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The Aviator

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The Anxiety Disorders - Annenberg Learner

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Imagine a society whose citizens are protected from psychological disorders. This final episode visits several programs that are attempting to eliminate known risk factors - including social isolation and inadequate parenting skills - that often lead to serious disorders. The stories are touching; the results are promising.

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Anxiety

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Module 2- Dys Beh. Video Reflection Template

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Binge Eating Disorder: Symptoms, Treatment, and Help for Compulsive Overeating

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Do you struggle with binge eating? Learn about compulsive overeating, binge eating disorder, and what you can do to stop it.

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To avoid monotony, and provide a basic framework for my story, I'd like to get the basic facts out of the way. I developed anorexia nervosa at ten years old. The weight loss was quick and drastic, and when my parents' friends began asking if I had a terminal disease, they got right on the phone to make an appointment with the nearest specialist. I was diagnosed at the beginning of my fifth grade year, and fought and cried and saw three treatment providers weekly. By the beginning of the next school year, however, I was better. I thrived in middle school, and even remember joking with friends about how "I couldn't even be anorexic again if I tried." False. At thirteen, a few months before middle school graduation, I relapsed. It was slow, and it was gradual, but my eating disorder came back with a force that I hadn't even remotely felt when I was ten. On my first visit back to my old specialist, in early August, I was admitted directly to the hospital.

That year, my freshman year of high school, was marked with three more hospitalizations, bringing my total time spent in the hospital, and not spent in school, to seven months. I was discharged from my last hospitalization in late June, when all of my friends were finishing their final exams of freshman year. I continued to fight and struggle, probably even harder than I had in the hospital, to get healthy.

I want to share what it's really like to live with an eating disorder - beginning to end, no glitz, no glamour, no vain teenage girl who wants to be skinny. Most people think eating disorders are sociocultural illnesses caused by the media. While our societal obsession with thinness can certainly exacerbate the illness, in reality, eating disorders have some of the strongest genetic and neurobiological underpinnings of any mental illness. For me, what started off as a simple diet quickly set off a very different reward and motivation system, and my behaviors became compulsive rather than logical. Further, when most people think of eating disorders, they think of white, young, rich, skinny girls. Unfortunately, this stereotype is wildly inaccurate. Rates of most eating disorders are equal across socioeconomic brackets, in white, latino, asian, and black communities, and rates of bulimia can actually be higher in black and latino communities. One in three sufferers are men. Roughly 30% of sufferers struggle with an eating disorder for their entire lives, so we're not just talking about teens. And the majority of people with eating disorders are not underweight: you really can't tell just by looking at someone. The one thing I am certain that all sufferers would all agree on is that there is absolutely no glamour in suffering. I hope I can provide concrete evidence of this.

My eating disorder was not a reaction to any traumatic experience, nor an attempt to fix any horrible flaw. I was born into a loving family, and had a happy childhood. I was also born into a family with an extensive history of OCD, anxiety issues, and depression. My eating disorder began at 10 when my babysitter went on a diet, and I decided to try it. My relapse at 13 started, rather innocuously, as a way to make myself "perfect." I didn't like the few pounds that puberty had caused me to gain, so I decided to lose them.

It was harmless at the beginning, and felt great. I don't think it had very much to do with a number or how I looked (as a few pounds is pretty insignificant). I just loved that I had set a goal and achieved it so quickly. The important thing to point out is that at this point, my personality had been unaffected. I am, by nature, an extremely outgoing and vocal person. I've always been the "social-butterfly" type in and out of school, speaking my mind with very few worries or restraints. This is something I never intended to change. With the reemergence of the eating disorder, however, it completely did.

I never understood that losing weight - too much weight - not only had physical consequences, but psychological ones as well. I slowly started to become much more isolated and withdrawn and socially anxious. I didn't have energy, and wasn't fun anymore. When I talk about my anorexia, I liken it to OCD, and in fact, 41% of patients with eating disorders have an OCD diagnosis as well. The logical, or at least semi-logical, goal on which my actions were motivated was long past. Restricting had become my new answer for everything; starvation was my default mode. When my parents fought, for example, not eating lunch would take care of all the uncomfortable feelings I was having. Logically, I knew that losing weight was unhealthy, and would make me unattractive, and that I was pretty close to destroying my family if I kept this up. It didn't matter, though, what I thought or knew or wanted, as the eating disorder had grown to a new level, the mental anguish of putting that food in my mouth was just too much. Kind of like a compulsive handwasher, you know it doesn't make logical sense, but you can't stop doing it. It was extremely gradual, which made it even harder to pinpoint, as there was no distinct change. Eventually, though, I lost all aspects of Kristina and became all consumed in darkness.

When I was engaged in anorexia, I was a completely different person. All of my time and energy went into protecting my disorder. I'll give you a few illustrative examples. At the time, my parents were doing family based treatment, now the gold standard for adolescents with anorexia, where parents prepare, serve, and monitor everything you eat. I was required to have caloric beverages at every meal, which my parents would monitor. I would sneak out, walk to the grocery store a mile away, buy diet beverages, and when my parents were in another room, intricately switch the labels and dispose of the drinks that my parents had bought. Similarly, I was obsessed with scales, I used to weight myself multiple times a day and that number dictated everything. My parents threw away my scales, and three separate times, I lied about afterschool plans and took the bus to Macys to buy a new scale. Keep in mind, I'm a 13 year old, in the suburbs, without a car, before UBER. Perhaps the anecdote that best captures who anorexia turned me into is this one. It was a weekend, my mom was supervising me for lunch, and I was delaying because I knew she had a hair appointment, and just maybe I'd get out of eating. Should have thought that one through a little more, because she just made me come to the hairdresser with her to eat in front of her. It was a frigid January day, and I was wearing a down jacket. Every time my mom would turn to glance at her hair, I would frantically tear a chunk of my sandwich off and stuff it into my jacket. That's who anorexia made me. I didn't care about my neighbors looking at me strangely thinking "what in the world is this girl doing;" I was more scared that I'd have to eat the sandwich.

Something else weird happened to me when I was in my disorder, too: I didn't want to get better. Anorexia and the treatment world became my identity, they were safe, and they were comfortable. I looked up to the 40 and 50 year olds in my treatment centers who had been in and out of hospitals upwards of 30 times. When doctors told me they thought I was going to be a chronic case like them, I thought it was cool. This is actually pretty common. Anasognosia, which means "lack of insight into illness" is a term that we typically associate with schizophrenia and bipolar disorder, but it happens commonly in eating disorders too. People with eating disorders often don't think they're sick, don't think they need help, and don't think recovery is possible.

Clearly, and thankfully, I got better. There was no click. I also didn't have any wonderfully compelling reason. It was more of a "what do I have to lose". (No pun intended.) I decided that real life was at least worth giving a shot; if it didn't work the eating disorder would be waiting for me with open arms. The recovery process, though, was hell. People always told me to latch on to the things in my life and parts of myself that were unrelated to the eating disorder. That made sense, except for the fact that nothing, not even one small fraction of my life, was "unrelated to my eating disorder." Everything I could think of inevitably led back to mirrors, or food, or weight, or perfection, or calories, or body image, or measuring cups, or The Best Little Girl in the World. No, I was unable to dissect and revive any "normal" pieces of myself. Essentially, I had to wipe my slate clean and restart.

When I returned to school in September of my sophomore year, I felt, socially, like a five year old. To make matters worse, my insight and self-awareness were far beyond age appropriate, so I was painfully cognizant of my awkwardness. My self-consciousness extended far beyond body image - (though, thinking that you look 200 pounds while still idealizing 60 pound girls on feeding tubes is a pretty torturous mental state to be in.) I vaguely remembered the bold, happy girl that I used to be, and longed to be her again. But there was such a disconnect between me and her; I had no idea how she had gotten so confident, and even less of an idea about how shy, strange, me could even come close. The simplicity and convenience of anorexia was so tempting. But my parents were breathing down my neck, and my body was tired, and I logically knew that no matter how many times I went into the hospital, I would eventually have to come out, and face all of this. Comparatively, facing it in the present would probably be my least painful option.

Recovery required me to step way out of my comfort zone for about two years. Or, rather, forever. That comfort zone was keeping me sick, and so I had to eventually create a new comfort zone. Eating wise, I had to butcher all my "sick" rules. No more measuring cups, fat intake limits, or "I don't eat after 8pm." If we had a surprise pizza party in school, I ate pizza. It killed me to forgo my turkey and lettuce on whole wheat bread for a fresh baked cheesy slice, but that's what normal teenagers do. I wanted to be a normal teenager. I got rid of my scale. Best decision ever. I had tried to convince myself for years that I could have a healthy relationship with my scale, as it was my biggest security blanket, but our relationship had never been anything but unhealthy and I knew it was hindering my recovery. I resisted my crazy impulses to "body check" by seeing exactly how my clothes fit and where they hung and scrunched. Sometimes I felt like I was crawling out of my skin, but I wouldn't let myself do the checking.

Socially was probably the hardest. As previously mentioned, I had horrible anxiety around social situations. Or really, around people in general. At first, I challenged myself in little ways, though at the time they seemed enormous. I began to call friends to get coffee with me, or get our nails done. Once I had built up enough confidence in myself and realized I could hold a conversation and be fun for an hour or two, I stepped up. When my friends would call and invite me to parties, instead of saying I'm sick or tired or have homework, I would say yes. For a few solid months, I was miserable. I kept putting myself out there, though, in hopes that I would eventually begin to actually enjoy spending my time as normal teenagers do. Today I do.

After a solid while of doing well, I hit a minor plateau. For a while, I thought that this was "as good as it was going to get." This is where the self-insight work came in handy. Slowly, I began to realize that, frankly, I will always be a perfectionist. That's okay, and that doesn't mean that I will always have eating disordered thoughts and be unhappy with my body. For me, it wasn't about trying to rid myself of my perfectionist tendencies, but rather, redefining my image of perfection and who I wanted to be. I stopped idealizing waif bodies; healthy Kristina was beautiful and had a real woman's body. She exercised to feel healthy and strong, and not in a panic about eating too much at lunch. She ate ice cream with her friends, and was able to laugh at herself. She got excited about books, and current events, and making a difference in the world. She radiated an inner confidence that made people gravitate towards her. She was happy.

I never believed I'd be one of those girls who ate whatever they wanted and embraced their healthy bodies. I also never tried. There was no click, no "magical pill" to cure me. I made a conscious decision to change my life, and worked at it. Now I'm a real person. I have hopes and dreams. I have real relationships. I go out and socialize. I care about important things instead of how many calories I ate for lunch or how much I weigh. People don't pity me anymore, they want to be friends with me. None of this would be possible if I hadn't gotten rid of my eating disorder. So, as a dear friend of mine once told me: You have a choice. Miserable sick little girl who misses out on everything. Or real girl who LIVES. Try it.

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To avoid monotony, and provide a basic framework for my story, I'd like to get the basic facts out of the way. I developed anorexia nervosa at ten years old. The weight loss was quick and drastic, and when my parents' friends began asking if I had a terminal disease, they got right on the phone to make an appointment with the nearest specialist.

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The Clinician's Pathway Program (CPP) and its assessment tools, the CBQ and JJ, were developed by Dr. Demitri Papolos. By clicking the links below you will leave www.jbrf.org and be redirected to the research site that contains the CPP and the CBQ & JJ assessments. If you have any questions or concerns regarding these tools please direct them to Dr. Papolos's system administrator at CPP@drpapolos.com To Set Up a New CPP Account To Access an Existing CPP Account
Scoring for assessments within the CPP is a fee-based service offered by the private practice of Demitri Papolos, M.D.; this service is independent of JBRF but may be accessed through the JBRF website. Dr. Papolos developed the CBQ & JJ measures and their automated scoring report with the support of JBRF. Questions and/or concerns with regard to the scored report should be addressed to CPP@drpapolos.com

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JBRF - Juvenile Bipolar Research Foundation

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The Clinician's Pathway Program (CPP) and its assessment tools, the CBQ and JJ, were developed by Dr. Demitri Papolos. By clicking the links below you will leave www.jbrf.org and be redirected to the research site that contains the CPP and the CBQ & JJ assessments.

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

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

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

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

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

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

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

* The child's parent or caregiver

* General and special education teachers

* The school principal

* The child's parent or caregiver

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

* At least one special education teacher

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

* A district representative with authority over special education services

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

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

* Specific accommodations, supports, or services for the child

* Names of who will provide each service

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

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

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

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

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

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

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

* How the child will participate in standardized tests

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

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

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

How to resolve disputes

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

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

* Mediation

* Alternative dispute resolution

* Impartial hearing

* Complaint to the Office for Civil Rights (OCR)

* Lawsuit

* Mediation

* Due process complaint

* Resolution session

* Civil lawsuit

* State complaint

* Lawsuit

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

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

About the author

About the author

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

Reviewed by

Reviewed by

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

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

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

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Disruptive Behavior

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Strategies for Disruptive & Conduct Disorders

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Working to deliver a better special education service

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Leonardo Dicaprio's hand washing scene from the Aviator (2004)

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"They are touching things!" - Howard Hughes

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Most children and parents will have some distress or upset - so how do I know when a child or family needs additional help?

Ask your patients (and their parents) about reactions and coping.

Listen for ongoing or severe traumatic stress symptoms.

Consider a referral for a more thorough evaluation with a mental health professional if:

Traumatic stress reactions are severe or prolonged (more than a month).

Traumatic stress reactions interfere with recovery or with returning to normal activities.

Consider: Is the child participating in daily activities to the extent possible given their medical condition? Are stress reactions interfering with treatment adherence? Are new fears or worries troubling the child or parent?

Steps for making a referral Effective mental health treatment for traumatic stress Online resources - help in finding a mental health professional Distinguishing between types of mental health professionals
Therapist Resource Guide: There are many ongoing stressors that children and families endure after diagnosis of an illness or an injury. This guide focuses specifically on medical traumatic stress and responses that children and families may have.

Steps for making a referral

Mention concerns you have identified.
Say something like: "I'm concerned that (you are / your child is) having these upsetting thoughts and feelings. It might be useful to talk with a specialist who can help your family more."

Involve child and family in making a plan.
Ask for their ideas about what is needed now
Say something like: "What issues or difficulties are impacting you / your family the most right now? What would help make things better?"

Ask for permission to offer advice. Present advice as range of possibilities; be sure to incorporate patient/family ideas

Say something like: "I have some suggestions that have helped other patients in the past in situations similar to yours. May I share them with you?"

Range of possibilities might include: patient education materials / websites; speaking with social worker, local clergy, school counselor; seeking out support group, referral to therapist / community mental health center.

Ask about their readiness to act on this now or in the future.
Say something like: "Is this (suggested plan) something you would be willing to do when you leave today, or if you need it next week...month?"

Ask about barriers to potential plans / referrals, and strategies to overcome barriers.
Say something like: "What kinds of things would interfere with following-up on this plan we just discussed? How can we work through this so you end up getting the help you need.?"

Involve the child and parent in setting the agenda*:*Adapted from Wissow et al. (2008)

Keep the door open.

If your patient or their parents are not quite ready to act on a suggested referral now, arrange to follow up to see how your patient is doing.

You might say: "I'd like to talk with you again in a few weeks to see how things are going."

Promote continuity of care.
If your care for this patient is ending, ask permission to communicate your concerns about traumatic stress reactions or risk factors to the child's primary care provider, or to other providers who will continue to take care of this patient.

Facilitating collaboration between pediatric health care and mental health providers: The American Academy of Pediatrics Task Force on Mental Health has developed tools to facilitate collaboration between pediatric health care providers and mental health professionals, including a Physician Referral and Feedback Form template

Effective mental health treatment for traumatic stress

There are very good and helpful treatments for children who continue to have traumatic stress symptoms.
What treatment approaches are effective?
Evidence-based treatments include cognitive-behavioral treatment approaches, and in particular Trauma-Focused Cognitive Behavior Therapy (TF-CBT).

Click here for a fact sheet about effective treatments for youth trauma from the National Child Traumatic Stress Network.

A recent article includes informative summaries of effective mental health treatments for child traumatic stress symptoms, and guidance for health care professionals:
Cohen, J, Kelleher, K, Mannarino, A.. Identifying, treating, and referring traumatized children: The role of pediatric providers. Archives of Pediatric and Adolescent Medicine 2008;162(5):447-452 How can I help parents find effective treatment for their child?
When helping parents find a counselor or therapist to help their child with traumatic stress symptoms, you might suggest that they ask prospective therapists questions such as:

Do you have experience working with children after trauma?

What is your approach to working with this type of problem?

What is your success rate?

How do you work with parents?

The National Child Traumatic Stress Network offers useful tips and information about finding a mental health professional to help children and their families after trauma.

Online resources - help in finding a mental health professional

The National Child Traumatic Stress Network (NCTSN) has trauma-trained, child mental health professionals and community-based treatment centers in 35 states in the US. For information about or referral to a NCTSN center near you, please go to the NCTSN Organizational Members site.
American Psychological Association - Psychologist Locator National Association of Social Workers - Find a Licensed Social Worker American Academy of Child and Adolescent Psychiatrists - Psychiatrist Finder Anxiety Disorders Association of America - Find a Therapist Sidran Institute Help Desk - Locate Trauma Resources ISTSS Clinician Directory - Find a Clinician, Counselor or Mental Health Professional
Distinguishing between types of mental health professionals

Psychologists are professionals who have earned a doctoral degree (Ph.D. or Psy.D.) after 4-6 years of graduate-level training in human behavior and development, psychological testing and evaluation, and psychotherapy. Psychologists are licensed by the state in which they practice.

Psychiatrists are physicians (M.D. or D.O.) who have completed medical school, plus additional advanced training in the evaluation and treatment of psychiatric disorders and emotional and behavioral problems. Psychiatrists are licensed by the state in which they practice. As medical doctors, psychiatrists can prescribe and monitor medications.

Clinical Social Workers are professionals who have earned a master's degree (M.S.W.) after 2-3 years of graduate training. Clinical Social Workers are licensed by the state in which they practice (LCSW or similar credential - varies by state).

Marriage and Family Therapists are professionals who have completed a master's degree (M.A. or M.S.) after 2-3 years of graduate training. Some Marriage and Family Therapists have completed a required amount of clinical hours and passed a state-administered examination to become licensed marriage and family therapist (LMFT).

Licensed Professional Counselors (LPC) & Licensed Mental Health Counselors (LMHC) are mental health professionals who have earned a master's degree (M.A. or M.S.) after 2-3 years of graduate training and have obtained a required amount of clinical experience and passed a state-administered licensing examination.

For more information on the training and credentialing of mental health professionals, see Mayo Clinic: Mental health providers.

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When and How to Refer for Mental Health Care

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Pediatric providers can follow specific steps to determine if and how to refer a child and familiy for further mental health services after a medically traumatic event. Providers can also become familiar with current evidence-based treatments and online resources for mental health services for traumatic stress.

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Most children and parents will have some distress or upset - so how do I know when a child or family needs additional help?

Ask your patients (and their parents) about reactions and coping.

Listen for ongoing or severe traumatic stress symptoms.

Consider a referral for a more thorough evaluation with a mental health professional if:

Traumatic stress reactions are severe or prolonged (more than a month).

Traumatic stress reactions interfere with recovery or with returning to normal activities.

Consider: Is the child participating in daily activities to the extent possible given their medical condition? Are stress reactions interfering with treatment adherence? Are new fears or worries troubling the child or parent?

Steps for making a referral Effective mental health treatment for traumatic stress Online resources - help in finding a mental health professional Distinguishing between types of mental health professionals
Therapist Resource Guide: There are many ongoing stressors that children and families endure after diagnosis of an illness or an injury. This guide focuses specifically on medical traumatic stress and responses that children and families may have.

Steps for making a referral

Mention concerns you have identified.
Say something like: "I'm concerned that (you are / your child is) having these upsetting thoughts and feelings. It might be useful to talk with a specialist who can help your family more."

Involve child and family in making a plan.
Ask for their ideas about what is needed now
Say something like: "What issues or difficulties are impacting you / your family the most right now? What would help make things better?"

Ask for permission to offer advice. Present advice as range of possibilities; be sure to incorporate patient/family ideas

Say something like: "I have some suggestions that have helped other patients in the past in situations similar to yours. May I share them with you?"

Range of possibilities might include: patient education materials / websites; speaking with social worker, local clergy, school counselor; seeking out support group, referral to therapist / community mental health center.

Ask about their readiness to act on this now or in the future.
Say something like: "Is this (suggested plan) something you would be willing to do when you leave today, or if you need it next week...month?"

Ask about barriers to potential plans / referrals, and strategies to overcome barriers.
Say something like: "What kinds of things would interfere with following-up on this plan we just discussed? How can we work through this so you end up getting the help you need.?"

Involve the child and parent in setting the agenda*:*Adapted from Wissow et al. (2008)

Keep the door open.

If your patient or their parents are not quite ready to act on a suggested referral now, arrange to follow up to see how your patient is doing.

You might say: "I'd like to talk with you again in a few weeks to see how things are going."

Promote continuity of care.
If your care for this patient is ending, ask permission to communicate your concerns about traumatic stress reactions or risk factors to the child's primary care provider, or to other providers who will continue to take care of this patient.

Facilitating collaboration between pediatric health care and mental health providers: The American Academy of Pediatrics Task Force on Mental Health has developed tools to facilitate collaboration between pediatric health care providers and mental health professionals, including a Physician Referral and Feedback Form template

Effective mental health treatment for traumatic stress

There are very good and helpful treatments for children who continue to have traumatic stress symptoms.
What treatment approaches are effective?
Evidence-based treatments include cognitive-behavioral treatment approaches, and in particular Trauma-Focused Cognitive Behavior Therapy (TF-CBT).

Click here for a fact sheet about effective treatments for youth trauma from the National Child Traumatic Stress Network.

A recent article includes informative summaries of effective mental health treatments for child traumatic stress symptoms, and guidance for health care professionals:
Cohen, J, Kelleher, K, Mannarino, A.. Identifying, treating, and referring traumatized children: The role of pediatric providers. Archives of Pediatric and Adolescent Medicine 2008;162(5):447-452 How can I help parents find effective treatment for their child?
When helping parents find a counselor or therapist to help their child with traumatic stress symptoms, you might suggest that they ask prospective therapists questions such as:

Do you have experience working with children after trauma?

What is your approach to working with this type of problem?

What is your success rate?

How do you work with parents?

The National Child Traumatic Stress Network offers useful tips and information about finding a mental health professional to help children and their families after trauma.

Online resources - help in finding a mental health professional

The National Child Traumatic Stress Network (NCTSN) has trauma-trained, child mental health professionals and community-based treatment centers in 35 states in the US. For information about or referral to a NCTSN center near you, please go to the NCTSN Organizational Members site.
American Psychological Association - Psychologist Locator National Association of Social Workers - Find a Licensed Social Worker American Academy of Child and Adolescent Psychiatrists - Psychiatrist Finder Anxiety Disorders Association of America - Find a Therapist Sidran Institute Help Desk - Locate Trauma Resources ISTSS Clinician Directory - Find a Clinician, Counselor or Mental Health Professional
Distinguishing between types of mental health professionals

Psychologists are professionals who have earned a doctoral degree (Ph.D. or Psy.D.) after 4-6 years of graduate-level training in human behavior and development, psychological testing and evaluation, and psychotherapy. Psychologists are licensed by the state in which they practice.

Psychiatrists are physicians (M.D. or D.O.) who have completed medical school, plus additional advanced training in the evaluation and treatment of psychiatric disorders and emotional and behavioral problems. Psychiatrists are licensed by the state in which they practice. As medical doctors, psychiatrists can prescribe and monitor medications.

Clinical Social Workers are professionals who have earned a master's degree (M.S.W.) after 2-3 years of graduate training. Clinical Social Workers are licensed by the state in which they practice (LCSW or similar credential - varies by state).

Marriage and Family Therapists are professionals who have completed a master's degree (M.A. or M.S.) after 2-3 years of graduate training. Some Marriage and Family Therapists have completed a required amount of clinical hours and passed a state-administered examination to become licensed marriage and family therapist (LMFT).

Licensed Professional Counselors (LPC) & Licensed Mental Health Counselors (LMHC) are mental health professionals who have earned a master's degree (M.A. or M.S.) after 2-3 years of graduate training and have obtained a required amount of clinical experience and passed a state-administered licensing examination.

For more information on the training and credentialing of mental health professionals, see Mayo Clinic: Mental health providers.

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When and How to Refer for Mental Health Care

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Pediatric providers can follow specific steps to determine if and how to refer a child and familiy for further mental health services after a medically traumatic event. Providers can also become familiar with current evidence-based treatments and online resources for mental health services for traumatic stress.

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Most children and parents will have some distress or upset - so how do I know when a child or family needs additional help?

Ask your patients (and their parents) about reactions and coping.

Listen for ongoing or severe traumatic stress symptoms.

Consider a referral for a more thorough evaluation with a mental health professional if:

Traumatic stress reactions are severe or prolonged (more than a month).

Traumatic stress reactions interfere with recovery or with returning to normal activities.

Consider: Is the child participating in daily activities to the extent possible given their medical condition? Are stress reactions interfering with treatment adherence? Are new fears or worries troubling the child or parent?

Steps for making a referral Effective mental health treatment for traumatic stress Online resources - help in finding a mental health professional Distinguishing between types of mental health professionals
Therapist Resource Guide: There are many ongoing stressors that children and families endure after diagnosis of an illness or an injury. This guide focuses specifically on medical traumatic stress and responses that children and families may have.

Steps for making a referral

Mention concerns you have identified.
Say something like: "I'm concerned that (you are / your child is) having these upsetting thoughts and feelings. It might be useful to talk with a specialist who can help your family more."

Involve child and family in making a plan.
Ask for their ideas about what is needed now
Say something like: "What issues or difficulties are impacting you / your family the most right now? What would help make things better?"

Ask for permission to offer advice. Present advice as range of possibilities; be sure to incorporate patient/family ideas

Say something like: "I have some suggestions that have helped other patients in the past in situations similar to yours. May I share them with you?"

Range of possibilities might include: patient education materials / websites; speaking with social worker, local clergy, school counselor; seeking out support group, referral to therapist / community mental health center.

Ask about their readiness to act on this now or in the future.
Say something like: "Is this (suggested plan) something you would be willing to do when you leave today, or if you need it next week...month?"

Ask about barriers to potential plans / referrals, and strategies to overcome barriers.
Say something like: "What kinds of things would interfere with following-up on this plan we just discussed? How can we work through this so you end up getting the help you need.?"

Involve the child and parent in setting the agenda*:*Adapted from Wissow et al. (2008)

Keep the door open.

If your patient or their parents are not quite ready to act on a suggested referral now, arrange to follow up to see how your patient is doing.

You might say: "I'd like to talk with you again in a few weeks to see how things are going."

Promote continuity of care.
If your care for this patient is ending, ask permission to communicate your concerns about traumatic stress reactions or risk factors to the child's primary care provider, or to other providers who will continue to take care of this patient.

Facilitating collaboration between pediatric health care and mental health providers: The American Academy of Pediatrics Task Force on Mental Health has developed tools to facilitate collaboration between pediatric health care providers and mental health professionals, including a Physician Referral and Feedback Form template

Effective mental health treatment for traumatic stress

There are very good and helpful treatments for children who continue to have traumatic stress symptoms.
What treatment approaches are effective?
Evidence-based treatments include cognitive-behavioral treatment approaches, and in particular Trauma-Focused Cognitive Behavior Therapy (TF-CBT).

Click here for a fact sheet about effective treatments for youth trauma from the National Child Traumatic Stress Network.

A recent article includes informative summaries of effective mental health treatments for child traumatic stress symptoms, and guidance for health care professionals:
Cohen, J, Kelleher, K, Mannarino, A.. Identifying, treating, and referring traumatized children: The role of pediatric providers. Archives of Pediatric and Adolescent Medicine 2008;162(5):447-452 How can I help parents find effective treatment for their child?
When helping parents find a counselor or therapist to help their child with traumatic stress symptoms, you might suggest that they ask prospective therapists questions such as:

Do you have experience working with children after trauma?

What is your approach to working with this type of problem?

What is your success rate?

How do you work with parents?

The National Child Traumatic Stress Network offers useful tips and information about finding a mental health professional to help children and their families after trauma.

Online resources - help in finding a mental health professional

The National Child Traumatic Stress Network (NCTSN) has trauma-trained, child mental health professionals and community-based treatment centers in 35 states in the US. For information about or referral to a NCTSN center near you, please go to the NCTSN Organizational Members site.
American Psychological Association - Psychologist Locator National Association of Social Workers - Find a Licensed Social Worker American Academy of Child and Adolescent Psychiatrists - Psychiatrist Finder Anxiety Disorders Association of America - Find a Therapist Sidran Institute Help Desk - Locate Trauma Resources ISTSS Clinician Directory - Find a Clinician, Counselor or Mental Health Professional
Distinguishing between types of mental health professionals

Psychologists are professionals who have earned a doctoral degree (Ph.D. or Psy.D.) after 4-6 years of graduate-level training in human behavior and development, psychological testing and evaluation, and psychotherapy. Psychologists are licensed by the state in which they practice.

Psychiatrists are physicians (M.D. or D.O.) who have completed medical school, plus additional advanced training in the evaluation and treatment of psychiatric disorders and emotional and behavioral problems. Psychiatrists are licensed by the state in which they practice. As medical doctors, psychiatrists can prescribe and monitor medications.

Clinical Social Workers are professionals who have earned a master's degree (M.S.W.) after 2-3 years of graduate training. Clinical Social Workers are licensed by the state in which they practice (LCSW or similar credential - varies by state).

Marriage and Family Therapists are professionals who have completed a master's degree (M.A. or M.S.) after 2-3 years of graduate training. Some Marriage and Family Therapists have completed a required amount of clinical hours and passed a state-administered examination to become licensed marriage and family therapist (LMFT).

Licensed Professional Counselors (LPC) & Licensed Mental Health Counselors (LMHC) are mental health professionals who have earned a master's degree (M.A. or M.S.) after 2-3 years of graduate training and have obtained a required amount of clinical experience and passed a state-administered licensing examination.

For more information on the training and credentialing of mental health professionals, see Mayo Clinic: Mental health providers.

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When and How to Refer for Mental Health Care

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Pediatric providers can follow specific steps to determine if and how to refer a child and familiy for further mental health services after a medically traumatic event. Providers can also become familiar with current evidence-based treatments and online resources for mental health services for traumatic stress.

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Referral Flow Chart

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Find resources to address the psychological and emotional impact of the COVID 19 pandemic for children, families, and healthcare staff

Welcome to Health Care Toolbox, brought to you by the Center for Pediatric Traumatic Stress (CPTS), a multidisciplinary center co-located at the Children's Hospital of Philadelphia and Nemours A.I. duPont Hospital for Children. CPTS was created to address medical trauma in the lives of children and families.

Our goals for Health Care Toolbox are to increase awareness of medical traumatic stress in children, provide information and evidence-based recommendations for health care providers, and guide parents and families to resources to help them cope with a child's illness or injury.

We also offer online education for health care providers! Check out our online courses on Pediatric Medical Traumatic Stress and Trauma-Informed Care. These courses are free and offer CE credit for nurses.

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Find resources to address the psychological and emotional impact of the COVID 19 pandemic for children, families, and healthcare staff Welcome to Health Care Toolbox, brought to you by the Center for Pediatric Traumatic Stress (CPTS), a multidisciplinary center co-located at the Children's Hospital of Philadelphia and Nemours A.I.

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Knowing How and When to Refer - Assignment

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Knowing How and When to Refer - Assignment

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Module 7 - Knowing How and When to Refer

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The following was included in TCTA's 2018-19 Survival Guide, the ultimate reference tool for Texas educators, and is current as of September 2018 but is subject to change. The information below is for information purposes only, and is not intended to substitute for advice from an attorney.
Teachers are often the first adults to whom abused children turn for help, and educators - those who see the children every day and can observe their appearance and behavior - are considered a primary source for helping to spot and stop a child's suffering.

Reporting requirements and immunity provisions

Texas law requires any professional who suspects that a child is being abused or neglected to make a report to the Texas Department of Family and Protective Services or any local or state law enforcement agency within 48 hours.
Reports must be made of any type of suspected abuse or neglect, not just acts of physical abuse. The obligation to report includes abuse that may occur in the future. Failure to report is a class B misdemeanor punishable by a fine of up to $2,000, 180 days in jail or both.
Abuse defined

The definition of abuse includes physical, sexual or mental abuse, and also failure to make a reasonable effort to prevent a child from being abused. The contents of a report must include, if known:

1. the name and address of the child;

2. the name and address of the person responsible for the care, custody or welfare of the child; and

3. any other pertinent information concerning the alleged or suspected abuse or neglect.

Those reporting are not required to have proof that a child is being abused but must have reasonable cause to know or suspect abuse. As long as the report is made in good faith, the reporter is protected from civil and criminal liability. The commissioner of education has enacted rules supporting state law that require school district policies to inform employees of their immunity from liability for good faith reports as well as the penalties for failure to report.

Districts should provide training to new teachers on recognition and prevention of child abuse and/or neglect, including sexual abuse. The training may be provided as part of district staff development for all employees. For more information, see page 22.

Strict confidentiality provided

The Texas Family Code specifically states that both a child abuse report and the identity of an individual making a report are confidential and may be disclosed only by order of a court or to a law enforcement officer for the purposes of conducting a criminal investigation.

A court may not order the disclosure of a reporter's identity or a child abuse report unless a motion has been filed and the judge has conducted a private review of the requested information and determined that the disclosure is essential to the administration of justice, and is not likely to endanger the life or safety of the child or reporter.

Your responsibility to report

It is suggested that, as a professional courtesy, you inform an administrator of your suspicions of abuse; however, this action does not satisfy or negate your responsibility under Texas law to make a report within 48 hours. The Texas Family Code states that "a professional may not delegate to or rely on another person to make the report."

Rules developed by the commissioner of education stress that district procedures may not undermine state law by requiring school personnel to report suspected child abuse to administrators prior to making the report to the proper authorities.

Additional information on child abuse/neglect and reporting requirements is available on the Texas Department of Family and Protective Services website.

Abuse hotline

Call the Texas Department of Family and Protective Services' 24-hour, toll-free telephone hotline to report suspected abuse or neglect: 800-252-5400. Or file a nonemergency report online.

See also Student Health and Wellness.

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Child abuse or neglect reporting requirements

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The following was included in TCTA's 2018-19 Survival Guide, the ultimate reference tool for Texas educators, and is current as of September 2018 but is subject to change. The information below is for information purposes only, and is not intended to substitute for advice from an attorney.