptoms occurring in children with these disorders include: defiance of authority figures, angry outbursts, and other antisocial behaviors such as lying and stealing. It is felt that the difference between oppositional defiant disorder and conduct disorder is in the severity of symptoms and that they may lie on a continuum often with a developmental progression from ODD to CD with increasing age.

Oppositional defiant disorder (ODD) refers to a recurrent pattern of negative, defiant, disobedient and hostile behavior toward authority figures lasting at least six months. To be diagnosed with ODD four (or more) of the following symptoms must be present:

often loses temper

often argues with adults

often actively defies or refuses to comply with adults' requests or rules

often deliberately annoys people

often blames others for his or her mistakes or misbehavior

is often touchy or easily annoyed by others

is often angry and resentful

is often spiteful or vindictive.

These behaviors must be exhibited more frequently than in other children of the same age and must cause significant impairment in social, academic or occupational functioning to warrant the diagnosis.

Conduct disorder (CD) involves more serious behaviors including aggression toward people or animals, destruction of property, lying, stealing and skipping school. The behaviors associated with CD are often described as delinquency. Children exhibiting these behaviors should receive a comprehensive evaluation.

Children and adolescents with ADHD and CD often have more difficult lives and poorer outcomes than children with ADHD alone.
Incidence of ADHD and ODD or CD
Approximately one-third to one-half of all children with ADHD may have coexisting oppositional defiant disorder (ODD). These children are often disobedient and have outbursts of temper. The rate of children meeting full diagnostic criteria for ODD is similar across all ages. Males have a greater incidence of ADHD and ODD, as do children of divorced parents and mothers with low socioeconomic status. Children with the ADHD combined subtype seem to be more likely to have ODD.

In some cases, children with ADHD may eventually develop conduct disorder (CD), a more serious pattern of antisocial behaviors. Conduct disorder may occur in 25 percent of children and 45 percent of adolescents with ADHD. CD is more commonly seen in boys than girls, and increases in prevalence with age. Children with ADHD who also meet diagnostic criteria for CD are twice as likely to have difficulty reading, and are at greater risk for social and emotional problems. Non-aggressive conduct problems increase with age, while aggressive symptoms become less common.

Given the high co-occurrence of ADHD with disruptive behavior disorders, all children with ADHD symptoms and disruptive behaviors need to be assessed for the possibility that ODD or CD may be present in addition to ADHD.
Risks of having ADHD and a disruptive behavior disorder
Children with ADHD and CD are often at higher risk for contact with the police and the court system than children with ADHD alone. These children frequently lie or steal and tend to disregard the welfare of others. In addition, they risk getting into serious trouble at school or with the police. The risk for legal troubles may be mostly attributable to the symptoms of CD rather than ADHD.

Disruptive behavior disorders and untreated ADHD have been found to lead to an increased risk of substance use disorders. In addition, adolescents with disruptive behaviors disorders and ADHD are more likely to be aggressive and hostile in their interactions with others, and to be arrested. It has also been suggested that the greater impulsivity associated with the ADHD may cause greater antisocial behavior and its consequences. Thus, early recognition and treatment of both the ADHD and disruptive behaviors in children is essential.
Treatment of ADHD and Disruptive Behavior Disorders
All children with symptoms of ADHD and ODD/CD need to be assessed so that both types of problem behaviors can be treated. These children are difficult to live with and parents need to understand that they do not need to deal with their ADHD and ODD/CD child alone. Interventions such as parent training at home and behavioral support in the school can make a difference and parents should not hesitate to ask for assistance.

Home Interventions

Parent Training (PT): Parent training has been shown to be effective for treating oppositional and defiant behaviors. Standardized parent training programs are short-term interventions that teach parents specialized strategies including positive attending, ignoring, the effective use of rewards and punishments, token economies, and time out to address clinically significant behavior problems. Such training programs may include periodic booster sessions.

Severe cases of CD may require multisystemic therapy, an intensive family- and community-based treatment that addresses the multiple causes of serious antisocial behavior in youth. This approach is very comprehensive and demanding. The therapist using such an approach must possess access to developmental and clinical expertise. These intervention services are delivered in a variety of settings, such as home, school and peer groups. Academic and school-based problems are included and some therapists work directly with an entire peer group to influence change.

Parent-child interaction therapy is a treatment that teaches parents to strengthen the relationship with their child and to learn behavior management techniques. It has been found to be effective in the long term for young children with ODD and ADHD. Three to six years after treatment, the mothers of children with these disorders reported that the changes in their children's behavior and their own feelings of control had lasted. Mothers' reports of disruptive behavior decreased with time after treatment.

Collaborative Problem Solving (CPS): Another technique that seems to be promising for children with ADHD and ODD is collaborative problem-solving (CPS). CPS is a treatment that teaches difficult children and adolescents how to handle frustration and learn to be more flexible and adaptable. Parents and children learn to brainstorm for possible solutions, negotiate, make decisions, and implement solutions that are acceptable to both. They learn to resolve disagreements with less conflict.

Family Therapy: Often a child's behavior can have an effect on the whole family. Parents of children with ADHD often report marital difficulties. Mothers may be more depressed and siblings may also develop behavior problems. Family therapy is critical to helping a family address these issues and cope with the realities of having a child with ADHD and disruptive behaviors. Seeking out a counselor or family therapist in your neighborhood can help the entire family address these issues.

School Interventions

School-wide Positive Behavioral Supports: In addition to the environment at home, the school can have a significant impact on a child's behavior patterns. Many school systems now have programs in place to provide school-wide positive behavioral supports. The aim of these programs is to foster both successful social behavior and academic gains for all students. These programs consist of: (1) clear, consistent consequences for inappropriate behaviors; (2) positive contingencies for appropriate behaviors; and (3) team-based services for those students with the more extreme behavioral needs.

Tutoring: Children's ADHD symptoms, as well as oppositional symptoms, have been found to be significantly lower in one-on-one tutoring sessions than in the classroom.

Classroom Management: Providing appropriate instructional supports in the classroom can also lessen disruptive behavior. These include: creating an accepting and supportive classroom climate, promoting social and emotional skills, establishing clear rules and procedures, monitoring child behavior, utilizing rewards effectively, responding to mild problem behaviors consistently and effectively managing anger or aggressive behavior.
Medication
Overall results from several clinical studies indicate that medications used for the treatment of ADHD (stimulants as well as non-stimulants) remain an important component in the treatment of ADHD and coexisting ODD/CD. Children with these disorders treated with these medications were not only more attentive, but less antisocial and aggressive. ADHD medications are often effective treatments for aggressive or antisocial behavior in patients with ADHD and certainly play a role in any treatment program. See Managing Medication for Children with ADHD for more information.

In addition to using stimulant medications alone, medication combinations to reduce behavioral and conduct symptoms associated with attention-deficit/hyperactivity disorder appear to be very effective. In several studies, this treatment combination was reported to be well tolerated and unwanted effects were transient.

What can a parent do?

To increase the chance for a successful future and to discourage delinquent behaviors in children with ADHD, diagnosis and intervention is extremely important. It is essential for parents to provide structure and reinforce appropriate behavior. In addition, a positive behavior management plan to lessen anti-social behavior is important. Parents should discuss their child's behavioral symptoms with the pediatrician or family practitioner and seek a referral to a mental health professional who can suggest effective parenting strategies.

In addition, parents should contact their child's school counselor or school psychologist to discuss possible interventions to improve behaviors at school. Having the counselor or psychologist support the teacher in handling classroom behaviors often results in significant behavioral changes and decreases the incidence of expulsion. Consistent behavior management at home, school and elsewhere needs to be enforced.
For more information and further reading
Barkley, Russell. (1998). Your defiant child: 8 steps to better behavior . New York, NY: Guilford Press. This book is divided into two parts, "Getting to Know Your Defiant Child" and "Getting Along with Your Defiant Child." Part two contains an eight-step parenting program built on consistency.

Clark, Lynn. (1996) SOS! Help for parents . Berkeley, CA: Parents Press. This book helps parents learn methods for helping children to improve their behavior and techniques for aiding a variety of child personalities, from the stubborn and willful child to time-out basics. It focuses on the basic skills of time-out and how parents can use these techniques to further a child's behavior modification.

Forgatch, Marion S. and Gerald R. Patterson. (2005) Parents and adolescents living together: Family problem solving. Champaign, IL: Research Press. This book shows parents how to improve their communication and problem-solving skills, hold family meetings and get the whole family involved in solving problems. It explains how parents can teach their teenaged children to be responsible about schoolwork, sexual behavior and drugs and alcohol.

Goldstein, Sam; Robert Brooks and Sharon K. Weiss. (2004) Angry children, worried parents: Seven steps to help families manage anger . Plantation, FL: Specialty Press. This book helps parents cope with anger in their children. It presents the following seven steps to help children learn to manage anger: (1) understand why children become angry; (2) determine when your child needs help; (3) help the child become an active participant in the process; (4) use strategies to manage and express anger; (5) develop and implement a daily management plan; (6) assess and solve problems; and (7) instill a resilient mindset in the child.

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ADHD and Disruptive Behavior Disorders - CHADD

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Having ADHD along with a coexisting disruptive behavior disorder (ODD/CD) can complicate diagnosis and treatment and also worsen the prognosis. Even though many children with ADHD ultimately adjust, some (especially those with an associated conduct or oppositional defiant disorder) are more likely to drop out of school, have fewer years of overall education, have less...

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Nationwide Children's Hospital. (2020). Disruptive behavior disorder. 

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Nationwide Children's Hospital. (2020). Disruptive behavior disorder. 

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What Causes Disruptive Behavior Disorders?

The causes of disruptive behavior disorders are unknown. But the disorders are thought to spring from different factors working together:

Heredity. Children with disruptive behavior disorders often have parents with mental health disorders, including

Substance abuse.

Attention-deficit/hyperactivity disorder.

A mood disorder.

Schizophrenia.

Antisocial personality disorder.

However, affected children have also been known to come from healthy families that function well.

Environment. There is an increased risk for disruptive behavior disorders among children who were:

Rejected by their mothers as infants.

Separated from their parents.

Recipients of poor foster care.

Physically, emotionally, or sexually abused or neglected.

In addition, children who have lived in poverty, or witnessed domestic violence or substance abuse, are at a greater risk for developing the disorders.

Physical. There is a greater risk for developing disruptive behavior disorders among children who:

Had low birth weight.

Have suffered neurological damage.

Psychological. Children who have suffered from attention-deficit hyperactivity disorder are at a higher risk for developing disruptive behavior disorders.

Approximately one-third to one-half of all children with ADHD may have coexisting oppositional defiant disorder. Conduct disorder may occur in 25 percent of children and 45 percent of adolescents with ADHD.

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The causes of disruptive behavior disorders are unknown. But the disorders are thought to spring from different factors working together: Heredity. Children with disruptive behavior disorders often have parents with mental health disorders, including Substance abuse. Attention-deficit/hyperactivity disorder. A mood disorder. Schizophrenia. Antisocial personality disorder.

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Garey, J. (n.d.). Watching for signs of psychosis in teens. Child Mind Institute.

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Garey, J. (n.d.). Watching for signs of psychosis in teens. Child Mind Institute.

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There are fewer more frightening or challenging psychiatric conditions for a family to face than psychosis, an extreme mental state in which impaired thinking and emotions cause a person to lose contact with reality. This could mean hearing or seeing things that aren't there (hallucinations), or believing things that aren't true (delusions).

The illness most often associated with psychosis, schizophrenia, usually doesn't show up until very late adolescence or early adulthood. Recently, however, experts in the field have been working to identify high-risk kids who show symptoms that could serve as early warning signs of psychosis, and several academic centers have been set up to focus on this crucial period when it may be possible to change the trajectory of mental illness.

Not all the kids who are identified with what experts call "prodromal" symptoms will progress, or "convert" to full-blown psychotic illness. But early intervention has been shown to improve outcomes for those who do. And since psychotic symptoms cause disruption across a teenager's life, from school to friendships to family, researchers are hoping quick action can prevent impairment and prolong typical functioning.

What's more, some of the approaches that show promise in delaying onset of psychosis or mitigating symptoms include fairly simple lifestyle changes like stress reduction and sleep hygiene, and managing co-occurring disorders like anxiety. The key: identifying at-risk kids earlier when these low-impact measures are still effective.

What are "prodromal" symptoms?

Prodromal symptoms are "attenuated" or weak symptoms of psychosis. Moreover, "they are a warning sign," says Dr. Christoph Correll, the medical director of the Recognition and Prevention Program (RAP) at Zucker Hillside Hospital in Queens, NY, which specializes in diagnosing and treating early symptoms of mental illness in teenagers and young adults. "These signs can happen in people who don't go on to develop psychosis-but if we follow these people who are in the risk state based on these watered-down versions, one third will probably go on to develop psychosis. That's a lot more than in the general population."

Prodromal symptoms occur on a spectrum from very, very mild to severe and can include:

Withdrawing from friends and family/feeling suspicious of others

Changes in sleeping or eating patterns

Less concern with appearance, clothes or hygiene

Difficulty organizing thoughts or speech

Loss of usual interest in activities or of motivation and energy

Development of unusual ideas or behaviors

Unusual perceptions, such as visions or hearing voices (or even seeing shadows)

Feeling like things are unreal

Change in personality

Feelings of grandiosity (belief he has a superpower, etc)

In some cases, these symptoms represent the early stages of a disorder, and will eventually convert. In others, the symptoms actually fade or remain mild. Dr. Tiziano Colibazzi is a psychiatrist at Columbia Presbyterian's COPE clinic (Center for Prevention and Evaluation), which was established to research and treat prodromal symptoms. "We can identify a group of people that are at clinically high risk," says Dr. Colibazzi. "What we can't do is narrow that group down further to identify the 30 percent who will convert."

First step if you feel your child is at risk: An evaluation

The right treatment for prodromal symptoms depends entirely on how severe they are when they are diagnosed. The first step is a proper and complete diagnosis by a mental health professional with experience in assessing psychotic illness.

If you see marked changes in motivation, thinking, and/or behavior in your child, the first place to start is with her pediatrician to rule out a medical illness. Substance use also needs to be ruled out as the cause of any behavior changes in adolescents. After that, you're going to want to have your child evaluated by a qualified psychiatrist or psychologist. This in itself might be a multi-step process.

"You can't just look at the kid once and get a bit of a history and then know what's going on, " says Dr. Correll. "Kids develop; symptoms develop. And the trajectory-how things change, get better or worse, what other symptoms add on to it-will be highly informative in telling us something about the prognosis, what we expect to happen."

One aid to predicting the evolution and severity of symptoms, notes Dr. Colibazzi, is the patient's ability to doubt his symptoms. If your child retains the self-awareness to know that it's his mind that is playing tricks on him, it's an indication that symptoms are still in the very early stages. As symptoms become more severe, the patient's beliefs (whether paranoid, grandiose or hallucinatory) become increasingly difficult to challenge.

Lifestyle and mental health options

Psychotic symptoms and illnesses have been shown to vary quite a bit depending on the environment-the health of our bodies, our interpersonal relationships, our mindsets. As with any illness, but particularly important in at-risk youth, healthy living is key. Regardless of the severity of prodromal symptoms, Dr. Correll says that your child's outcome can be improved by making sure your kid sticks to a routine that includes:

Eating well

Getting regular exercise

Adhering to a regular sleep schedule

Reducing stress as much as possible

Staying away from drugs-particularly marijuana, which can interact with prodromal symptoms and increase the risk for psychosis significantly

Also, don't forget to address depression and anxiety. According to Dr. Correll, "adults who eventually developed schizophrenia identified a three to five year period during which they experienced depression or anxiety before developing the prodromal symptoms of psychosis and then developed full-blown psychosis." "So treating the depression early," he says, "might actually interrupt the progression from depression to psychosis in some patients."

Treatment for prodromal psychotic symptoms

Dr. Correll recommends trying several approaches. Mild symptoms call for more low-key treatments including:

Psycho-education: teaching both the kid and the family more about the symptoms and the illness.

Therapy, particularly cognitive behavioral therapy: "CBT can be good to change one's thinking patterns," says Correll, "and also to address developing self-esteem. We have to be careful that kids with a psychiatric diagnosis don't self-stigmatize and get into a hopeless or negative mode where they feel they can't achieve."

Lifestyle adjustments: Assessing whether the current school environment is best for the child. Perhaps a therapeutic social group to help the child cope.

Reducing Stress: Stress is often a trigger for symptoms, so reducing stress in these kids' lives is crucial and may prevent or delay conversion to psychotic illness.

Understanding prodromal symptoms and monitoring kids who are at high risk for psychotic illness means that parents can do more for their kids than wait for symptoms to get worse or merely hope for the best. Early monitoring and intervention can give high-risk kids an advantage, which researchers hope will eventually change the odds when it comes to psychotic illness.

"The duration of untreated psychosis does actually seem to affect the course of the illness," Dr. Colibazzi says. The longer the illness goes untreated, the greater the chance that it will cause serious disruption in all areas of the patient's life. "So it is reasonable to think that just following someone very closely and treating them very early, as soon as they develop symptoms, would be helpful."

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Psychosis Symptoms and Signs in Teens | Child Mind Institute

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There are fewer more frightening or challenging psychiatric conditions for a family to face than psychosis, an extreme mental state in which impaired thinking and emotions cause a person to lose contact with reality. This could mean hearing or seeing things that aren't there (hallucinations), or believing things that aren't true (delusions).

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Kids Health. (2021). Bipolar disorder factsheet (for schools). 

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Kids Health. (2021). Bipolar disorder factsheet (for schools). 

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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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Souma, et.al. (n.d.). Academic accommodations for students with psychiatric disabilities. 

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Souma, et.al. (n.d.). Academic accommodations for students with psychiatric disabilities. 

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Achieving equal access through accommodations and universal design

Tens of thousands of students enrolled in American postsecondary institutions report having a mental illness. Recent increases in the size of this group are due in part to improved medications that result in symptoms mild enough for them to enjoy the benefits and meet the challenges of postsecondary education. Students with psychiatric disabilities are entitled to reasonable academic accommodations as provided by the American Disabilities Act (ADA) of 1990 and 2008 amendments. Providing effective accommodations allows students equal access to academic courses and activities. The presence of students with disabilities also contributes to the diversity of the student population.

What is a Mental Illness?

"Mental illness" refers to the collection of all diagnosable mental disorders causing severe disturbances in thinking, feeling, relating, and functional behaviors. It can result in a substantially diminished capacity to cope with the demands of daily life.

A mental illness is a hidden disability; it is rarely apparent to others. However, students with mental illness may experience symptoms that interfere with their educational goals and that create a "psychiatric disability." These symptoms may include, yet are not limited to:

heightened anxieties, fears, suspicions, or blaming others

marked personality change over time

confused or disorganized thinking; strange or grandiose ideas

difficulty concentrating, making decisions, or remembering things

extreme highs or lows in mood

denial of obvious problems and a strong resistance to offers of help

thinking or talking about suicide

Psychiatric Diagnoses

A student with a mental illness may have one or more of the following psychiatric diagnoses (American Psychiatric Association, 1994).

Depression. This is a mood disorder that can begin at any age. Major depression may be characterized by a depressed mood most of each day, a lack of pleasure in previously enjoyed activities, thoughts of suicide, insomnia, and consistent feelings of worthlessness or guilt.

Bipolar affective disorder (BAD, previously called manic depressive disorder). BAD is a mood disorder with revolving periods of mania and depression. In the manic phase, a person might experience inflated self-esteem, high work and creative productivity, and decreased need to sleep. In the depressed phase, the person would experience the symptoms of depression (see above).

Borderline personality disorder (BPD). BPD is a personality disorder which includes both mood disorder and thought disorder symptoms. This diagnosis has both biological and environmental determinants. Individuals diagnosed with BPD may have experienced childhood abuse and family dysfunction. They may experience mood fluctuations, insecurities and mistrust, distortion of perceptions, dissociations, difficulty with interpersonal relationships, and limited coping skills.

Schizophrenia. This is a mental disorder that can cause a person to experience difficulty with activities of daily living and possibly delusions, hallucinations, and paranoia. Schizophrenic individuals typically demonstrate concrete thought processing and appreciate structure and routines.

Anxiety disorders. These are mood disorders in which the individual responds to thoughts, situations, environments, or people with fear and anxiety. Anxiety symptoms can disrupt a person's ability to concentrate and focus on tasks at hand. Symptoms may be in response to real or imagined fears. Specific anxiety disorders include generalized anxiety disorder, obsessive-compulsive disorder (OCD), panic disorder, social and specific phobias, and post-traumatic stress disorder (PTSD).

Functional Limitations

The following functional limitations related to psychiatric disabilities may affect academic performance and may require accommodations (Center for Psychiatric Rehabilitation, 1997).

Difficulty with medication side effects: side-effects of psychiatric medications that affect academic performance include drowsiness, fatigue, dry mouth and thirst, blurred vision, hand tremors, slowed response time, and difficulty initiating interpersonal contact.

Screening out environmental stimuli: an inability to block out sounds, sights, or odors that interfere with focusing on tasks. Limited ability to tolerate noise and crowds.

Sustaining concentration: restlessness, shortened attention span, distraction, and difficulty understanding or remembering verbal directions.

Maintaining stamina: difficulty sustaining enough energy to spend a whole day on campus attending classes; combating drowsiness due to medications.

Handling time pressures and multiple tasks: difficulty managing assignments, prioritizing tasks, and meeting deadlines. Inability to participate in multi-task work.

Interacting with others: difficulty getting along, fitting in, contributing to group work, and reading social cues.

Fear of authority figures: difficulty approaching instructors or TAs.

Responding to negative feedback: difficulty understanding and correctly interpreting criticism or poor grades. May not be able to separate person from task (personalization or defensiveness due to low self-esteem).

Responding to change: difficulty coping with unexpected changes in coursework, such as changes in the assignments, due dates or instructors. Limited ability to tolerate interruptions.

Severe test anxiety: the individual is rendered emotionally and physically unable to take an exam.

Instructional Strategies

Students with a history of psychiatric disabilities can be intelligent, sensitive, creative, and interesting. You can employ strategies that will promote their success in your class. For example:

Address a variety of learning styles (e.g. auditory, visual, kinesthetic, experiential, or a combination of styles).

Incorporate experiential learning activities.

Be prepared to set behavioral expectations for all students in your class.

Embrace diversity to include people with psychiatric disabilities.

Accommodations

Some students with mental illness may require accommodations to allow them equal access to classes, programs, and coursework. An accommodation is the removal of a barrier to full participation and learning. The emphasis is on access, not outcome. This is done by providing the student with a disability equal access to the content and activities of a course, but not necessarily assuring their success.

Each student with a disability is encouraged to register with the office that supports students with disabilities in order to receive accommodations. Personnel from this office typically send instructors a letter documenting specific accommodations required for the student with the disability. It is the responsibility of the instructor to provide the accommodations. It is the student's responsibility to fulfill the academic requirements of the course. The best solutions result when the instructor, student, and disability support service professional work cooperatively. Meeting as a group may facilitate problem-solving alternatives. Respecting the privacy of the student by not discussing his or her disability or accommodations with others outside of this meeting is essential. Review accommodations periodically with the student to assess effectiveness and adjust to changing needs.

The following are typical classroom, exam, and assignment accommodations that may be recommended by the disability student service professional for a student with a psychiatric disability.

Classroom Accommodations

Preferential seating, especially near the door to allow leaving class for breaks.

Assigned classmate as volunteer assistant.

Beverages permitted in class.

Prearranged or frequent breaks.

Tape recorder use.

Notetaker or photocopy of another student's notes.

Early availability of syllabus and textbooks.

Availability of course materials (lectures, handouts) on disk.

Private feedback on academic performance.

Examination Accommodations

Exams in alternate format (e.g., from multiple choice to essay; oral, presentation, role-play, or portfolio).

Use of assistive computer software (e.g., Optical Character Recognition, allowing scanned text to be read aloud by the computer's sound card; or speech recognition for converting the spoken word to printed word on the computer screen).

Extended time for test taking.

Exams individually proctored, including in the hospital.

Exam in a separate, quiet, and non-distracting room.

Increased frequency of exams.

Assignment Accommodations

Substitute assignments in specific circumstances.

Advance notice of assignments.

Permission to submit assignments handwritten rather than typed.

Written assignments in lieu of oral presentations or vice versa.

Assignments completed in dramatic formats (e.g., demonstration, role-play, and sculpture).

Assignment assistance during hospitalization.

Extended time to complete assignments.

Not all requested accommodations are "reasonable." An accommodation is not reasonable if:

Making the accommodation or having the individual involved in the activity poses a direct threat to the health or safety of others.

Making the accommodation means making a substantial change in an essential element of the curriculum.

Making the accommodation would require a substantial alteration in the manner in which educational opportunities are provided, such as the course objectives being altered.

Making the accommodation would impose an undue financial or administrative burden to the institution.

References

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed). Washington, DC: Author.

Center for Psychiatric Rehabilitation. (1997). How does mental illness affect the way I function at school? Boston University. www.bu.edu/cpr/jobschool/functed.htm.

Additional Resources

DO-IT has created a collection of videos that can be freely viewed at www.washington.edu/doit/videos/index.php. Of particular relevance are the following titles: Building the Team: Faculty, Staff and Students Working Together, Equal Access: Universal Design of Instruction, and Invisible Disabilities and Postsecondary Education. You may also find the following resources useful as you explore this topic further.

National Alliance on Mental Illness (NAMI)

About DO-IT

DO-IT (Disabilities, Opportunities, Internetworking, and Technology) serves to increase the successful participation of individuals with disabilities in challenging academic programs such as those in science, engineering, mathematics, and technology. Primary funding for DO-IT is provided by the National Science Foundation, the State of Washington, and the U.S. Department of Education. DO-IT is a collaboration of UW Information Technology and the Colleges of Engineering and Education at the University of Washington.

Grants and gifts fund DO-IT publications, videos, and programs to support the academic and career success of people with disabilities. Contribute today by sending a check to DO-IT, Box 354842, University of Washington, Seattle, WA 98195-4842.

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Acknowledgment

This publication was developed under a grant from the U.S. Department of Education, #P33A990042. However, these contents do not necessarily represent the policy of the U.S. Department of Education, and you should not assume endorsement by the federal government.

Copyright © 2012, 2009, 2008, 2006, 2001, University of Washington. Permission is granted to copy these materials for educational, noncommercial purposes provided the source is acknowledged.

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By: Alfred Souma, Nancy Rickerson, and Sheryl Burgstahler

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Academic Accommodations for Students with Psychiatric Disabilities | DO-IT

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Achieving equal access through accommodations and universal design Tens of thousands of students enrolled in American postsecondary institutions report having a mental illness. Recent increases in the size of this group are due in part to improved medications that result in symptoms mild enough for…

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Miller, C. (2021). Early treatment for schizophrenia improves outcomes. Child Mind Institute.

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Miller, C. (2021). Early treatment for schizophrenia improves outcomes. Child Mind Institute.

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The first sign of psychosis is usually withdrawal. A teenager or young adult, often someone who's had no prior emotional or behavioral issues, begins to be less engaged with what's going on around him. Instead of school, work, friends, family and fun, he is preoccupied with what's going on internally, increasingly fixated on disturbing ideas that are bubbling up.

He's being monitored by the FBI. There's a chip implanted in his brain. His parents are trying to poison him. He begins seeing and hearing things that others don't see and hear, and becomes suspicious even of people he is closest to. In turn, his speech and his behavior no longer make sense to them.

This is a psychotic break - when someone loses touch with reality, experiencing delusions (false beliefs) or hallucinations (seeing or hearing things that are not there) and what's called "disorganized" speech. In the United States, about 100,000 teenagers and young adults each year experience a first episode of psychosis, with the peak onset between the ages of 15 and 25.

A first psychotic break is terrifying both for the person experiencing it and those who are close to him, says child and adolescent psychiatrist Michael Birnbaum. Neither understands what's happening. "Behavior can drastically change in a very scary way. People stop communicating in the same way. The way they use words and sentences to express what they're thinking becomes totally disorganized."

A person experiencing a psychotic episode usually ends up in the hospital when his behavior escalates to a point of crisis. "Sometimes people are picked up by the police," says Dr. Birnbaum, who is an expert in first episode psychosis. "Sometimes parents or teachers are so frightened that they call 911."

Breakthrough psychosis treatment

The most common cause of psychosis is a psychiatric disorder: schizophrenia or, less often, bipolar disorder or severe depression. Psychosis can recur episodically with these illnesses, severely undermining a young person's developing sense of self, along with school, work and relationships. But there's substantial good news in the treatment of psychosis: evidence shows that treatment after the initial episode can dramatically reduce the number and intensity of future recurrences.

The right treatment within the first two to three years after the first episode has been shown to decrease relapses of psychosis by more than 50 percent and prevent much of the disability associated with a psychotic illness.

"The earlier we intervene, the better the outcome," says Dr. Birnbaum. "This is the take-home message. Get help as soon as possible."

What is early treatment?

Dr. Birnbaum is director of an early treatment program for teenagers and young adults who've experienced psychotic symptoms for the first time. The program has two locations, at Zucker Hillside Hospital in Queens, New York, and at Lenox Hill Hospital in Manhattan. The specialized treatment that's offered in centers like Dr. Birnbaum's has proven so successful that the federal government earmarked $25 million to aid development of these programs across the country - and then doubled it to $50 million.

Patients generally enter these early treatment programs following their release from the hospital. In the hospital they've been given medication that reduces their symptoms, but they may not be symptom-free, since anti-psychotic medication takes 6 to 8 weeks to take full effect. So even if they're considered safe to go home, Dr. Birnbaum explains, patients and their families both have a lot to deal with. Getting into an outpatient program as soon as possible helps them do just that.

The treatment that has been shown to be successful, called Coordinated Specialty Care, involves a combination of services coordinated by a group of professionals working with the patient and the family. They include:

Related: How Does CBT Help People With Psychosis?

Unlike the old standard treatment for schizophrenia, which involved higher doses of medication and no follow-up after hospitalization, the goal of early treatment is not only to reduce psychotic symptoms, but also to help young people learn to manage them and to construct a support network to prevent relapse.

A team approach

At Zucker Hillside, after an extensive initial assessment, patients meet once a week with a therapist for a session of CBTp, which is aimed at helping them handle ongoing symptoms and develop healthy coping strategies. For example, a patient might work on identifying delusional beliefs, figuring out strategies for "reality testing" them, and coming up with alternative, more helpful ways of thinking.

Patients are each assigned to a psychiatrist on staff, who monitors their medication to make sure they're getting the most benefit, at the lowest dose, with the fewest problematic side effects.

The team also works with families, who are essential to recovery. Young people who've experienced psychosis do better when families support their keeping appointments, taking their medications and eating, sleeping and taking care of themselves. These are important skills, since stress can trigger a relapse. Parents also learn how to respond when a son or daughter talks about aliens and the FBI - "how to express love without supporting delusions," as Dr. Birnbaum puts it - and skills for dealing with a crisis and with suicidality.

Finally, staff members work with patients to get them back on track with school and work. "We don't want people to assume the role of a sick person," Dr. Birnbaum notes. "We want them to go back to school despite having these obstacles. Go back to work despite having a temporary handicap. The idea is that this is a bump in the road that we can get over. The best way to start feeling better is to start doing things again."

Related: Before a Psychotic Episode: Watching for Warning Signs in Teens

At Zucker Hillside there is also an assortment of groups to build recovery skills and encourage exercise and social interaction. And there are competitive game nights to help strengthen cognitive functions such as memory and processing speed, which can be weakened in the wake of a psychotic episode. "Some people feel that their brain just isn't working the way it used to," Dr. Birnbaum says.

Some activities are designed to make staying in treatment attractive for young patients, so they remain long enough to get the benefit of early intervention.

Empowering the patient

After an episode, some patients are quickly back to normal, with medicine, while others continue to have psychotic symptoms, but at a less acute level. Delusions and hallucinations might not go away completely, but they are less intense, and the patient can give them less weight and learn to manage them, Dr. Birnbaum says. "They're in the back of their minds, rather than at the front."

Patients also vary in their receptiveness to therapy and taking medication. An important part of the program is empowering the individuals who are being treated to participate with the professionals in joint decision-making about their treatment.

"Young people who don't want to take medication don't have to," says Dr. Birnbaum. "We strongly encourage it. I know the medication is incredibly helpful. But it's an individual decision how much medication they want to take for how long."

Patients who've been taking medication may decide they want to try a lower dose, or go off meds, to see if their symptoms will return. The team approaches it as an experiment, a learning opportunity. Sometimes symptoms don't return, and the patient stays at the lower dose; other times they do, and the patient will ask to go back to the higher dose.

"I would rather have these open and honest discussions than have them say, 'Yes doctor, I'm taking the medication,' and then go home and not take anything - lie to me about it. Or just disappear and don't come back."

A message of hope

Part of the goal of early treatment is to eliminate the stigma attached to schizophrenia, and to show patients, and their families, that it is a more manageable illness than they may think. Patients "graduate" from the Early Treatment Program at Zucker Hillside when they have a good grasp of their illness and they know what they need to do to stay better.

The national initiative to expand these programs aims to change not only the model of treatment but to send a message of hope and optimism.

What Dr. Birnbaum calls "the old story" of schizophrenia was a grim one. But thanks to early intervention programs there is a new story that recovery is possible. These programs are designed, as he puts it, "to stop mental illness in its tracks before it has a chance to take over somebody's life."
To find an earlySt treatment center near you, check out the list of programs around the country compiled by Strong 365, a group that aims to fight stigma surrounding psychosis and encourage more young people to get early treatment.

Read More:
Teen Suicides: What Are the Risk Factors?
What Are the Symptoms of Depression in Teenagers?

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First Psychotic Episode: Why Early Treatment is Critical

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The first sign of psychosis is usually withdrawal. A teenager or young adult, often someone who's had no prior emotional or behavioral issues, begins to be less engaged with what's going on around him. Instead of school, work, friends, family and fun, he is preoccupied with what's going on internally, increasingly fixated on disturbing ideas that are bubbling up.

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West Virginia Board of Education. (2017-2018). Addressing mental health in school crisis prevention and response. 

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West Virginia Board of Education. (2017-2018). Addressing mental health in school crisis prevention and response. 

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Abrams, Z. (2020, October 1). Treating bipolar disorder in kids and teens. American Psychological Association. 

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Abrams, Z. (2020, October 1). Treating bipolar disorder in kids and teens. American Psychological Association. 

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CE credits: 1

Learning objectives: After reading this article, CE candidates will be able to:

1. Explain how the research base on pediatric bipolar disorder has evolved since 1990.

2. Understand the basic diagnostic criteria for pediatric bipolar disorder and know what tools are used to assess it.

3. List and describe the top-line pharmacological and psychosocial treatments for bipolar disorder in children and adolescents.

For more information on earning CE credit for this article, go CE Corner.

Of the nearly 11,000 articles on bipolar disorder in children and adolescents, more than 90% have been published in the last 15 years-after most practitioners were trained and licensed. Keeping up with that explosion of literature can be a challenge, says Eric Youngstrom, PhD, a professor of psychology, neuroscience and psychiatry at the University of North Carolina at Chapel Hill (UNC Chapel Hill).

"It's great to have the research," says Youngstrom, who also directs the Center for Excellence in Research and Treatment of Bipolar Disorder at UNC Chapel Hill. "But the speed of its arrival creates a challenge. How do we find and digest it? How do we learn about new tools and skills and use them?"

The rapid acceleration in research occurred after bipolar disorder was embraced by practitioners as a legitimate diagnosis for youth in the 1990s. Now, studies show that about 4% of people under 18, including children as young as 5, have the disorder, which is characterized by episodes of mania or hypomania-a slightly milder mood state-and, in most cases, depression (Van Meter, A., et al., The Journal of Clinical Psychiatry, Vol. 80, No. 3, 2019; Luby, J.L., & Navsaria, N., The Journal of Child Psychology and Psychiatry, Vol. 51, No. 4, 2010). About 3% of U.S. adults have bipolar disorder, according to the National Institute of Mental Health.

Over the past decade or so, experts across psychology and psychiatry have helped refine assessment and treatment of bipolar disorder among children and adolescents.

Researchers have also designed and tested psychosocial approaches that combine education, skill building and lifestyle modifications to help kids and parents manage the condition. Evidence to support those interventions is growing, giving hope to children and teens for a less tumultuous transition to adulthood if bipolar disorder is diagnosed and addressed early on.

"The field has come a really long way, even in the last five or 10 years, in terms of both diagnosis and treatment," says Tina Goldstein, PhD, an associate professor of psychiatry and psychology at the University of Pittsburgh. "Now, a big focus is disseminating those insights for use by practitioners in various settings."

An overlooked diagnosis

Bipolar disorder was described by modern psychiatrists as early as 1851, though practitioners long believed that mood disorders did not develop until adulthood (Mason, B.L., et al., Behavioral Sciences, Vol. 6, No. 3, 2016). That perspective began to shift in the 1980s when two researchers based at the University of California, Los Angeles (UCLA)-psychologist Michael Strober, PhD, and psychiatrist Gabrielle Carlson, MD-studied a group of 60 teenagers with depression and characterized youth bipolar disorder (Archives of General Psychiatry, Vol. 39, No. 5, 1982).

Though some clinicians were skeptical at first, most ultimately embraced the new findings-perhaps too heartily. Between 1994-95 and 2002-03, outpatient visits with a diagnosis of bipolar disorder increased 40-fold among youth (Moreno, C., et al., Archives of General Psychiatry, Vol. 64, No. 9, 2007). Working at The Ohio State University's Wexner Medical Center, one of the first clinics to specialize in diagnosing the disorder, Mary Fristad, PhD, ABPP, says only about a third of youths referred to her practice for treatment of bipolar disorder had been accurately diagnosed. Instead, many of those patients were suffering from attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder, autism spectrum disorder, depression, anxiety disorders or conduct disorders.

"That experience spoke to the need for better assessment tools and adequate training of clinicians to perform differential diagnosis," Fristad says.

A second wave of research soon began to fill in those gaps. Psychiatrist Barbara Geller, MD, based at Washington University in St. Louis, led the charge to characterize pediatric bipolar disorder and to establish basic diagnostic criteria (Archives of General Psychiatry, Vol. 65, No. 10, 2008). Researchers also began to develop and test treatments for pediatric populations-including mood stabilizers and antipsychotic drugs known to be effective for adults with bipolar disorder, as well as psychosocial interventions to help children and families cope with the diagnosis.

In the last five years, more specialized research has started to help practitioners better understand pediatric bipolar disorder and to differentiate it from other conditions. Psychologists have also studied patients with comorbid conditions, such as ADHD or anxiety disorders (Arnold, L.E., et al., The Journal of Child Psychology and Psychiatry, Vol. 61, No. 2, 2020). Neuroscientific methods such as fMRI and electroencephalography are also being applied to better characterize the physiological underpinnings of the disorder in children.

Diagnosing in children

The criteria used to diagnose bipolar disorder in children and adolescent populations are the same as those used for adults-fluctuations between depression, which can include extreme sadness, low energy levels, loss of pleasure and suicidal ideation, and hypomania or mania, which can involve periods of elevated mood, irritability, a decreased need for sleep, increases in goal-oriented behaviors and inflated self-esteem.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) distinguishes three subcategories of the disorder. Bipolar I is characterized by cycles of episodic major depression and full mania with impairment. Bipolar II involves major depression alternating with briefer and less-impairing periods of hypomania. Two other categories-"other specified bipolar and related disorder" and cyclothymic disorder-describe people with shorter manic or depressive episodes or episodes that fall one or two symptoms short of the full syndrome criteria.

But these disorders can look different in children, who may have more rapidly cycling moods and more "mixed" periods, characterized by simultaneous mania and depression, so experts say specialized assessment tools are needed.

"One of the challenges both in assessing and treating bipolar disorder in kids is that some of the symptoms can look a lot like extreme versions of normal child or adolescent behaviors," says Anna Van Meter, PhD, an assistant professor at New York-based health-care provider Northwell Health's Feinstein Institutes for Medical Research.

Clinicians who assess children and adolescents for bipolar disorder typically start with a symptom checklist, then they conduct a clinical interview that evaluates risk factors-such as a family history of the disorder-and draws on semi-structured interviewing tools such as the Kiddie Schedule for Affective Disorders and Schizophrenia for School Aged Children (Hunt, J.I., et al., Journal of Child and Adolescent Psychopharmacology, Vol. 15, No. 6, 2005).

In fact, clinicians can diagnose bipolar disorder in children more accurately when they ask the children, their teachers and their caregivers to fill out empirically validated questionnaires that ask about mood, energy levels and other factors, Youngstrom and Van Meter found in a metaanalysis (Youngstrom, E.A., et al., Archives of Scientific Psychology, Vol. 3, No. 1, 2015). These scales are available for free on the learning community Wikiversity and at EffectiveChildTherapy.org, supported by APA's Div. 53 (Society of Clinical Child and Adolescent Psychology).

"Improving our accuracy is important because on average, individuals with bipolar disorder will go about 10 years from initially seeking mental health services to receiving a bipolar disorder diagnosis," Van Meter says.

Early intervention

Even before a patient experiences manic and depressive episodes that warrant a bipolar disorder diagnosis, early intervention may hold promise to alter the condition's course for those at risk of developing it. Working with teens who had a first-degree family history of bipolar disorder but no existing mood disorder diagnosis, Goldstein tested Interpersonal and Social Rhythm Therapy (IPSRT), an educational and skill-based approach that aims to help individuals with bipolar disorder establish and maintain regular daily routines to help stabilize their moods. In a small randomized trial, she found that IPSRT helped teens establish more regular sleep-wake cycles, which appeared to mediate mood fluctuations (Goldstein, T.R., et al., Journal of Affective Disorders, Vol. 235, 2018).

Psychologist David Miklowitz, PhD, a professor of psychiatry at UCLA's Semel Institute for Neuroscience and Human Behavior, tested family-focused therapy (FFT), a psychosocial intervention that includes psychoeducation and skill training on communication and problem-solving for youth and their family members. In a three-site randomized trial involving children and teens who had mood instability and a family history of bipolar disorder, his group found that FFT elongated the intervals of wellness between mood episodes and reduced both depressive episodes and suicidal ideation (JAMA Psychiatry, Vol. 77, No. 5, 2020).

"We can't erase bipolar disorder, but we may see a milder course of the illness and lower levels of suicidality when we intervene at an early stage," Miklowitz says.

Increasingly, psychologists and psychiatrists are relying on "risk calculators" to determine who might be a good candidate for such early interventions. Goldstein helped develop one such tool for youth with a family history, which uses information about a child's age, mood and other factors to determine the likelihood that they will develop bipolar disorder (Hafeman, D.M., et al., JAMA Psychiatry, Vol. 74, No. 8, 2017).

"Clinicians anywhere can plug in patient data online, then use the calculator to make decisions with a family about early intervention and treatment options," she says.

Psychologists are also testing ways that technology can help young patients who have already received a diagnosis. Last year, Van Meter launched a study to describe the "digital phenotype" of bipolar disorder in adolescents by quantifying digital markers of their behavior. By passively monitoring teens' smartphones, she obtains estimates of their weekly schedules, physical activity, screen time and degree of social interaction-some of the factors clinicians expect to change before a manic or depressive episode occurs.

"My hope is that we can use this type of monitoring to prospectively identify when a patient is becoming symptomatic so that we can intervene to prevent a full relapse," says Van Meter.

Digital monitoring is also less burdensome for patients than self-reporting and may provide a more accurate snapshot of behavior, she adds. Teenagers and their caregivers complete informed consent for passive monitoring, which logs data about how a phone is used but does not monitor the content of messages or who the participant contacts.

Treatment options

For most cases of pediatric bipolar disorder, the American Academy of Child and Adolescent Psychiatry recommends a combination of medication and psychotherapy ("Practice Parameter for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder," Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 46, No. 1, 2007).

Mood stabilizers and antipsychotic drugs, which have been used for decades to treat bipolar disorder in adults, are also effective in pediatric populations. "In most cases, medication helps stabilize kids so that they can participate effectively in psychotherapy, which then helps with longer-term symptom management and coping strategies," says Amy West, PhD, an associate professor of clinical pediatrics and psychology at Children's Hospital Los Angeles and the University of Southern California's Keck School of Medicine. "I see the two as working in concert."

But many parents express concern about their child or teen using such medications. Antipsychotics, for instance, can cause metabolic disturbances that may result in weight gain and an increased risk for Type 2 diabetes (Harrison, J.N., et al., Journal of Pediatric Health Care, Vol. 26, No. 2, 2012). Miklowitz says more work is needed to establish guidelines for when psychotherapy alone is sufficient to treat bipolar disorder.

At the same time, families that do include medication in a child's treatment may not be getting its full benefit. In a three-month study of teens taking psychotropic drugs for bipolar disorder, Goldstein monitored medication adherence using Bluetooth-equipped pillboxes (Journal of Child and Adolescent Psychopharmacology, Vol. 26, No. 10, 2016).

"What we learned was really distressing. Almost half the time, kids were not taking their medications as prescribed," she says. "But the patients, parents and psychiatrists all reported more than 90% medication adherence."

To address that gap, Goldstein designed a brief intervention that uses motivational interviewing techniques to better understand kids' feelings about taking mood-stabilizing medications, as well as how to stimulate behavior change. She found that the intervention improved adherence compared with a control group (Journal of Affective Disorders, Vol. 265, 2020). The intervention can even be delivered by a nurse or peer educator without a background in mental health, she says.

Psychologists have also been instrumental in developing psychosocial interventions for bipolar disorder to equip kids and families with the tools and information they need to function well. Three popular evidence-based interventions all focus on education, skill building and lifestyle shifts-such as establishing regular sleep-wake cycles, often key for achieving remission-among children and family members.

"We know that the family system is really important for maintaining youth stability following a bipolar diagnosis, so these interventions tend to focus on helping families create a new normal," says West.

FFT, the intervention Miklowitz developed, works with adolescents who have bipolar disorder and their family members to recognize symptoms of the condition and develop a plan for managing manic and depressive episodes. It also helps parents reduce their own stress and expressed emotion. Eight randomized controlled trials have shown that FFT, when delivered in combination with mood-stabilizing medications, reduces symptom severity and relapse in both adolescents and adults with bipolar disorder (Miklowitz, D.J., & Chung, B., Family Process, Vol. 55, No. 3, 2016).

Along with psychiatrist Mani Pavuluri, MD, West developed and tested an intervention known as RAINBOW, which targets children ages 7 to 13 and their families ("RAINBOW: A Child- and Family-Focused Cognitive-Behavioral Treatment for Pediatric Bipolar Disorder, Clinician Guide," Oxford University Press, 2017). Its 12 sessions focus on education about the nature of the disorder, skill building to help kids regulate their emotions, and coping and parenting strategies for caregivers, such as the importance of creating routines. It incorporates cognitive-behavioral therapy, interpersonal psychotherapy and mindfulness-based approaches.

Using a group therapy format, Fristad also developed a widely used psychosocial treatment program, Multifamily Psychoeducational Psychotherapy (MF-PEP), for children and adolescents with mood disorders (Archives of General Psychiatry, Vol. 66, No. 9, 2009). Psychoeducation, a primary component of MF-PEP, teaches parents strategies for managing manic and depressive episodes, as well as how to navigate school and health systems to best support their child (Fristad, M.A., Development and Psychopathology, Vol. 18, No. 4, 2006).

"You can be a great parent, but that doesn't mean you automatically know what to do if your child is suddenly suicidal or is experiencing a manic episode," Fristad says.

Alternative treatments

Researchers are also exploring other interventions for bipolar disorder to help practitioners manage special cases, such as patients with high levels of suicidality or those who don't respond well to medications.

Goldstein adapted a model of dialectical behavior therapy for youth with bipolar disorder, finding that it decreased suicidal ideation compared with typical psychosocial treatment for the condition in a small randomized trial (Journal of Child and Adolescent Psychopharmacology, Vol. 25, No. 2, 2015). She is working to replicate those findings in a larger sample.

Nutritional interventions also show promise for treating bipolar disorder. Fristad has tested the use of broad-spectrum nutrients for children not taking mood stabilizers or antipsychotic medications, with promising results (The Journal of Alternative and Complementary Medicine, Vol. 18, No. 7, 2012). In a randomized controlled trial, she also found that dietary supplementation with omega-3 fatty acids can help reduce both manic and depressive symptoms and improve executive functioning (Journal of Child and Adolescent Psychopharmacology, Vol. 25, No. 10, 2015; The Journal of Child Psychology and Psychiatry, Vol. 59, No. 6, 2018).

But even the top-line pharmacological, psychosocial and lifestyle interventions only help 50% to 60% of pediatric bipolar patients, says West.

"There's a lot of room for improvement in terms of translating our findings into better assessments and treatments," she says.

For example, research on the neural underpinnings of bipolar disorder should directly inform the development of psychological interventions, West says. In addition, research to optimize the match between a child and a given course of treatment could speed up progress and ultimately improve patient outcomes, says Goldstein.

Most important, new findings and best practices for treating bipolar disorder in children and adolescents need to reach private practice and community settings to help the broadest patient population.

"The need is so high, and unfortunately it takes time for evidence-based practices to permeate the field," West says. "We need to do a better job of preparing practitioners to understand pediatric bipolar disorder and to feel comfortable diagnosing and treating it."

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Treating bipolar disorder in kids and teens

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CE credits: 1 Learning objectives: After reading this article, CE candidates will be able to: Explain how the research base on pediatric bipolar disorder has evolved since 1990. Understand the basic diagnostic criteria for pediatric bipolar disorder and know what tools are used to assess it.

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Care Transitions Network. (n.d.). Diagnosing psychotic disorders: Mood and psychosis.

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Care Transitions Network. (n.d.). Diagnosing psychotic disorders: Mood and psychosis.

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National Eating Disorders Association. (2021). Toolkits. 

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National Eating Disorders Association. (2021). Toolkits. 

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NEDA Toolkits are free resources designed to educate on eating disorders.

Parent Toolkit

The NEDA Parent Toolkit is for anyone who wants to understand more about how to support a family member or friend affected by an eating disorder. You will find answers to your insurance questions; signs, symptoms and medical consequences; information about treatment and levels of care; and questions to ask when choosing a treatment provider.
Download the Parent Toolkit >
Educator Toolkit

The NEDA Educator Toolkit is a resource for educators, staff who work in a school setting or those who work with youth outside of school. If you want to understand more about eating disorders, if you'd like to know how to support students and young people who may be affected, this information will help you.
Download the Educator Toolkit >
Coach & Athletic Trainer Toolkit

The Coach & Athletic Trainer Toolkit is a resource for staff who work in gyms, school settings, outside athletic groups, dance studios, etc. who would like to know how to support athletes who may be affected by eating disorders. We've included frequently asked questions and common myths about eating disorders, strategies for assisting athletes and much more.
Download the Coach & Trainer Toolkit >
WORKPLACE TOOLKIT

Maintaining a healthy workplace environment is vital to the happiness and productivity of your organization. If an employee or coworker is struggling with an undetected eating disorder or disordered eating, it can take a major toll on them. Encourage eating disorders screenings to improve overall workplace wellness and to get help to those who need it.
Download the Workplace Toolkit >

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NEDA Toolkits are free resources designed to educate on eating disorders. Parent Toolkit The NEDA Parent Toolkit is for anyone who wants to understand more about how to support a family member or friend affected by an eating disorder.

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National Eating Disorders Collaboration. (n.d.).Treatment options. 

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National Eating Disorders Collaboration. (n.d.).Treatment options. 

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The Therapeutic Team

Due to the complex nature of eating disorders, treatment can often mean working with a multidisciplinary team of practitioners.

Stages of Change

The Stages of Change model is a guide to understanding the five different stages on the way to recovery, although&nbsp;some people may skip back and forth between these stages, especially in cases where relapse is common.

Barriers to Care

Vital access to treatment and recovery can be hampered by a limited availability of care or lack of care in remote areas, by stigma, poor professional skills and poor understanding of the pathways to care.

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Due to the complex nature of eating disorders, treatment can often mean working with a multidisciplinary team of practitioners. The Stages of Change model is a guide to understanding the five different stages on the way to recovery, although some people may skip back and forth between these stages, especially in cases where relapse is common.

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Martin, et.al. (2012). Solution-focused counseling for eating disorders.

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Martin, et.al. (2012). Solution-focused counseling for eating disorders.

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Buser, J. (2012). The school counselor's role in addressing eating disorder symptomatology among adolescents. Vistas Online. 

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Buser, J. (2012). The school counselor's role in addressing eating disorder symptomatology among adolescents. Vistas Online. 

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National Institute of Mental Health. (2016). Eating disorders. U.S. Department of Health and Human Services.

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National Institute of Mental Health. (2016). Eating disorders. U.S. Department of Health and Human Services.

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Overview

There is a commonly held misconception that eating disorders are a lifestyle choice. Eating disorders are actually serious and often fatal illnesses that are associated with severe disturbances in people's eating behaviors and related thoughts and emotions. Preoccupation with food, body weight, and shape may also signal an eating disorder. Common eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder.

Signs and Symptoms

Risk Factors

Treatments and Therapies

Join a Study

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There is a commonly held misconception that eating disorders are a lifestyle choice. Eating disorders are actually serious and often fatal illnesses that are associated with severe disturbances in people's eating behaviors and related thoughts and emotions. Preoccupation with food, body weight, and shape may also signal an eating disorder.

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Child Mind Institute. (n.d.). Eating disorders. 

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Child Mind Institute. (n.d.). Eating disorders. 

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Eating disorders are characterized by an unhealthy relationship with food and eating habits that impair physical health or social functioning. They usually develop in adolescence, and they are more common in girls than boys.

By using this site, you agree to our Terms of Use and Online Privacy Statement, which describes our use of cookies. By using this site without adjusting your settings, you agree to our use of cookies. Read More

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Eating disorders are characterized by an unhealthy relationship with food and eating habits that impair physical health or social functioning. They usually develop in adolescence, and they are more common in girls than boys. By using this site, you agree to our Terms of Use and Online Privacy Statement, which describes our use of cookies.

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Missouri Comprehensive School Counseling Program: Responsive Services. (2015, May). School counselor referral process guide. 

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Missouri Comprehensive School Counseling Program: Responsive Services. (2015, May). School counselor referral process guide. 

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Guide Response Service Referral Process Guide

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Search for up-to-date data on all Missouri School Districts.

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We Are Teachers. (2019 October 1). 10 ways to help students who struggle from anxiety. 

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We Are Teachers. (2019 October 1). 10 ways to help students who struggle from anxiety. 

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Chances are you've seen a significant increase in the number of students who struggle with mental health over the past several years. According to JAMA Pediatrics, even before the pandemic, the rate of child and adolescent anxiety increased 27% between 2016 and 2019. By 2020, more than 5.6 million youths were diagnosed with anxiety. With symptoms such as trouble concentrating, an upset stomach, or sleeplessness, anxiety can be one of the most debilitating challenges students face in classrooms today.

We know anxiety is more than just "worries." It can influence classroom performance just as much as any other learning disability. Kids who are worried and anxious aren't doing it on purpose. The nervous system acts automatically, especially when it comes to worry (which often stems from fight-or-flight reflexes). That's why phrases like "just relax" or "calm down" aren't helpful. But with practice, kids can learn to slow down their anxious brains, and we can learn to help them. Here are a few ways you can help anxious kids in the classroom.

1. Educate yourself about anxiety

The more you understand about anxiety, the more you can arm yourself with strategies to help your students. This article from district superintendent Jon Konen provides a definition of anxiety, its causes, how to recognize it, types of anxiety disorders, and, most importantly, how you can help as a teacher.

2. Create strong bonds

Building strong bonds and connecting to youth can protect their mental health. Schools and parents can create these protective relationships with students and help them grow into healthy adulthood. Try these 12 Ways To Build Strong Classroom Community.

3. Practice those deep breaths

When people slow down their breathing, they slow down their brain. When I notice that one of my kids is struggling with anxiety, I'll often lead the whole class in a breathing exercise. It helps the child who is overwhelmed and usually a few other kids too. Sometimes I'll do it just because the whole class is squirrelly and we need to focus. Slow, deep breaths are the key. This article about belly breathing describes the process I like to use with my kids. It works every single time.

4. Take a break and go outside

Being out in nature can also calm an anxious brain. Sometimes just a change of scenery is what makes the difference. Breathing the cool air or making time to notice chirping birds can also calm an overactive worrier. Asking students to carefully observe their environment can help them turn the focus away from their worries and toward something more tangible: How many different kinds of trees do you see? How many different bird songs do you hear? How many different shades of green are in the grass?

It doesn't hurt for us to take a mental break sometimes too. Check out 20 Terrific Guided Meditation for Teachers.

5. Talk openly about anxiety

Don't set anxiety up as something you want (or should) get rid of. It's part of life, and it's not realistic to think it'll go away completely. You can help students see and understand this in your own actions. Check out this great article of what you should (and shouldn't) do when working with kids dealing with anxiety.

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6. Tackle the topic with a good book

Often, when one of my kids is struggling, the school counselor will come and share a picture book about managing anxiety with the entire class. Some kids may not be receptive to direct, one-on-one intervention, but they will respond beautifully if they know the whole class is receiving the same information. Check out this list of great books for kids with anxiety.

7. Get kids moving

Exercise helps anyone who is feeling anxious. Anxiety can end up looking like anger, so if you see this, try taking a movement break. You probably already have some favorite ways to do this, but if you're looking for some ideas, check out our video above. You can also get the free set of printables for that right here.

8. Try walking and talking

Building on the moving idea, if you have a student that needs some one-on-one attention, try the " On My Walk " activity. I used to have a student who struggled a lot with anxiety, and this worked great with her. After a couple of loops around the playground with me, everything would feel a little better. Our walk served three purposes: 1. It removed her from the situation. 2. It gave her a chance to explain the issue to me. 3. It got her blood pumping, which clears out the anxiety-producing energy and brings in the positive exercise endorphins.

9. Focus on the positive by having students keep a gratitude journal

The brain is incapable of producing anxious thoughts while it is producing positive thoughts stemming from gratitude. If you can trigger a positive train of thought, you can sometimes derail the anxiety. I knew a teacher who had his fifth graders keep gratitude journals, and every day they would record at least one thing they were thankful for. When his students seemed overwhelmed by negativity or mired in anxiety, he'd encourage them to reread their journals.

Check out the video above for another inspiring teacher or these 22 videos to help kids understand gratitude.

10. Validate students' feelings

Before trying to problem-solve with students who are in the midst of racing thoughts or have completely shut down, Phyllis Fagell, a school counselor and therapist based in Maryland and Washington, D.C., recommends validating their feelings. For instance, saying, "If I was afraid I might look dumb, I'd be worried about raising my hand too," may reduce the impact of anxiety and help a student relax, develop trust, and feel understood. Fagell also reminds teachers not to shame anxious students. For more, check out the full article from WGU.

11. Remind kids to eat healthily and stay well

For the most part, teachers don't really have a lot of control over what students eat and how much they sleep, but these things do matter when it comes to managing anxiety. Not surprisingly, a healthy diet and plenty of sleep make a difference in how well a student is able to handle situations that could be overwhelming. It's one of the reasons that snack and rest time are an essential part of the day for preschoolers!

For your younger students, check out 17 tasty books that teach kids about nutrition and healthy eating habits for a list of picture books about healthy eating.

12. Encourage families to make sure their children are getting enough sleep

With all the extracurricular activities available to kids, not to mention the allure of high-stimulus technology, many kids are just not getting the amount of healthy sleep they need. According to the CDC, children ages 6-12 need as much as 9-12 hours of sleep each night. Preschoolers need even more (10-13 hours), and teens need between 8 and 10 hours. A solid night's sleep does wonders for improving mood, concentration, and outlook. Good sleep quality is also essential. Encourage healthy sleep habits in your students with these Tips for Better Sleep.

13. Create a space where kids can express their anxiety

You've probably heard of classroom safe spaces, and this is a great option to offer if you have students dealing with anxiety. A safe space is a comfy zone in the classroom where kids can go to decompress and regroup. Many teachers include glitter jars, headphones, books, or other items to help kids get back on track.

14. Use fidgets

Another helpful idea, which can stand on its own or be part of your safe space, is offering students classroom fidgets. Sometimes this can work wonders in just giving kids an outlet for their amped-up energy. Here are 39 of our favorite classroom fidgets.

15. Try aromatherapy

Aromatherapy is thought to help activate certain receptors in the brain, potentially easing anxiety. Whether in the form of essential oil, incense, or a candle, natural scents like lavender, chamomile, and sandalwood can be very soothing. Check for sensitivities among your students before introducing a scent to the whole class. An alternative could be an unlit candle, dried herbs, or a sachet treated with essential oil kept in the classroom safe space for students to use individually.

16. Teach kids to recognize their warning signs

Everyone experiences anxiety differently. For children, signs may include shortness of breath, stomachaches, or inability to settle down and concentrate, among others. Coaching students to recognize their unique triggers and warning signs can help them know when to take a step back. Integrate social-emotional strategies throughout the day to help students learn to manage their anxiety.

17. Incorporate Zones of Regulation strategies

Students with anxiety need concrete, easy-to-use strategies to help them cope. Rooted in cognitive therapy, Zones of Regulation is a curriculum developed to help kids understand and learn to manage their emotions. This informative article offers 18 helpful strategies.

18. Offer individual accommodations

For older students, accommodations can make all the difference. Many students struggle with performance anxiety, especially when it comes to tests. When a student is feeling anxious, their brain simply can't function as effectively. When we can set up our tests and assignments so anxious kids are less stressed, they'll likely perform better. Extended time and cue sheets could help kids who suffer from test anxiety. For other accommodations for kids who struggle with anxiety, check out this list from Worry Wise Kids.

The good news about anxiety is that it is one of the most manageable mental-health struggles that children face in the classroom. With the right support and strategies, most children are able to develop strategies that help them manage their anxiety.

The Child Mind Institute offers a " Symptom Checker " to help inform you about a student's possible diagnoses and information and articles to help facilitate a conversation.

19. Mind your classroom management

Schools play a critical role in helping students manage anxiety by creating environments where all students feel that they are cared for, supported, and belong. Certain classroom management approaches strengthen school connectedness. From teacher expectations and behavior management to student autonomy and empowerment, these strategies make a difference.

20. Teach inclusivity

Poor mental health is a growing problem for children and adolescents. According to a JAMA Pediatrics meta-analysis of 29 studies including 80, 879 youths, the prevalence of depression and anxiety symptoms has significantly increased, remains high, and therefore warrants attention.

And some groups are affected more than others. In a report by the CDC, feelings of anxiety and depression were found to be more common among lesbian, gay, or bisexual students and female students. Almost half of lesbian, gay, or bisexual students and nearly one-third of students not sure of their sexual identity reported they had seriously considered suicide-far more than heterosexual students. It is essential that schools put serious effort into creating safe, inclusive classrooms and invest in curricula that supports equity. Here are 50 Tips for Facilitating a More Inclusive Classroom and 5 Ways Social-Emotional Learning Can Help Your Class Become a More Inclusive Community.

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20 Ways To Help Students Who Struggle With Anxiety

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If you have students with anxiety in your classroom, words like "relax" don't help. Instead, try these ideas.

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KidsHealth. (2019, May). Anxiety disorders factsheet (for schools). 

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KidsHealth. (2019, May). Anxiety disorders factsheet (for schools). 

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What Teachers Should Know

Anxiety disorders are among the most common mental health problems of childhood and adolescence.

Anxiety disorders cause people to feel excessively frightened, distressed, or uneasy during situations in which most people would not feel that way. Left untreated, anxiety disorders can impair students' ability to work or study and may affect their personal relationships. In the most severe cases, anxiety disorders can make going to school incredibly difficult.

The most common anxiety-related disorders affecting kids and teens are:

Generalized anxiety disorder. With this common anxiety disorder, children worry excessively about many things, such as school, the health or safety of family members, or the future in general. These students also may have physical symptoms, such as headaches, stomachaches, muscle tension, or tiredness. Their worries might cause them to miss school or avoid social activities.

Obsessive compulsive disorder (OCD). Children with OCD have excessive preoccupying thoughts (obsessions) and repetitive actions done to try to relieve their anxiety (compulsions).

Specific phobias. These are unrealistic and excessive fears, such as a fear of dogs or enclosed spaces. Phobias usually cause people to avoid the things they fear.

Social anxiety disorder (social phobia). This anxiety is triggered by social situations or speaking in front of others. It is an intense fear of being judged in social situations or performance. A less common form, calledselective mutism, causes some students to be too fearful to talk at all in certain situations.

Panic disorder. A panic attack can happen for no apparent reason. With a panic attack, a person has sudden and intense physical symptoms that can include a pounding heart, shortness of breath, or dizziness caused by the body's normal fear response.

Posttraumatic stress disorder (PTSD). This results from a past traumatic event/experience.

Separation anxiety disorder: High level of distress when separated from a caregiver.

Students with an anxiety disorder may:

have trouble concentrating in class or completing classwork

feel self-conscious and avoid certain situations

have physical symptoms, such as a racing heart, fast breathing, tense muscles, sweaty palms, a queasy stomach, and trembling hands or legs

take medication to help reduce anxiety

miss class time due to problems coping at school, or needing to talk with a school counselor or therapist

What Teachers Can Do

Students with anxiety disorders may have difficulty completing their work. Teachers can help ease anxiety levels by:

talking with parents or guardians to learn about strategies that work at home

allowing students extra time to do work

checking that their assignments are written down correctly

giving them daily schedules

modifying assignments and reducing workloads when necessary

promoting relaxation techniques and allowing for breaks throughout day

encouraging school attendance, which may require shortened school days and modified class schedules

allowing them a safe space and ability to go speak with a counselor, if needed

easing anxiety in the classroom by pairing with a peer

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Anxiety Disorders Factsheet (for Schools)

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Anxiety disorders are among the most common mental health problems of childhood and adolescence. Anxiety disorders cause people to feel excessively frightened, distressed, or uneasy during situations in which most people would not feel that way. Left untreated, anxiety disorders can impair students' ability to work or study and may affect their personal relationships.

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Child Mind Institute. (n.d.). Teachers guide to anxiety in the classroom. 

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Child Mind Institute. (n.d.). Teachers guide to anxiety in the classroom. 

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Sometimes anxiety is easy to identify - when a child is too nervous to read aloud or make a presentation in class. Other times anxiety in the classroom can look like something else entirely - an upset stomach, disruptive or angry classroom behavior, ADHD or even a learning disorder. In this guide we outline the types of anxiety that are common in children, and the symptoms of anxiety you might see in your classroom.

Types Of Anxiety in Children

There are many different types of anxiety, which is one of the reasons it can be hard to detect in the classroom. What they all have in common, says neurologist and former teacher Ken Schuster, PsyD, is that anxiety "tends to lock up the brain," making school hard for anxious kids.

Children can struggle with:

Separation anxiety: When children are worried about being separated from caregivers. These kids can have a hard time at school drop-offs and throughout the day.

Social anxiety: When children are excessively self-conscious, making it difficult for them to participate in class and socialize with peers.

Selective mutism: When children have a hard time speaking in some settings, like at school around the teacher.

Generalized anxiety: When children worry about a wide variety of everyday things. Kids with generalized anxiety often worry particularly about school performance and can struggle with perfectionism.

Obsessive-compulsive disorder: When children's minds are filled with unwanted and stressful thoughts. Kids with OCD try to alleviate their anxiety by performing compulsive rituals like counting or washing their hands.

Specific phobias: When children have an excessive and irrational fear of particular things, like being afraid of animals or storms.

Inattention and Restlessness

When a child is squirming in his seat and not paying attention, we tend to think of ADHD, but classroom anxiety could also be the cause. When kids are anxious in the classroom, they might have a hard time focusing on the lesson and ignoring the worried thoughts overtaking their brains.

Some kids might appear really 'on' at one point but then they can suddenly drift away, depending on what they're feeling anxious about," says Dr. Ken Schuster. "That looks like inattention, and its, but it's triggered by anxiety."

School Attendance Problems and Clingy Kids

It might look like truancy, but for kids for whom school is a big source of anxiety, refusing to go to school is also pretty common. School refusal rates tend to be higher after vacations or sick days, because kids have a harder time coming back after a few days away.

Going to school can also be a problem for kids who have trouble separating from their parents. Some amount of separation anxiety is normal, but when kids don't adjust to separation over time and their anxiety makes going to school difficult or even impossible, it becomes a real problem. Kids with separation anxiety may also feel compelled to use their phones throughout the day to check in with their parents.

Disruptive Behavior in the Classroom

Acting out is another thing we might not associate with anxiety. But when a disruptive student is compulsively kicking the chair of the kid in front of him, or throws a tantrum whenever the schedule is ignored or a classmate isn't following the rules, anxiety may well be the cause. Similarly, kids who are feeling anxious might ask a lot of questions, including repetitive ones, because they are feeling worried and want reassurance.

Anxiety in children can cause aggresion. When children are feeling upset or threatened and don't know how to handle their feelings, their fight or flight response to protect themselves can kick in - and some kids are more likely to fight. They might attack another child or a teacher, throw things or push over a desk because they're feeling out of control.

Trouble Answering Questions in Class

Sometimes kids will do perfectly well on tests and homework, but when they're called on in class, teachers hit a wall. There are several different reasons why this might happen.

"Back when I was teaching, I would notice that when I had to call on someone, or had to figure out whose turn it was to speak, it was like the anxious kid always tended to disappear," says Dr. Schuster. "The eager child is making eye contact, giving you some kind of physical presence in the room like 'Call on me, call on me!' "

But when kids are anxious about answering questions in class, "they're going to break eye contact, they might look down, they might start writing something even though they're not really writing something. They're trying to break the connection with the teacher in order to avoid what's making them feel anxious."

If they do get called on, sometimes kids get so anxious that they freeze. They might have been paying attention to the lesson and they might even know the answer, but when they're called on their anxiety level becomes so heightened that they can't respond.

Why do Students with Anxiety Take Frequent Trips to the Nurse

Anxiety in children can manifest in physical complaints, too. If a student is having unexplained headaches, nausea, stomachaches or even vomiting, those could be symptoms of anxiety. So can a racing heart, sweaty palms, tense muscles and being out of breath.

Anxiety and Learning: Problems in Certain Subjects

When a child starts doubting her abilities in a subject, anxiety can become a factor that gets in the way of her learning or showing what she knows. Sometimes this can be mistaken for a learning disorder when it's really just anxiety in children.

However anxiety can also go hand in hand with learning disorders. When kids start noticing that something is harder for them than the other kids, and that they are falling behind, they can understandably get anxious. The period before a learning disorder is diagnosed can be particularly stressful for kids.

Students with Anxiety: Not Turning in Homework

When a student turning in homework, it could be because she didn't do it, but it could also be because she is worried that it isn't good enough. Likewise, anxiety can lead to second guessing - an anxious child might erase his work over and over until there's a hole in the paper - and spending so much time on something that it never gets finished.

We tend to think of perfectionism as a good thing, but when children are overly self-critical it can sabotage even the things they are trying their hardest at, like schoolwork.

You might also notice that some students with anxiety will start worrying about tests much earlier than their classmates and may begin dreading certain assignments, subjects or even school itself.

Avoiding Socializing or Group Work in School

Some kids will avoid or even refuse to participate in the things that make them anxious. This includes obvious anxiety triggers like giving presentations, but also things like gym class, eating in the cafeteria and doing group work.

When kids start skipping things, it might look to their teachers and peers like they are uninterested or underachieving, but the opposite might be true. Sometimes kids avoid things because they are afraid of making a mistake or being judged.

Dr. Schuster notes that when kids get social anxiety, sometimes they have a much easier time showing what they know when teachers engage them one-to-one, away from the group.

This guide was last reviewed or updated on September 7, 2021.

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Sometimes anxiety is easy to identify - when a child is too nervous to read aloud or make a presentation in class. Other times anxiety in the classroom can look like something else entirely - an upset stomach, disruptive or angry classroom behavior, ADHD or even a learning disorder.

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Children's Mental Health. (2021, March 22). Data and statistics on children's mental health. U.S. Department of Health & Human Services.

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Children's Mental Health. (2021, March 22). Data and statistics on children's mental health. U.S. Department of Health & Human Services.

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Centers for Disease Control and Prevention

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Mental health is an important part of children's overall health and well-being. Mental health includes children's mental, emotional, and behavioral well-being. It affects how children think, feel, and act. It also plays a role in how children handle stress, relate to others, and make healthy choices.

Mental disorders among children are described as serious changes in the way children typically learn, behave, or handle their emotions, causing distress and problems getting through the day. Among the more common mental disorders that can be diagnosed in childhood are attention-deficit/hyperactivity disorder (ADHD), anxiety, and behavior disorders.

There are different ways to assess mental health and mental disorders in children. CDC uses surveys, like the National Survey of Children's Health, to describe the presence of positive indicators of children's mental health and to understand the number of children with diagnosed mental disorders and whether they received treatment. In this type of survey, parents report on indicators of positive mental health for their child and report any diagnoses their child has received from a healthcare provider. The information on this page provides data about indicators of positive mental health in children and mental health disorders that are most common in children.

Facts about mental health in U.S. children

National data on positive mental health indicators that describe mental, emotional, and behavioral well-being for children are limited. Based on the data we do have:

Facts about mental disorders in U.S. children

ADHD, anxiety problems, behavior problems, and depression are the most commonly diagnosed mental disorders in children. Estimates for ever having a diagnosis among children aged 3-17 years, in 2016-19, are given below.

ADHD 9.8% (approximately 6.0 million)

Anxiety 9.4% (approximately 5.8 million)

Behavior problems 8.9% (approximately 5.5 million)

Depression 4.4% (approximately 2.7 million)

Some of these conditions commonly occur together. For example, among children aged 3-17 years in 2016:

Having another mental disorder was most common in children with depression: about 3 in 4 children with depression also had anxiety (73.8%) and almost 1 in 2 had behavior problems (47.2%).

For children with anxiety, more than 1 in 3 also had behavior problems (37.9%) and about 1 in 3 also had depression (32.3%).

For children with behavior problems, more than 1 in 3 also had anxiety (36.6%) and about 1 in 5 also had depression (20.3%).

For adolescents, depression, substance use and suicide are important concerns. Among adolescents aged 12-17 years in 2018-2019 reporting on the past year:

Learn more about high-risk substance use among youth. Learn more about suicide.

Mental, behavioral, and developmental disorders begin in early childhood
1 in 6 U.S. children aged 2-8 years (17.4%) had a diagnosed mental, behavioral, or developmental disorder.

Prevalence of mental disorders change with age

Diagnoses of ADHD, anxiety, and depression become are more common with increased age.

Behavior problems are more common among children aged 6-11 years than younger or older children.

Adverse childhood events (ACEs) are associated with children's physical and mental health. In 2016-2019, among children aged 6-17 years:

Children who were discriminated against based on race or ethnicity had higher percentages of one or more physical health conditions (37.8% versus 27.1%), and one or more mental health conditions (28.9% versus 17.8%).

Racial/ethnic discrimination was almost seven times as common among children with three other ACEs compared to those with no other ACEs.

Note: The estimates reported on this page are based on parent report, using nationally representative surveys. This method has several limitations. It is not known to what extent children receive these diagnoses accurately. Estimates based on parent-reported diagnoses may match those based on medical records, but some children may also have mental disorders that have not been diagnosed, or receive diagnoses that may not be the best fit for their symptoms. Limited information on measuring children's mental health nationally is available.

Read more about children's mental health from a community study.

Access to mental health treatment

Early diagnosis and appropriate services for children and their families can make a difference in the lives of children with mental disorders. Access to providers who can offer services, including screening, referrals, and treatment, varies by location. CDC is working to learn more about access to behavioral health services and supports for children and their families.
View information by state describing the rates of different types of providers who can offer behavioral health services providers by county. Read a recent report describing shortages of services, barriers to treatment, and how integration of behavioral health care with pediatric primary care could address the issues. Read a policy brief on potential ways to increase access to mental health services for children in rural areas
Data sources for mental health and related conditions

There are many different datasets which include information on children's mental health and related conditions for children living in the United States.

Healthy People 2030
Healthy People 2030 sets data-driven national objectives to improve health and well-being over the next decade, including children's mental health and well-being.

National Survey of Family Growth (NSFG)
NSFG gathers information on family life, marriage and divorce, pregnancy, infertility, use of contraception, and general and reproductive health.

National Health and Nutrition Examination Survey (NHANES)
NHANES assesses health and nutritional status through interviews and physical examinations, and includes conditions, symptoms, and concerns associated with mental health and substance abuse, as well as the use and need for mental health services.

National Health Interview Survey (NHIS)
NHIS collects data on children's mental health, mental disorders, such as ADHD, autism spectrum disorder, depression and anxiety problems, and use and need for mental health services.

National Survey of Children's Health (NSCH)
NSCH examines the health of children, with emphasis on well-being, including medical homes, family interactions, the health of parents, school and after-school experiences, and safe neighborhoods. This survey was redesigned in 2016.

For previous versions of this survey, see also:
National Survey of Children's Health (NSCH 2003, 2007, 2011-12)
National Survey of Children with Special Healthcare Needs (NS-CSHCN 2001, 2005-6, 2009-10)

National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome (NS-DATA)
NS-DATA collects information about children, 2-15 years old in 2011-2012, who had ever been diagnosed with ADHD and/or Tourette syndrome (TS), with the goal of better understanding diagnostic practices, level of impairment, and treatments for this group of children.

National Survey on Drug Use and Health (NSDUH)
NSDUH, administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), provides national- and state-level data on the use of tobacco, alcohol, and illicit drugs (including non-medical use of prescription drugs), as well as data on mental health in the United States.

National Vital Statistics System (NVSS)
NVSS contains vital statistics from the official records of live births, deaths, causes of death, marriages, divorces, and annulment recorded by states and independent registration areas

National Youth Tobacco Survey (NYTS)
NYTS is a nationally representative school-based survey on tobacco use by public school students enrolled in grades 6-12.

School Associated Violent Death Study (SAVD)
SAVD plays an important role in monitoring trends related to school-associated violent deaths (including suicide), identifying the factors that increase the risk, and assessing the effects of prevention efforts.

School Health Policies and Programs Study (SHPPS)
SHPPS is a national survey assessing school health policies and practices at the state, district, school, and classroom levels. Collected data includes mental health and social service policies.

Web-based Injury Statistics Query and Reporting System (WISQARS)
WISQARS is an interactive database system that provides customized reports of injury-related data.

Youth Risk Behavior Surveillance System (YRBSS)
The YRBSS monitors health-risk behaviors, including tobacco use, substance abuse, unintentional injuries and violence, sexual behaviors that contribute to unintended pregnancy, and sexually transmitted diseases.

References

1. Perou R, Bitsko RH, Blumberg SJ, Pastor P, Ghandour RM, Gfroerer JC, Hedden SL, Crosby AE, Visser SN, Schieve LA, Parks SE, Hall JE, Brody D, Simile CM, Thompson WW, Baio J, Avenevoli S, Kogan MD, Huang LN. Mental health surveillance among children - United States, 2005-2011. MMWR 2013;62(Suppl; May 16, 2013):1-35. [Read summary]

2. Bitsko RH, Claussen AH, Lichtstein J, Black LJ, Everett Jones S, Danielson MD, Hoenig JM, Davis Jack SP, Brody DJ, Gyawali S, Maenner MM, Warner M, Holland KM, Perou R, Crosby AE, Blumberg SJ, Avenevoli S, Kaminski JW, Ghandour RM. Surveillance of Children's Mental Health - United States, 2013 - 2019 MMWR, , 2022 / 71(Suppl-2);1-42. [Read article]

3. Ghandour RM, Sherman LJ, Vladutiu CJ, Ali MM, Lynch SE, Bitsko RH, Blumberg SJ. Prevalence and treatment of depression, anxiety, and conduct problems in U.S. children. The Journal of Pediatrics, 2018. Published online before print October 12, 2018 [Read summary]

4. Bitsko RH, Holbrook JR, Ghandour RM, Blumberg SJ, Visser SN, Perou R, Walkup J. Epidemiology and impact of healthcare provider diagnosed anxiety and depression among US children. Journal of Developmental and Behavioral Pediatrics. Published online before print April 24, 2018 [Read summary]

5. Cree RA, Bitsko RH, Robinson LR, Holbrook JR, Danielson ML, Smith DS, Kaminski JW, Kenney MK, Peacock G. Health care, family, and community factors associated with mental, behavioral, and developmental disorders and poverty among children aged 2-8 years - United States, 2016. MMWR, 2018;67(5):1377-1383. [Read article]

6. Hutchins HJ, Barry CM, Valentine V, Bacon S, Njai R, Claussen AH, Ghandour RM, Lebrun-Harris LA, Perkins K, Robinson LR (submitted). Perceived racial/ethnic discrimination, physical and mental health conditions in childhood, and the relative role of other adverse experiences. Adversity and Resilience Science published online May 23, 2022. [Read summary]

7. US Department of Health and Human Services Health Resources and Services Administration & Maternal and Child Health Bureau. Mental health: A report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, and National Institutes of Health, National Institute of Mental Health; 1999. [Read report]

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Data and Statistics on Children's Mental Health | CDC

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Read data highlights about children's mental health.

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KidsHealth. (2019). Panic Disorder factsheet (for schools)

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KidsHealth. (2019). Panic Disorder factsheet (for schools)

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What Teachers Should Know

Panic disorder is an anxiety disorder in which a person experiences panic attacks. A panic attack is when someone has a sudden, intense physical response with a feeling of unexplained and paralyzing fear.

A panic attack can happen for no apparent reason and the person may have sudden and intense physical symptoms that may last 10 to 20 minutes. The symptoms can include:

pounding heart or chest pain (feeling like having a heart attack)

shortness of breath

dizziness, hot flashes, or chills

sweating, shaking, or tingling in fingers or toes

feeling like a loss of control, or having a fear of dying or other unrealistic thoughts

Mild worrying in kids and teens is normal. But a panic attack may dramatically affect a student's life by interrupting normal activities.

Many kids and teens have a single panic attack, which does not require intervention because it doesn't happen again. But students with panic disorder may:

have difficulty concentrating in class or completing classwork

miss class time due to problems coping at school, or needing to talk with a school counselor or therapist

need to visit the school nurse to take medication for anxiety

feel self-conscious or isolated, and avoid places and situations that they think they might cause a panic attack

What Teachers Can Do

Students with anxiety disorders may have difficulty completing classwork and homework, which can cause panic attacks and possibly lead to panic disorder.

Teachers can help ease anxiety levels by:

keeping communications open with the student, parents or guardians, and school counselors and trying to identify triggers that may cause panic attacks

providing a safe place and a cue system in which the student signals the teacher that a panic attack might be coming and the student needs to take a time-out

adjusting the amount of classwork and homework

encouraging the entire class to use relaxation techniques throughout the day

encouraging students to exercise regularly, which can help reduce feelings of anxiety in patients with panic disorder

Students with panic attacks or panic disorder need encouragement and, sometimes, just someone to listen. A flexible and supportive environment will help improve your student's class participation and encourage the student to develop coping skills.

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Panic Disorder Factsheet (for Schools) (for Parents) - Nemours KidsHealth

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What teachers should know about panic attacks and how to help students who have them.

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Child Mind Institute. (2021). Quick facts on illness anxiety disorder. 

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Child Mind Institute. (2021). Quick facts on illness anxiety disorder. 

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Overview

We usually call people who are excessively concerned about getting sick hypochondriacs. But the psychiatric community has split this behavior into two disorders: somatic symptom disorder (those who misinterpret routine physical symptoms like headaches or fatigue as serious illness) and illness anxiety disorder.

Individuals with illness anxiety disorder are preoccupied about having or getting a serious illness, despite having no or very mild physical symptoms. They are excessively anxious about health and disease, and their worries are not assuaged by test results or doctors' reassurance that nothing is wrong. Some become too anxious to even see a doctor.

Symptoms

Conviction that a disease is present even though symptoms are either nonexistent or very mild

Frequent trips to doctors or a fear of visiting the doctor

Constantly checking one's body for signs of illness

Intense anxiety during doctor's appointments

Requesting to see multiple doctors for the same minor issue and becoming increasingly frustrated and anxious at the repeated lack of diagnosis

Feeling or expressing severe alarm upon reading or hearing about illnesses and health issues

Excessive Internet research about the suspected disease

Avoiding activities that could jeopardize their health, such as visiting sick relatives or exercising

Treatment of Illness Anxiety Disorder

Like its counterpart, somatic symptom disorder, IAD is most often treated with cognitive behavioral therapy (CBT), which helps patients identify where their fears come from and help them cope with them. Serotonin reuptake inhibitors (SSRIs) are also used to reduce anxiety in individuals with IAD.

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We usually call people who are excessively concerned about getting sick hypochondriacs. But the psychiatric community has split this behavior into two disorders: somatic symptom disorder (those who misinterpret routine physical symptoms like headaches or fatigue as serious illness) and illness anxiety disorder.

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Child Mind Institute. (2021). Anxiety basics. 

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Child Mind Institute. (2021). Anxiety basics. 

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Separation anxiety disorder: Children feel extremely upset when they have to be away from parents or caregivers. This anxiety goes beyond what other kids their age normally feel.

Symptoms of separation anxiety include:

Worry about parents or caregivers getting sick or dying

Refusing to leave home or go to school

Fear of sleeping or being alone

Nightmares about separation

Physical symptoms (such as headaches or stomachaches) before an upcoming separation

Children with separation anxiety disorder show symptoms for at least four weeks.

Social anxiety disorder: Children with social anxiety disorder feel extremely self-conscious around other people. They are so afraid of being embarrassed that they avoid social situations and even speaking in class.

Symptoms of social anxiety disorder in children include:

Avoiding most social situations or feeling terrible when they have to participate in them

Physical symptoms like shaking, sweating or trouble breathing in social situations

In young children, tantrums and crying in social situations

Fear of others seeing their anxiety and judging them for it

For a child to be diagnosed with social anxiety disorder, their worry must be so extreme that it interferes with daily life.

Selective mutism: Children with selective mutism have a hard time speaking in some situations, like at school. These kids aren't just shy. Their anxiety is so bad that they feel frozen and are not able to speak.

To get a diagnosis of selective mutism, the child must:

Be able to speak in some situations but not others

Have had the problem for at least a month

Have problems with school and social activities as a result

Children are not diagnosed with selective mutism if their trouble speaking is caused by a communication disorder or language barrier.

Generalized anxiety disorder: Children with generalized anxiety disorder worry about a lot of everyday things. Their worry is not caused by anything specific and it is bad enough to get in the way of daily life.

Symptoms of generalized anxiety disorder in children include:

Restlessness

Feeling on edge

Feeling tired much of the time

Problems concentrating

Feeling angry

Trouble sleeping

To be diagnosed with generalized anxiety disorder, children must experience symptoms most days for at least six months.

Panic disorder: Children with panic disorder have frequent, unexpected panic attacks. Panic attacks cause physical feelings that can make kids think they are dying or having a heart attack.Children are diagnosed with panic disorder when they experience at least one panic attack and show other signs including:

Constant fear of more panic attacks

A big change from normal behavior after the panic attacks, like avoiding places that remind them of an attack

When diagnosing a child with panic disorder, a professional also rules out medical causes and other disorders like PTSD.

Obsessive-compulsive disorder (OCD): Children with OCD have thoughts and worries that make them very anxious. They develop rules for themselves that they feel they must follow to control the anxiety.

Obsessions are the unwanted thoughts that make kids feel upset and anxious.

Compulsions are the rules kids feel they have to follow to get rid of their anxiety.

Children can be diagnosed with OCD when they have obsessions, compulsions or both.

Specific phobia: Kids with specific phobias are very afraid of one or more specific things. This fear is of something that isn't normally considered dangerous. Phobias disrupt kids' lives when they go out of their way to avoid the things they're afraid of.

Common phobias in children include:

Animals or insects

Parts of the natural world, like water or heights

Blood or shots

Specific situations, like crowds or tight spaces

Others including vomiting, choking or loud sounds

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Quick Guide to Anxiety in Children - Child Mind Institute

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Download our free guide to different kinds of anxiety in children. Anxiety causes an extreme feeling of unease in kids. While some anxiety in stressful situations is normal, it becomes a disorder if it lasts a long time or gets in the way of daily life.

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ASCA National Model: A framework for school counseling programs. (n.d.). 

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ASCA National Model: A framework for school counseling programs. (n.d.). 

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Llorente-Ybañez, K. (2014). Addressing anxiety in school settings: Information for counselors. VISTASOnline. 

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Llorente-Ybañez, K. (2014). Addressing anxiety in school settings: Information for counselors. VISTASOnline. 

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ASCA Appropriate Activities for School Counselors

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ASCA Appropriate Activities for School Counselors

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Center for Parent Information and Resources. (2019). Emotional disturbance. 

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Center for Parent Information and Resources. (2019). Emotional disturbance. 

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Links updated, November 2021
This information in Spanish

The mental health of our children is a natural and important concern for us all. The fact is, many mental disorders have their beginnings in childhood or adolescence, yet may go undiagnosed and untreated for years. ( 1)

We refer to mental disorders using different "umbrella" terms such as emotional disturbance, behavioral disorders, or mental illness. Beneath these umbrella terms, there is actually a wide range of specific conditions that differ from one another in their characteristics and treatment. These include (but are not limited to):

anxiety disorders;

bipolar disorder (sometimes called manic-depression);

conduct disorders;

eating disorders;

obsessive-compulsive disorder (OCD); and

psychotic disorders.

You may be reading this fact sheet with one of these specific disorders in mind, or you may be looking for information about emotional disturbances in general. In either case, keep reading to find out what different emotional distubances have in common, how they are defined in federal law, and where to find more detailed information on specific disorders.
Quick-Jump Menu
Definition
IDEA defines emotional disturbance as follows:
We've chosen to use the term "emotional disturbance" in this fact sheet because that is the term used in the nation's special education law, the Individuals with Disabilities Education Act (IDEA).

"...a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child's educational performance:

(A) An inability to learn that cannot be explained by intellectual, sensory, or health factors.

(B) An inability to build or maintain satisfactory interpersonal relationships with peers and teachers.

(C) Inappropriate types of behavior or feelings under normal circumstances.

(D) A general pervasive mood of unhappiness or depression.

(E) A tendency to develop physical symptoms or fears associated with personal or school problems." ( 2)

As defined by IDEA, emotional disturbance includes schizophrenia but does not apply to children who are socially maladjusted, unless it is determined that they have an emotional disturbance. ( 3)

Characteristics

As is evident in IDEA's definition, emotional disturbances can affect an individual in areas beyond the emotional. Depending on the specific mental disorder involved, a person's physical, social, or cognitive skills may also be affected. The National Alliance on Mental Illness of Southern Arizona puts this very well:

Mental illnesses are medical conditions that disrupt a person's thinking, feeling, mood, ability to relate to others and daily functioning. Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a diminished capacity for coping with the ordinary demands of life. ( 4)

Some of the characteristics and behaviors seen in children who have an emotional disturbance include:

Hyperactivity (short attention span, impulsiveness);

Aggression or self-injurious behavior (acting out, fighting);

Withdrawal (not interacting socially with others, excessive fear or anxiety);

Immaturity (inappropriate crying, temper tantrums, poor coping skills); and

Learning difficulties (academically performing below grade level).

Children with the most serious emotional disturbances may exhibit distorted thinking, excessive anxiety, bizarre motor acts, and abnormal mood swings.

Many children who do not have emotional disturbance may display some of these same behaviors at various times during their development. However, when children have an emotional disturbance, these behaviors continue over long periods of time. Their behavior signals that they are not coping with their environment or peers.

Causes

No one knows the actual cause or causes of emotional disturbance, although several factors-heredity, brain disorder, diet, stress, and family functioning-have been suggested and vigorously researched. A great deal of research goes on every day, but to date, researchers have not found that any of these factors are the direct cause of behavioral or emotional problems.

According to NAMI, mental illnesses can affect persons of any age, race, religion, or income. Further:

Mental illnesses are not the result of personal weakness, lack of character, or poor upbringing. Mental illnesses are treatable. Most people diagnosed with a serious mental illness can experience relief from their symptoms by actively participating in an individual treatment plan. ( 5)

Frequency

Of the 74.5 million children in the United States, an estimated 17.1 million have or have had a psychiatric disorder. ( 6) Half of all psychiatric illness occurs before the age of 14, and 75% by the age of 24. The most common psychiatric disorders in childhood are anxiety disorders, AD/HD and disruptive behavior, depression and bipolar disorders, and eating disorders. ( 7)

Help for School-Aged Children

IDEA requires that special education and related services be made available free of charge to every eligible child with a disability, including preschoolers (ages 3-21). These services are specially designed to address the child's individual needs associated with the disability-in this case, emotional disturbance, as defined by IDEA (and further specified by states). In the 2016 school year, more than 349,000 children and youth with emotional disturbance received these services to address their individual needs related to emotional disturbance. ( 8)

Determining a child's eligibility for special education and related services begins with a full and individual evaluation of the child. Under IDEA, this evaluation is provided free of charge in public schools.
10 Basic Steps in Special Education Questions Often Asked by Parents about Special Education Services Evaluating Children for Disability Developing Your Child's IEP
There is a lot to know about the special education process, much of which you can learn here on the CPIR site. We invite you to read the wide range of publications we offer on the topic, especially:

A Look at Specific Emotional Disturbances

As we mentioned, emotional disturbance is a commonly used umbrella term for a number of different mental disorders. Let's take a brief look at some of the most common of these.

We all experience anxiety from time to time, but for many people, including children, anxiety can be excessive, persistent, seemingly uncontrollable, and overwhelming. An irrational fear of everyday situations may be involved. This high level of anxiety is a definite warning sign that a person may have an anxiety disorder.

The term "anxiety disorder" is a broad term covering several different disabilities that share the core symptom of irrational fear. These include such different disorders as generalized anxiety disorder, panic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), social anxiety disorder (also called social phobia), and specific phobias. ( 9)

According to the Anxiety Disorders Association of America, anxiety disorders are the most common psychiatric illnesses affecting children and adults. ( 10) They are also highly treatable. Unfortunately, only about 36.9% of those affected receive treatment. ( 11)

Also known as manic-depressive illness, bipolar disorder is a serious medical condition that causes dramatic mood swings from overly "high" and/or irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes in mood. ( 12)

For most people with bipolar disorder, these mood swings and related symptoms can be stabilized over time using an approach that combines medication and psychosocial treatment. ( 13)

Conduct Disorder

Conduct disorder refers to a group of behavioral and emotional problems in youngsters. Children and adolescents with this disorder have great difficulty following rules and behaving in a socially acceptable way. ( 14) This may include some of the following behaviors:

aggression to people and animals;

destruction of property;

deceitfulness, lying, or stealing; or

truancy or other serious violations of rules. (15)

Treatment will depend on the child's symptoms, age, and general health. It will also depend on how severe the condition is. Treatment may include:

helping the child learn how to better solve problems, communicate, and handle stress, as well as how to control impulses and anger (what's known as cognitive-behavioral therapy);

family therapy;

peer group therapy (to help better social and interpersonal skills); and

medications (although these are not typically used to treat conduct disorder). (16)

Eating disorders are characterized by extremes in eating behavior-either too much or too little-or feelings of extreme distress or concern about body weight or shape. Females are much more likely than males to develop an eating disorder. ( 17)

Anorexia nervosa and bulimia nervosa are the two most common types of eating disorders. Anorexia nervosa is characterized by self-starvation and dramatic loss of weight. Bulimia nervosa involves a cycle of binge eating, then self-induced vomiting or purging. Both of these disorders are potentially life-threatening. ( 18)

Binge eating is also considered an eating disorder. It's characterized by eating excessive amounts of food, while feeling unable to control how much or what is eaten. Unlike with bulimia, people who binge eat usually do not purge afterward by vomiting or using laxatives. ( 19)

According to the National Eating Disorders Association:

Treating an eating disorder generally involves a combination of psychological and nutritional counseling, along with medical and psychiatric monitoring. Treatment must address the eating disorder symptoms and medical consequences, as well as psychological, biological, interpersonal, and cultural forces that contribute to or maintain the eating disorder... Many people utilize a treatment team to treat the multi-faceted aspects of an eating disorder. ( 20)

Obsessive-Compulsive Disorder

Often referred to as OCD, obsessive-compulsive disorder is actually considered an anxiety disorder (which was discussed earlier in this fact sheet). OCD is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions). Repetitive behaviors (handwashing, counting, checking, or cleaning) are often performed with the hope of preventing obsessive thoughts or making them go away. Performing these so-called "rituals," however, provides only temporary relief, and not performing them markedly increases anxiety. ( 21)

A large body of scientific evidence suggests that OCD results from a chemical imbalance in the brain. ( 22) Treatment for most people with OCD should include one or more of the following:

therapist trained in behavior therapy;

Cognitive Behavior Therapy (CBT);

medication (usually an antidepressant). (23)

"Psychotic disorders" is another umbrella term used to refer to severe mental disorders that cause abnormal thinking and perceptions. Two of the main symptoms are delusions and hallucinations. Delusions are false beliefs, such as thinking that someone is plotting against you. Hallucinations are false perceptions, such as hearing, seeing, or feeling something that is not there. Schizophrenia is one type of psychotic disorder. ( 24) There are others as well.

Treatment for psychotic disorders will differ from person to person, depending on the specific disorder involved. Most are treated with a combination of medications and psychotherapy (a type of counseling). ( 25)

More about School

As mentioned, emotional disturbance is one of the categories of disability specified in IDEA. This means that a child with an emotional disturbance may be eligible for special education and related services in public school. These services can be of tremendous help to students who have an emotional disturbance.

Typically, educational programs for children with an emotional disturbance need to include attention to providing emotional and behavioral support as well as helping them to master academics, develop social skills, and increase self-awareness, self-control, and self-esteem. A large body of research exists regarding methods of providing students with positive behavioral support (PBS) in the school environment, so that problem behaviors are minimized and positive, appropriate behaviors are fostered. (See the resource section at the end of this fact sheet for more information on PBS.) It is also important to know that, within the school setting:

For a child whose behavior impedes learning (including the learning of others), the team developing the child's Individualized Education Program (IEP) needs to consider, if appropriate, strategies to address that behavior, including positive behavioral interventions, strategies, and supports.

Students eligible for special education services under the category of emotional disturbance may have IEPs that include psychological or counseling services. These are important related services available under IDEA and are to be provided by a qualified social worker, psychologist, guidance counselor, or other qualified personnel.

Recognizing and Addressing the Impact of COVID-19 | As young people return to in-person schooling in the 2021-2022 school year, they may bring with them the impact of the pandemic's trauma. This makes it essential that schools consider the possibility that many students will need to be re-evaluated to determine if they need additional services, especially behavioral support and mental health services, than they needed prior to COVID-19. Two resources of great relevance to reopening schools and returning students are the following:

Other Considerations

Children and adolescents with an emotional disturbance should receive services based on their individual needs, and everyone involved in their education or care needs to be well-informed about the care that they are receiving. It's important to coordinate services between home, school, and community, keeping the communication channels open between all parties involved.

The Importance of Support

Families often need help in understanding their child's disability and how to address the needs that arise from the disability. Help is available from psychiatrists, psychologists, and other mental health professionals that work in the public or private sector. There is also a network of mental health support operating in every state as well as locally.

To locate systems of support in your community or state, visit the organizations we've listed below. They can connect you with local resources, including support groups that provide connection and understanding, information, referral, and advocacy for those living with emotional disturbance.

There are also support groups available from organizations that address specific mental disorders under the umbrella term of emotional disturbance. See the resources at the end of this fact sheet to identify some of these groups.

Resources of More Information

AACAP | American Academy of Child and Adolescent Psychiatry | AACAP offers Facts for Families, a series in English, Spanish, and several other languages that includes many briefs on specific mental disorders, including the ones mentioned in this publication.

AACAP also operates different Resource Centers, which offer consumer-friendly definitions, answers to frequently asked questions, clinical resources, expert videos, Facts for Families, and much more. Visit the Resource Center home page if you are concerned with one of the following:

Anxiety Disorders

Autism

Bipolar Disorder

Conduct Disorder

Depression

Oppositional Defiant Disorder

NIMH | National Institute of Mental Health | NIMH is clearly a source of authoritative information on specific mental disorders. Phone: 1.866.615.6464. TTY: 1.866.415.8051

NAMI | National Alliance on Mental Illness | NAMI is an excellent source of information and connection on mental illness, including the individual disorders mentioned in this fact sheet. NAMI's website and toll-free helpline are available in English and Spanish.

SAMHSA is the Substance Abuse & Mental Health Services Administration. It offers many resources to consumers, including:.

Detailed information on specific emotional disturbances, or related issues such as positive behavior supports, is also available from these sources:

Anxiety Disorders Association of America | https://adaa.org/

Center on Positive Behavioral Interventions and Supports | The PBIS Center provides research-based information on how to provide behavioral supports to children who need them. | https://www.pbis.org

Conduct Disorders | A soft place to land for battle-weary parents
https://www.conductdisorders.com/community/

Encyclopedia of Mental Disorders | http://www.minddisorders.com/index.html

National Eating Disorders Association
1.800.931.2237 | www.nationaleatingdisorders.org

Something Fishy | (eating disorders)
https://www.something-fishy.org

**Highly Rated Resource! This resource was reviewed by 3-member panels of Parent Center staff working independently from one another to rate the quality, relevance, and usefulness of CPIR resources. This resource was found to be of "High Quality, High Relevance, High Usefulness" to Parent Centers.
________________________________________

References

2 | Code of Federal Regulations, Title 34, §300.8(c)(4)(i)

3 | Code of Federal Regulations, Title 34, §300.8(c)(4)(ii)

5 | Ibid.

7 | Ibid.

11 | Ibid.

13 | Ibid.

14 | American Academy of Adolescent and Child Psychiatry. (2013, August). Conduct disorder: Facts for families. Washington, DC: Author. Available online at:
http://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/Facts_for_Families_Pages/Conduct_Disorder_33.aspx

15 | Ibid.

16 | Johns Hopkins Medicine Health Library. (n.d.). Conduct disorder in children. Baltimore, MD: Author. Online at:
https://www.hopkinsmedicine.org/healthlibrary/conditions/mental_health_disorders/conduct_disorder_90,P02560

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Links updated, November 2021 This information in Spanish The mental health of our children is a natural and important concern for us all. The fact is, many mental disorders have their beginnings in childhood or adolescence, yet may go undiagnosed and untreated for years.

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Family Resource Center - Child Mind Institute

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Find resources and information to help you support children who are struggling with mental health, behavior or learning challenges.

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Stuntzner, S. and Hartley, M. (2014). Disability and the counseling relationship what counselors need to know.

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Stuntzner, S. and Hartley, M. (2014). Disability and the counseling relationship what counselors need to know.

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U.S. Department of Health and Human Services. (2007). Children's mental health disorder fact sheet for the classroom. 

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U.S. Department of Health and Human Services. (2007). Children's mental health disorder fact sheet for the classroom. 