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This website offers great special education resources for students with Emotional and Behavioral Disorders. In addition to the list of resources, it provides support for parents, including blogs and personal accounts from individuals who have firsthand experience raising children with EBD. These personal stories are a guidance for families facing similar challenges.

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Special Education Resources For EBD - Special Ed Resource

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Children with Emotional Behavior Disorders, just like all children, learn in their own unique way. Luckily Special Education Resources can help in success

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The National Association of Naset offers a valuable information about EBD, providing parents with a better understanding of the disorder and practical strategies to support their children. Their website includes many topics such as examples, causes, assessment, and a section named "Parent Information". By reading these resources, parents can gain more knowledge on EBD and provide guidance to effectively assist their children in challenges associated with the disorder.

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Some of these files may require Adobe Reader for PDF files. These files are noted as PDF at the end of the site explanation. If you do not have Adobe Reader you can download it for free.

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This website shows different types of disorders, including EBD, accompanied by a detailed table about this disorder. It is a great resource for parents looking for in-depth information. With a lot of helpful content, this website also provides parents information on the complexities of these disorders.

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Abstract

Mental health problems in children and adolescents include several types of emotional and behavioural disorders, including disruptive, depression, anxiety and pervasive developmental (autism) disorders, characterized as either internalizing or externalizing problems. Disruptive behavioural problems such as temper tantrums, attention deficit hyperactivity disorder, oppositional, defiant or conduct disorders are the commonest behavioural problems in preschool and school age children. The routine Paediatric clinic or Family Medicine/General Practitioner surgery presents with several desirable characteristics that make them ideal for providing effective mental health services to children and adolescents. DSM-5 and ICD-10 are the universally accepted standard criteria for the classification of mental and behaviour disorders in childhood and adults. The age and gender prevalence estimation of various childhood behavioural disorders are variable and difficult to compare worldwide. A review of relevant published literature was conducted, including published meta-analyses and national guidelines. We searched for articles indexed by Ovid, PubMed, PubMed Medical Central, CINAHL, EMBASE, Database of Abstracts and Reviews, and the Cochrane Database of Systematic reviews and other online sources. The searches were conducted using a combination of search expressions including "childhood", "behaviour", "disorders" or "problems". Childhood behaviour and emotional problems with their related disorders have significant negative impacts on the individual, the family and the society. They are commonly associated with poor academic, occupational, and psychosocial functioning. It is important for all healthcare professionals, especially the Paediatricians to be aware of the range of presentation, prevention and management of the common mental health problems in children and adolescents.

Keywords: Childhood behavioural disorders, Disruptive behaviour disorder, Conduct disorder, Challenging behaviour, Emotional disorder, Anxiety, Depression, Autism, Pervasive developmental disorders

Core tip: Mental health problems in children and young people (CYP) include several types of emotional and behavioural disorders, including disruptive, depression, anxiety and pervasive developmental (autism) disorders, characterized as either "internalizing" or "externalizing". The routine Paediatric or General Practitioner clinic present with several desirable characteristics that make them ideal for providing effective mental health services to CYP. Childhood mental health disorders have significant negative impacts on the individual, the family and the society. It is particularly important for all Paediatricians to be aware of the range of presentation, prevention and management of the common mental health problems in CYP.

INTRODUCTION

Mental health disorders (MHD) are very common in childhood and they include emotional-obsessive-compulsive disorder (OCD), anxiety, depression, disruptive (oppositional defiance disorder (ODD), conduct disorder (CD), attention deficit hyperactive disorder (ADHD) or developmental (speech/language delay, intellectual disability) disorders or pervasive (autistic spectrum) disorders[ 1]. Emotional and behavioural problems (EBP) or disorders (EBD) can also be classified as either "internalizing" (emotional disorders such as depression and anxiety) or "externalizing" (disruptive behaviours such as ADHD and CD). The terminologies of "problems" and "disorders" are interchangeably used throughout this article.

While low-intensity naughty, defiant and impulsive behaviour from time to time, losing one's temper, destruction of property, and deceitfulness/stealing in the preschool children are regarded as normal, extremely difficult and challenging behaviours outside the norm for the age and level of development, such as unpredictable, prolonged, and/or destructive tantrums and severe outbursts of temper loss are recognized as behaviour disorders. Community studies have identified that more than 80% of pre-schoolers have mild tantrums sometimes but a smaller proportion, less than 10% will have daily tantrums, regarded as normative misbehaviours at this age[ 2, 3]. Challenging behaviours and emotional difficulties are more likely to be recognized as "problems" rather than "disorders" during the first 2 years of life[ 4].

Emotional problems, such as anxiety, depression and post-traumatic stress disorder (PTSD) tend to occur in later childhood. They are often difficult to be recognised early by the parents or other carers as many children have not developed appropriate vocabulary and comprehension to express their emotions intelligibly[ 5]. Many clinicians and carers also find it difficult to distinguish between developmentally normal emotions ( e.g., fears, crying) from the severe and prolonged emotional distresses that should be regarded as disorders[ 6]. Emotional problems including disordered eating behaviour and low self-image are often associated with chronic medical disorders such as atopic dermatitis, obesity, diabetes and asthma, which lead to poor quality of life[ 7- 9].

Identification and management of mental health problems in primary care settings such as routine Paediatric clinic or Family Medicine/General Practitioner surgery are cost-effective because of their several desirable characteristics that make it acceptable to children and young people (CYP) ( e.g., no stigma, in local setting, and familiar providers). Several models to improve the delivery of mental health services in the Paediatric/Primary care settings have been recommended and evaluated recently, including coordination with external specialists, joint consultations, improved Mental Health training and more integrated on-site intervention with specialist collaboration[ 10, 11].

A review of relevant published literature was conducted, including published meta-analyses and national guidelines. We searched for articles indexed by Ovid, PubMed, PubMed Medical Central, CINAHL, the Cochrane Database of Systematic reviews and other online sources. The searches were conducted using a combination of search expressions including "childhood", "behaviour", "disorders" or "problems".

CLINICAL PRESENTATIONS OF CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS

Various definitions for a wide range of childhood behavioural disorders are being used. The DSM-5[ 12] offers the commonest universally accepted standard criteria for the classification of mental and behaviour disorders. The ICD-10 is the alternative classification standard[ 13].

Challenging behaviours

Any abnormal pattern of behaviour which is above the expected norm for age and level of development can be described as "challenging behaviour". It has been defined as: "Culturally abnormal behaviour (s) of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy or behaviour which is likely to seriously limit or deny access to and use of ordinary community facilities"[ 14]. They can include self-injury, physical or verbal aggression, non-compliance, disruption of the environment, inappropriate vocalizations, and various stereotypies. These behaviours can impede learning, restrict access to normal activities and social opportunities, and require a considerable amount of both manpower and financial resources to manage effectively.

Many instances of challenging behaviour can be interpreted as ineffective coping strategies for a young person, with or without learning disability (LD) or impaired social and communication skills, trying to control what is going on around them. Young people with various disabilities, including LD, Autism, and other acquired neuro-behavioural disorders such as brain damage and post-infectious phenomena, may also use challenging behaviour for specific purposes, for example, for sensory stimulation, gaining attention of carers, avoiding demands or to express their limited communication skills[ 15]. People who have a diverse range of neurodevelopmental disorders are more likely to develop challenging behaviours[ 16].

Some environmental factors have been identified which are likely to increase the risk of challenging behaviour, including places offering limited opportunities for making choices, social interaction or meaningful occupation. Other adverse environments are characterized by limited sensory input or excessive noise, unresponsive or unpredictable carers, predisposition to neglect and abuse, and where physical health needs and pain are not promptly identified. For example, the rates of challenging behaviour in teenagers and people in their early 20s is 30%-40% in hospital settings, compared to 5% to 15% among children attending schools for those with severe LD[ 15].

Aggression is a common, yet complex, challenging behaviour, and a frequent indication for referral to child and adolescent Psychiatrists. It commonly begins in childhood, with more than 58% of preschool children demonstrating some aggressive behaviour[ 17]. Aggression has been linked to several risk factors, including individual temperaments; the effects of disturbed family dynamics; poor parenting practices; exposure to violence and the influence of attachment disorders. No single factor is sufficient to explain the development of aggressive behaviour[ 18]. Aggression is commonly diagnosed in association with other mental health problems including ADHD, CD, ODD, depression, head injury, mental retardation, autism, bipolar disorder, PTSD, or dyslexia[ 19].

Disruptive behaviour problems

Disruptive behaviour problems (DBP) include attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and conduct disorder (CD). They constitute the commonest EBPs among CYP. Recent evidence suggests that DBPs should be regarded as a multidimensional phenotype rather than comprising distinct subgroups[ 20].

ADHD is the commonest neuro-behavioural disorder in children and adolescents, with prevalence ranging between 5% and 12% in the developed countries[ 21]. ADHD is characterized by levels of hyperactivity, impulsivity and inattention that are disproportionately excessive for the child's age and development[ 12]. The ICD-10[ 13] does not use the term "ADHD" but "hyperkinetic disorder", which is equivalent to severe ADHD. DSM-5 distinguishes between three subtypes of the disorder: predominantly hyperactive/impulsive, predominantly inattentive and combined types (Table ).

Table 1

Criteria

6 of 9 inattentive symptoms

6 of 9 hyperactivity/ impulsivity symptoms

Both criteria for (1) and (2)

Details

Fails to pay close attention to details or makes careless mistakes

Squirms and fidgets

Has difficulty sustaining attention

Can't stay seated

Does not appear to listen

Runs/climbs excessively

Struggles to follow through on instructions

Can't play/work quietly

Has difficulty with organization

"On the go"/"driven by a motor"

Avoids or dislikes tasks requiring a lot of thinking

Blurts out answers

Loses things

Is unable to wait for his turn

Is easily distracted

Intrudes/interrupts others

Talks excessively

Other criteria

Onset before age of 12, lasting more than 6 mo, symptoms pervasive in 2 or more settings, causing significant impairment of daily functioning o development

CD refers to severe behaviour problems (Table ), characterized by repetitive and persistent manifestations of serious aggressive or non-aggressive behaviours against people, animals or property such as being defiant, belligerent, destructive, threatening, physically cruel, deceitful, disobedient or dishonest, excessive fighting or bullying, fire-setting, stealing, repeated lying, intentional injury, forced sexual activity and frequent school truancy[ 13, 22]. Children with CD often have trouble understanding how other people think, sometimes described as being callous-unemotional. They may falsely misinterpret the intentions of other people as being mean. They may have immature language skills, lack the appropriate social skills to establish and maintain friendships, which aggravates their feelings of sadness, frustration and anger[ 12].

Table 2

A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 mo as evidenced by at least four out of 8 symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling

A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 mo from any of the categories below, with at least one criterion present in the past 6 mo

Aggression to people and animals: (1) Often bullies, threatens, or intimidates others; (2) Often initiates physical fights; (3) Has used a weapon that can cause serious physical harm to others ( e.g., a bat, brick, broken bottle, knife, gun); (4) Has been physically cruel to people; (5) Has been physically cruel to animals; (6) Has stolen while confronting a victim ( e.g., mugging, purse snatching, extortion, armed robbery); (7) Has forced someone into sexual activity

Angry/irritable mood: (1) Often loses temper; (2) Is often touchy or easily annoyed; (3) Is often angry and resentful

Argumentative/defiant behavior: (4) Often argues with authority figures or, for children and adolescents, with adults; (5) Often actively defies or refuses to comply with requests from authority figures or with rules; (6) Often deliberately annoys others; (7) Often blames others for his or her mistakes or misbehavior

Destruction of property: (8) Has deliberately engaged in fire setting with the intention of causing serious damage; (9) Has deliberately destroyed others' property (other than by fire setting)

Deceitfulness or theft: (10) Has broken into someone else's house, building, or car; (11) Often lies to obtain goods or favors or to avoid obligations ( i.e., "cons" others); (12) Has stolen items of nontrivial value without confronting a victim ( e.g., shoplifting, but without breaking and entering; forgery)

Vindictiveness: (8) Has been spiteful or vindictive at least twice within the past 6 mo

Serious violations of rules: (13) Often stays out at night despite parental prohibitions, beginning before age 13 yr; (14) Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period; (15) Is often truant from school, beginning before age 13 yr

Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic and the behavior should occur at least once per week for at least 6 mo

The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning

The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context ( e.g., family, peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning

If the individual is age 18 yr or older, criteria are not met for antisocial personality disorder

Specify whether: Childhood-onset type (prior to age 10 yr); Adolescent-onset type or Unspecified onset

Specify if: With limited prosocial emotions: Lack of remorse or guilt; Callous-lack of empathy; Unconcerned about performance or Shallow or deficient affect

Specify current severity: Mild; Moderate or Severe

The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder

ICD-10

It also requires the presence of three symptoms from the list of 15 (above), and duration of at least 6 mo. There are four divisions of conduct disorder: Socialised conduct disorder, unsocialised conduct disorder, conduct disorders confined to the family context and oppositional defiant disorder

Specify current severity: Mild; moderate or severe based on number of settings with symptoms shown

CD is the commonest reason for CYP referral for psychological and psychiatric treatment. Roughly 50% of all CYP with a MHD have a CD[ 23]. About 30%-75% of children with CD also have ADHD and 50% of them will also meet criteria for at least one other disorder including Mood, Anxiety, PTSD, Substance abuse, ADHD, learning problems, or thought disorders[ 24, 25]. Majority of boys have an onset of CD before the age of 10 years, while girls tend to present mainly between 14 and 16 years of age[ 26]. Most CYP with CD grow out of this disorder, but a minority become more dissocial or aggressive and develop antisocial personality disorder as adults.

ODD is considered to be the mildest and commonest of the DBPs, with prevalence estimates of 6%-9% for pre-schoolers and boys outnumbering girls by at least two to one[ 27]. CYP with ODD are typically openly hostile, negativistic, defiant, uncooperative, and irritable. They lose their tempers easily and are mean and spiteful towards others (Table ). They are mostly defiant towards authority figures, but they may also be hostile to their siblings or peers. This pattern of adversarial behaviour significantly negatively impact on their lives at home, school, and wider society, and seriously impairs all their relationships[ 28].

Emotional problems

Emotional problems in later childhood include panic disorder, generalized anxiety disorder (GAD), separation anxiety, social phobia, specific phobias, OCD and depression. Mild to moderate anxiety is a normal emotional response to many stressful life situations. Anxiety is regarded as a disorder when it is disproportionately excessive in severity in comparison to the gravity of the triggering circumstances, leading to abnormal disruption of daily routines. Panic disorder is characterized by panic attacks untriggered by external stimuli. GAD is characterized by generalized worry across multiple life domains. Separation anxiety disorder is characterized by fear related to actual or anticipated separation from a caregiver. Social anxiety disorder (also called social phobia), is characterized by fear of social situations where peers may negatively evaluate the person[ 12].

Common manifestations of Anxiety disorders include physical symptoms such as increased heart rate, shortness of breath, sweating, trembling, shaking, chest pain, abdominal discomfort and nausea[ 29]. Other symptoms include worries about things before they happen, constant concerns about family, school, friends, or activities, repetitive, unwanted thoughts (obsessions) or actions (compulsions), fears of embarrassment or making mistakes, low self-esteem and lack of self-confidence[ 30].

Depression often occurs in children under stress, experiencing loss, or having attentional, learning, conduct or anxiety disorders and other chronic physical ailments. It also tends to run in families[ 7- 9, 31]. Symptoms of depression are diverse and protean, often mimicking other physical and neurodevelopmental problems, including low mood, frequent sadness, tearfulness, crying, decreased interest or pleasure in almost all activities; or inability to enjoy previously favourite activities, hopelessness, persistent boredom; low energy, social isolation, poor communication, low self-esteem and guilt, feelings of worthlessness, extreme sensitivity to rejection or failure, increased irritability, agitation, anger, or hostility, difficulty with relationships, frequent complaints of physical illnesses such as headaches and stomach aches, frequent absences from school or poor performance in school, poor concentration, a major change in eating and/or sleeping patterns, weight loss or gain when not dieting, talk of or efforts to run away from home, thoughts or expressions of suicide or self-destructive behaviour[ 31].

Disruptive mood dysregulation disorder (DMDD) is a childhood disorder characterized by a pervasively irritable or angry mood recently added to DSM-5. The symptoms include frequent episodes of severe temper tantrums or aggression (more than three episodes a week) in combination with persistently negative mood between episodes, lasting for more than 12 mo in multiple settings, beginning after 6 years of age but before the child is 10 years old[ 32].

Autistic spectrum and pervasive development disorder

The definition of Autism has evolved over the years and has been broadened over time. DSM-IV-TR[ 33] and the ICD-10[ 13] defined the diagnostic category of pervasive developmental disorders (PDD) as the umbrella terminology used for a group of five disorders characterized by pervasive "qualitative abnormalities in reciprocal social interactions and in patterns of communication, and by a restricted, stereotyped, repetitive repertoire of interests and activities" affecting "the individual's functioning in all situations". These included autism, asperger syndrome, childhood disintegrative disorder (CDD), pervasive developmental disorder not otherwise specified (PDD-NOS) and Rett syndrome.

Autism and Asperger Syndrome are the most widely recognised and clinically diagnosed among this group of disorders. CDD is a term used to describe children who have had a period of normal development for the first 2-3 years before a relatively acute onset of regression and emergence of autistic symptoms. PDD-NOS was used, particularly in the United States, to describe individuals who have autistic symptoms, but do not meet the full criteria for Autism or Asperger's Syndrome, denote a milder version of Autism, or to describe atypical autism symptoms emerging after 30 mo of age, and autistic individuals with other co-morbid disorders[ 34].

The category of PDD has been removed from DSM-5[ 12] and replaced with Autism Spectrum disorders (ASD). ASD (Table ) is diagnosed primarily from clinical judgment usually by a multidisciplinary team, with minimal support from diagnostic instruments. Most individuals who received diagnosis based on the DSM-IV should still maintain their diagnosis under DSM-5, with some studies confirming that 91% to 100% of children with PDD diagnoses from the DSM-IV retained their diagnosis under the ASD category using the new DSM-5[ 35, 36], while a systematic review has found a slight decrease in the rate of ASD with DSM-5[ 37].

Table 3

Persistent deficits in social communication and social interaction across multiple contexts, as manifested by 3 out 3 of the following, currently or by history

Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions

Deficits in nonverbal communicative behaviours used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication

Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers

Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two out of 4 of the following, currently or by history

Stereotyped or repetitive motor movements, use of objects, or speech ( e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases)

Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior ( e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day)

Highly restricted, fixated interests that are abnormal in intensity or focus ( e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest)

Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment ( e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement)

Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life)

Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning

With or without accompanying intellectual impairment With or without accompanying language impairment

Associated with a known medical or genetic condition or environmental factor

Specify current severity based on social communication impairments and restricted, repetitive patterns of behavior

There are many intervention approaches and strategies, used alone or in combination, for supporting individuals with ASD. These interventions need to individualized and be closely tailored to the level of social and linguistic abilities, cultural background, family resources, learning style and degree of communication skills[ 38].

Various communication enhancement strategies have been designed to manage ASD[ 39], including augmentative and alternative communication (AAC), Facilitated Communication, computer-based instruction and video-based instruction (Table ). Several behavioural and psychological interventions (Table ) have also been used successfully in managing ASD children, including applied behaviour analysis (ABA) and functional communication training (FCT)[ 40].

Table 4

Augmentative and alternative communication

Supplements/replaces natural speech and/or writing with aided [ e.g., Picture Exchange Communication System, line drawings, Blissymbols, speech generating devices, and tangible objects] and/or unaided ( e.g., manual signs, gestures, and finger spelling) symbols

Effective in decreasing maladaptive or challenging behaviour such as aggression, self-injury and tantrums, promotes cognitive development and improves social communication

Scripts are often used to promote social interaction, initiate or sustain interaction

Table 5

ABA

Uses principles of learning theory to bring about meaningful and positive change in behaviour, to help individuals build a variety of skills ( e.g., communication, social skills, self-control, and self-monitoring) and help generalize these skills to other situations

Discrete trial training

A one-to-one instructional approach based on ABA to teach skills in small, incremental steps in a systematic, controlled fashion, documenting stepwise clearly identified antecedent and consequence ( e.g., reinforcement in the form of praise or tangible rewards) for desired behaviours

Anger management

Various strategies can be used to teach children how to recognise the signs of their growing frustration and learn a range of coping skills designed to defuse their anger and aggressive behaviour, teach them alternative ways to express anger, including relaxation techniques and stress management skills

Social (pragmatic) communication disorder

Social (pragmatic) communication disorder (SCD) is a new diagnosis included under Communication Disorders in the Neurodevelopmental Disorders section of the DSM-5[ 12]. It is characterized by persistent difficulties with using verbal and nonverbal communication for social purposes, which can interfere with interpersonal relationships, academic achievement and occupational performance, in the absence of restricted and repetitive interests and behaviours (Table ). Some authors consider that CYP with SCD present with similar but less severe restricted and repetitive interests and behaviours (RRIBs) characteristic of children on the autistic spectrum[ 41]. SCD is thought to occur more frequently in family members of individuals with autism[ 42].

Table 6

Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following

Deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for social context

Impairment in the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on a playground, talking differently to a child than to an adult, and avoiding use of overly formal language

Difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction

Difficulties understanding what is not explicitly stated ( e.g., making inferences) and nonliteral or ambiguous meaning of language ( e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation)

The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination

The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities)

The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar, and are not better explained by autism spectrum disorder, intellectual disability (intellectual developmental disorder), global developmental delay, or another mental disorder

The term "pragmatic" has been used previously to describe the communication skills that are needed in normal social intercourse and the rules that govern routine interpersonal interactions, including ability to pay at least some attention to the other person in a conversation, take turns, not interrupting the other speaker unless there is a very good reason, match language and volume to the situation and the listener, etc[ 43]. Social and pragmatic deficit are known to also occur in diverse clinical populations, including ADHD, William's syndrome, CD, closed head injury and spina bifida/hydrocephalus[ 44].

Treatment modalities that have been used for supporting children with SCD are similar to those that have been used for several years in children with ASD (Tables and ). The first randomized controlled trial of social communication interventions designed primarily for children with SCD was reported in 2012[ 45]. The Social Communication Intervention Project ( http://www.psych-sci.manchester.ac.uk/scip/) targets development in social understanding and interaction, verbal and non-verbal pragmatic skills and language processing among children with SCD.

Pathological demand avoidance or Newson's syndrome

Pathological demand avoidance (PDA) or Newson's Syndrome is increasingly being accepted as part of the autism spectrum. PDA was first used in 2003[ 46] for describing some CYP with autistic symptoms who showed some challenging behaviours. It is characterized by exceptional levels of demand avoidance requested by others, due to high anxiety levels when the individuals feel that they are losing control. Avoidance strategies can range from simple refusal, distraction, giving excuses, delaying, arguing, suggesting alternatives and withdrawing into fantasy, to becoming physically incapacitated (with an explanation such as "my legs don't work") or selectively mute in many situations. If they feel threatened to comply, they may become verbally or physically aggressive, best described as a "panic attack", apparently intended to shock[ 46]. They tend to resort to "socially manipulative" behaviours. The outrageous acts and lack of concern for their behaviour appears to draw parallels with conduct problems (CP) and callous-unemotional traits (CUT), but reward-based techniques, effective with CP and CUT, seem not to work in people with PDA[ 47]. PDA is currently neither part of the DSM-5[ 12] nor the ICD-10[ 13].

Though demand avoidance is a common characteristic of CYP with ASD, it becomes pathological when the levels are disproportionately excessive, and normal daily activities and relationships are negatively impaired. Unlike typically autistic children, people with PDA tend to have much better social communication and interaction skills, and are consequently able to use these abilities to their advantage. They often have highly developed social mimicry and role play, sometimes becoming different characters or personas. The people with PDA appear to retain a keen awareness of how to "push people's buttons", suggesting a level of social insight when compared to CYP with Autism. On the other hand, children with PDA exhibit higher levels of emotional symptoms compared to those with ASD or CD. They also often experience excessive mood swings and impulsivity. While the prevalence of ASD in boys is more than four times higher compared to that of girls, the risk of developing PDA appears to be the same for both boys and girls[ 47].

O'Nions et al[ 48] have recently reported on the development and preliminary validation of the "Extreme Demand Avoidance Questionnaire" (EDA-Q), designed to quantify PDA traits based on parent-reported information, with good sensitivity (0.80) and specificity (0.85). EDA-Q is available online (https:// www.pdasociety.org.uk/resources/extreme-demand-avoidance-questionnaire).

PREVALENCE OF BEHAVIOURAL AND EMOTIONAL DISORDERS IN CHILDHOOD

Accurate estimation of various childhood EBPs is difficult due to the problems of research methodologies relying on subjective assessments and varying definitions used. According to most studies, between 10% and 20% of CYP are affected annually by MHDs, and the rates are very similar across different racial and ethnic groups after controlling for income, resident status, education, and neighbourhood support. However, poverty and low socioeconomic status are risk factors that appear to increase the rate of MHDs across populations[ 49]. A 2001 WHO report [ 50] indicated the 6-mo prevalence rate for any MHD in CYP, up to age 17 years, to be 20.9%, with disruptive behaviour disorders (DBD) at 10.3%, second only to Anxiety disorders at 13%. About 5% of CYP in the general population suffer from Depression at any given point in time, which is more prevalent among girls (54%)[ 31, 51].

A previous British Child and Adolescent Mental Health (CAMH) survey carried out by the office of National Statistics (ONS) in 1999 and 2004, comprising 7977 interviews from parents, children and teachers, found the prevalence of MHD among CYP (aged 5-16 years) to be 6% for conduct problems, 4% for emotional problems (Depression or Anxiety) and 1.5% for Hyperkinetic disorders[ 51]. A similar survey in the United States between 2005 and 2011, the National survey of children's health (NSCH) involving 78042 households, indicated that 4.6% of CYP aged 3-17 years had a history DBD, with prevalence twice as high among boys as among girls (6.2% vs 3.0%), Anxiety (4.7%), Depression (3.9%), and ASD (1.1%)[ 24]. Reported prevalence rates for DMDD range from 0.8% to 3.3% with the highest rate in preschool children[ 52].

AETIOLOGY AND RISK FACTORS FOR CHILDREN'S BEHAVIOURAL AND EMOTIONAL DISORDERS

The exact causes of various childhood EBPs are unknown. Several studies have identified various combinations of genetic predisposition and adverse environmental factors that increase the risk of developing any of these disorders. These include perinatal, maternal, family, parenting, socio-economic and personal risk factors[ 53]. Table summarizes the evidence for various risk factors associated with development of childhood EBPs.

Table 7

Adverse family life

Dysfunctional families where domestic violence, poor parenting skills or substance abuse are a problem, lead to compromised psychological parental functioning, increased parental conflict, greater harsh, physical, and inconsistent discipline, less responsiveness to children's needs, and less supportive and involved parenting

Chronic stressors in children also lead to abnormal behaviour pattern of 'reactive responding' characterized by chronic vigilance, emotional reacting and sense of powerlessness

Physically aggressive behaviour rarely starts after age 5

Chronic irritability, temperament and anxiety symptoms before the age of 3 yr are predictive of later childhood anxiety, depression, oppositional defiant disorder and functional impairment

Children with intellectual disabilities are twice as likely to have behavioural disorders as normally developing children

Rate of challenging behaviour is 5% to 15% in schools for children with severe learning disabilities but is negligible in normal schools

Child's gender

Boys are much more likely than girls to suffer from several DBD while depression tends to predominantly affect more girls than boys

Unlike the male dominance in childhood ADHD and ASD, PDA tends to affect boys and girls equally

There is ample evidence supporting the genetic inheritability of many EBDs in CYP from their parents. From a prospective study of 209 parents along with their 331 biological offsprings, moderate inheritability ( r = 0.23, P < 0.001) between parental and offspring CD was found[ 74]. Anxiety seems to be transmissible from mothers to their preschool children, through both genetic factors and also through behaviour modelling and an anxious style of parenting[ 6].

A developmental taxonomy theory has been proposed by Patterson et al[ 75] to help understand the mechanisms underlying early onset and course of CPs. They described the vicious cycle of non-contingent parental responses to both prosocial and antisocial child behaviour leading to the inadvertent reinforcement of child behaviour problems. Parents' engagement in "coercive cycles" lead to children learning the functional value of their aversive behaviours ( e.g., physical aggression) for escape and avoidance from unwanted interactions, ultimately leading to the use of heightened aversive behaviours from both the child and parents to obtain social goals. This adverse child behavioural training combined with social rejection often lead to deviant peer affiliation and delinquency in adolescence[ 76].

NEUROBIOLOGY OF CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS

Conflicting findings have been reported in the brain structural variations among CYP with EBPs using magnetic resonance imaging (MRI) studies. The most consistently reported structural abnormalities associated with the DBD include reduced grey matter volume (GMV) in the amygdala, frontal cortex, temporal lobes, and the anterior insula, which is involved in part of a network related to empathic concern for others. Reduced GMV along the superior temporal sulcus has also been found, particularly in girls[ 77]. A decreased overall mean cortical thickness, thinning of the cingulate and prefrontal cortices; and decreased grey matter density in different brain regions have been reported[ 78].

Subtle neurobiological changes in different parts of the brain of CYP with EBPs have been reported from many research studies of functional scans. Peculiar brain changes have been found in the hypothalamus, inferior and superior parietal lobes, right amygdala and anterior insula[ 79]. Functional MRI studies have demonstrated less activation in the temporal cortex in violent adult offenders[ 80] and in antisocial and psychopathic individuals[ 81] compared to non-aggressive offenders.

Reduced basal Hypothalamic-Pituitary-Adrenal (HPA) axis activity has been reported in relation to childhood DBDs and exposure to abuse and neglect[ 82]. It has been hypothesized that high levels of prenatal testosterone exposure appears to be part of the complex aetiology of EBDs, providing possible explanation for the higher prevalence in males for DBDs, by increasing susceptibility to toxic perinatal environments such as exposure to maternal nicotine and alcohol in pregnancy[ 83].

COMPLICATIONS OF CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS

EBDs in childhood, if left untreated, may have negative short-term and long-term effects on an individual's personal, educational, family and later professional life. CD has been linked to failure to complete schooling, attaining poor school achievement, poor interpersonal relationships, particularly family breakup and divorce, and experience of long-term unemployment. DBPs in parents have been linked to the abuse of their offspring, thereby increasing their risk of developing CD[ 84, 85]. Children presenting with hyperactivity-inattention behaviours are more likely to have a more favourable educational outcome compared with those with aggression or oppositional behaviours[ 86, 87].

A high prevalence of sleep disturbances is associated with various childhood EBPs. Sleep problems in early childhood is associated with increased prevalence of later Anxiety disorders and ODD[ 88, 89].

Several studies have confirmed a strong relationship between early childhood EBPs and poor future long-term physical and mental health outcomes. Chronic irritability in preschool children, CD and ODD in older children each may be predictive of any current and lifetime Anxiety, Depression and DBDs in later childhood, Mania, Schizophrenia, OCD, major depressive disorder and panic disorder[ 84, 90- 92]. Individuals on the adolescent-onset CP path often consume more tobacco and illegal drugs and engage more often in risky sexual behaviour, self-harm, and have increased risk of PTSD, than individuals without childhood conduct problems. They also frequently experience parenting difficulties, including over-reactivity, lax and inconsistent discipline, child physical punishment and lower levels of parental warmth and sensitivity[ 74, 84, 93, 94]. Approximately 40%-50% of CYP with CD are at the risk of developing antisocial personality disorder in adulthood[ 84]. Other potential complications include adverse mental and physical health outcomes, social justice system involvement including incarceration, substance use and abuse, alcoholism, homelessness, poverty and domestic abuse[ 95, 96].

An analysis of several Scandinavian studies up to the 1980s has shown higher rates of violent death, estimated to be almost five times higher than expected among young people with previous MHD, with common associated predictive factors including behavioural problems, school problems, and co-morbid alcohol or drug abuse and criminality[ 97].

ASSESSMENT AND DIAGNOSIS OF CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS

Assessment through detailed history taking as well as observation of a child's behaviour are indispensable sources of information required for clinical diagnosis of EBPs[ 1]. This should include general medical, developmental, family, social, educational and emotional history. Physical and neurological examination should include assessment of vision, hearing, dysmorphic features, neuro-cutaneous stigmata, motor skills and cognitive assessment. Condition-specific and generic observer feedback on screening rating scales and questionnaires can be used to complement direct clinical observations.

There is no single gold-standard diagnostic tool available for the diagnosis of EBDs, which largely depends on the clinical skills of an integrated collaboration of multi-professional experts. Diagnosis relies on interpretation of subjective multi-source feedback from parents or carers, teachers, peers, professional or other observers provided through a number of psychometric questionnaires or screening tools[ 98]. Significant discrepancies between various respondents are quite common and clinical diagnosis cannot rely on the psychometric tools alone. There is evidence from the literature suggesting that parents have a tendency to over-report symptoms of ODD and CD in children compared to the teachers[ 99].

There are several screening tools that are used for assessing the risk of MHD among CYP. The tools help to identify which individuals would require more in-depth clinical interventions[ 100]. Supplement material shows a list of common Mental Health screening and assessment tools, summarizing their psychometric testing properties, cultural considerations and costs. The commonest behaviour screening tools include the Behavioral and Emotional Screening System (BESS; ages 3-18 years), the Behavior Assessment System for Children-2 nd edition, Pediatric Symptom Checklist (PSC), the Ages and Stages Questionnaire-Social Emotional (ASQ-SE, Ages 0 to 5 years) and the Achenbach System of Empirically Based Assessment (ASEBA), for children aged 1.5 years through adulthood.

MANAGEMENT OF BEHAVIOURAL AND EMOTIONAL DISORDERS IN CHILDREN

Identification of appropriate treatment strategies depend on careful assessment of the prevailing symptoms, the family and caregiver's influences, wider socio-economic environment, the child's developmental level and physical health. It requires multi-level and multi-disciplinarian approaches that include professionals such as Psychologists, Psychiatrists, Behavioural Analysts, Nurses, Social care staff, Speech and language Therapists, Educational staff, Occupational Therapists, Physiotherapists, Paediatricians and Pharmacists. Use of pharmacotherapy is usually considered only in combination with psychological and other environmental interventions[ 15].

Holistic management strategies will include various combinations of several interventions such as child- and family-focused psychological strategies including Cognitive Behavioural Therapy (CBT), behavioural modification and social communication enhancement techniques, parenting skills training and psychopharmacology. These strategies can play significant roles in the management of children with a wide range of emotional, behavioural and social communication disorders. Effective alternative educational procedures also need to be implemented for the school age children and adolescents.

In early childhood, similar parenting strategies have been found useful to manage several apparently dissimilar EBPs ( e.g., infant feeding or sleeping problems, preschool tantrums, disruptive and various emotional problems). This may suggest there is a common maintaining mechanism, which is probably related to poor self-regulation skills, involving the ability to control impulses and expressions of emotion[ 101].

Several studies have confirmed the effectiveness of various psychological and pharmacologic therapies in the management of childhood EBDs. A meta-analysis of thirty-six controlled trials, involving 3042 children (mean sample age, 4.7 years), evaluating the effect of psychosocial treatments including parenting programmes on early DBPs, demonstrated large and sustained effects (Hedges'g = 0.82), with the largest effects for general externalizing symptoms and problems of oppositionality and non-compliance, and were weakest, relatively speaking, for problems of impulsivity and hyperactivity[ 102].

The treatment of CD among CYP with callous-unemotional traits is still at early stages of research. The mainstay of management for CDs includes individual behavioural or cognitive therapy, psychotherapy, family therapy and medications[ 103].

Parental skills training

Any challenging behaviour from CYP is likely to elicit persistent negative reactions from many parents, using ineffective controlling strategies and a decrease in positive responses[ 104]. There is evidence from published research that social-learning and behaviourally based parent training is capable of producing lasting improvement in children with callous-unemotional traits or CD, reducing externalizing problems for children with DBDs, leading to significant parent satisfaction, particularly when delivered early in childhood[ 84, 105- 107]. These interventions are typically delivered in a group format, one 2-h session per week for 4-18 wk, by trained leaders, with the focus on improving parenting skills to manage child behaviour, where parents typically learn to identify, define and observe problem behaviours in new ways, as well as learn strategies to prevent and respond to oppositional behaviour[ 108, 109].

Pooled estimates from a review of 37 randomised controlled studies identified a statistically significant improvement on several rating scales among children with CD up to the age of 18 years[ 23]. A previous meta-analysis of 24 studies confirmed that Parent-Child Interaction Therapy (PCIT) demonstrated significantly larger effect sizes for reducing negative parent behaviours, negative child behaviours, and caregiver reports of child behaviour problems than did most or all forms of Positive Parenting Programme (Triple P)[ 110]. A recent Cochrane review of 13 studies confirmed the efficacy and cost-effectiveness of group-based parenting interventions for alleviating child conduct problems, enhancing parental mental health and parenting skills, at least in the short term[ 111].

Differentiated educational strategies

Research has focused on identifying alternative educational strategies that can be used to improve learning opportunities for children presenting with challenging behaviours from various causes. Supportive school strategies for children with EBDs have traditionally focused on classroom management, social skills and anger management, but many researchers have more recently argued that academically-focused interventions may be most effective[ 112]. Traditional school policies of suspending or expelling children with EBD can be harmful to them. Researchers have developed "step-by-step" guidelines for teachers to guide them in the selection and implementation of evidence-based strategies that have been identified as effective in increasing levels of engagement and achievement by children with EBD, including peer-assisted learning procedures, class-wide peer tutoring, self-management interventions and tiered intervention systems - most notably Response to Intervention (RtI) and Positive Behavioural Interventions and Supports (PBIS)[ 113, 114].

There is increasing evidence to confirm that school-based interventions to address emerging DBPs produce significant reductions in both parent-, self- and teacher-reported internalizing and externalizing symptoms[ 114, 115].

Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH) is an educational system designed for the management of children with Autism and related communication disorders[ 116, 117]. There is some evidence that TEACCH programmes also lead to some improvements in motor skills and cognitive measures[ 117].

Best practice management strategies for children with PDA are known to differ from those with Autism. Specific guidelines for children with PDA[ 118] have been published by the British institute for Learning Disabilities. Educational support for CYP with PDA relies on highly individualized strategies that allows them to feel in control. They would respond much better to more indirect and negotiative approaches. For example, "I wonder how we might..." is likely to be more effective than "Now let's get on with your work"[ 118].

Child-focused psychological interventions

Cognitive behavioural therapy (CBT) is one of the most widely used non-pharmacologic treatments for individuals with emotional disorders, especially depression, and with individuals with behavioural problems including ASD[ 119]. CBT integrates a combination of both cognitive and behavioural learning principles to encourage desirable behaviour patterns. Research evidence from several trials[ 120] provide strong support for the effectiveness of cognitive-behavioural interventions among CYP with Anxiety and Depression. A recent study of child-focused CBT programme introduced at schools has shown that it produces significant improvement in disruptive behaviours among children[ 121].

Self-esteem building strategies can help many children with EBDs, who often experience repeated failures at school and in their interactions with others. These children could be encouraged to identify and excel in their particular talents (such as sports) to help build their self-esteem.

Behavioural modification and social communication enhancement strategies

Behavioural interventions and techniques are designed to reduce problem behaviours and teach functional alternative strategies using the basic principles of behaviour change. Most interventions are based on the principles of Applied Behaviour Analysis (ABA) which is grounded on behavioural learning theory. Table summarizes the common behavioural modification strategies for management of childhood EBDs.

Several strategies have been designed to help children acquire important social skills, such as how to have a conversation or play cooperatively with others, using social group settings and other platforms to teach peer interaction skills and promote socially appropriate behaviours and communication. There is ongoing research in the development of social communication treatment approaches[ 45]. Table summarizes common social communication enhancement strategies.

PSYCHOPHARMACOLOGY OF CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS

Medications are often prescribed as part of a comprehensive plan for the management of childhood EBDs that includes other therapies. The greatest level of evidence for pharmacotherapy of childhood EBDs is available for their use in the management of childhood and adolescent ADHD. There is less evidence of any efficacy for medications in the management of other DBPs including ODD and CD. Table lists the common classes of medications used in the management of childhood EBD.

Table 8

Atypical antipsychotics

Aripiprazole, Clozapine, Olanzapine, Quetiapine, Risperidone, Ziprasidone

Low white blood cell count (Agranulocytosis - with Clozapine), Diabetes, Lipid abnormalities, Weight gain, Other medication-specific side effects

Selective Serotonin Reuptake Inhibitors

Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Sertraline

Headache, Nervousness, Nausea Insomnia, Weight Loss

Serotonin-norepinephrine reuptake inhibitor

Venlafaxine, Levomilnacipran, Duloxetine, Desvenlafaxine

Other antidepressants

Bupropion, Mirtazepine, Trazodone

Stimulants

Methylphenidate Immediate Release and Modified Release ( e.g., Concerta XL, Equasym XL), Dexamfetamines Immediate Release and Modified Release ( e.g., Lisdexamfetamine)

ADHD

Decreased appetite/ weight loss, Sleep problems, Jitteriness, restless, Headaches, Dry mouth, Dysphoria, feeling sad, Anxiety, Increased heart rate, Dizziness

Blood pressure and heart rate will be checked before treatment and periodically during treatment. Child's height and weight are monitored

Non-stimulants

Atomoxetine

Alpha-2 agonists

Clonidine, Guanfacine

Drowsiness, Dizziness, Sleepiness

Antihistamines

Hydroxyzine HCl, Hydroxyzine, Pamoate, Alimemazine

Sleepiness, Drowsiness, Dizziness, Dry mouth, Confusion, Blurred Vision, Balance problems, Heartburn

Psychostimulants (including different formulations of Methylphenidate and Dexamphetamines) remain the primary medication of choice for management of ADHD in CYP for more than 60 years. About 75% to 80% of children with ADHD will benefit from the use of psychostimulants. Non-stimulant therapy with Atomoxetine or alpha 2-adrenergic agonists (Clonidine and Guanfacine) are also effective second-line alternative options[ 133]. A recent analysis of 16 randomized trials and one meta-analysis, involving 2668 participants with ADHD, showed that both stimulant and non-stimulant medications led to clinically significant reductions in core symptoms with consistently high effect sizes. The psychosocial treatments alone combining behavioural, cognitive behavioural and skills training techniques demonstrated small- to medium-sized improvements for parent-rated ADHD symptoms, co-occurring emotional or behavioural symptoms and interpersonal functioning[ 134].

The use of pharmacological treatments for symptoms of ASD is common but challenging, as there are no medications that directly treat the social and language impairments present in individuals with ASD. The medications used most frequently include antipsychotics ( e.g., Risperidone) and Selective Serotonin Reuptake Inhibitors (SSRI) to treat mood and repetitive behaviour problems, and stimulants and other medications used to treat ADHD-related symptoms. The evidence base is good for using atypical antipsychotics to treat challenging and repetitive behaviours, but they also have significant side effects[ 119, 135]. Naltrexone is an opioid antagonist that has been shown from a systematic review (involving 155 children from 10 studies) to significantly improve symptoms of self-injury, irritability, restlessness and hyperactivity in autistic children, with minimal side effects and generally good tolerance, although long-term data are lacking[ 136].

Medication use in preschool children for control of ASD and ADHD symptoms is still largely controversial. Stimulant medications for treatment of ADHD are not uniformly licensed for pre-schoolers as there is limited available research evidence to confirm efficacy and safety. Moreover, the effectiveness of parenting interventions in this age group are comparable to the effects of using stimulant drugs among the older CYP[ 137, 138].

Research evidence from two systematic reviews and 20 randomized controlled trials has recently documented the efficacy of psychopharmacology in the management of childhood DBP. Psychostimulants have have been shown to have a moderate-to-large effect on oppositional behaviour, conduct problems, and aggression in youths with ADHD, with and without ODD or CD, while Atomoxetine has only a small effect. There is very-low-quality evidence that Clonidine and Guanfacine have a small-to-moderate effect on oppositional behaviour and conduct problems in youths with ADHD[ 139].

Other behavioural disorders in children could also be successfully treated by medications. Traditional and the newer atypical antipsychotics can be used for OCD, Depression, aggression and mood instability[ 140].

The commonest antidepressants in used in children are the SSRI and Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) medications as they work well and usually have fewer side effects compared to the older Tricyclic Antidepressants. Antidepressants can be used in the management of Major Depression, Anxiety, Seasonal Affective Disorder (SAD), OCD, PTSD and Social Anxiety. They may also be used to treat enuresis and pre-menstrual syndrome[ 141].

CONCLUSION

Childhood EBDs have significant negative impacts on the society, in the form of direct behavioural consequences and costs, and on the individual, in the form of poor academic, occupational and psychosocial functioning and on the family. The costs to society include the trauma, disruption and psychological problems caused to the victims of crime or aggression in homes, schools and communities, together with the financial costs of services to treat the affected individuals, including youth justice services, courts, prison services, social services, foster homes, psychiatric services, accident and emergency services, alcohol and drug misuse services, in addition to unemployment and other required state benefits[ 23].

Prevention and management of EBD is not easy and it requires an integrated multidisciplinary effort by healthcare providers at different levels to be involved in the assessment, prevention and management of affected individuals, and also to provide social, economic and psycho-emotional support to the affected families.

There is increasing evidence base for several psychosocial interventions but less so for pharmacological treatment apart from the use of stimulants for ADHD. Preventive measures that have been researched for controlling the risk of childhood emotional and behaviour problems include breastfeeding[ 142], avoiding second-hand smoke exposure in non-smoker youths [ 143] and intensive parenting interventions.

Footnotes

Conflict-of-interest statement: The author declares no conflict of interest for this article.

Manuscript source: Invited manuscript

Peer-review started: October 29, 2017

First decision: November 20, 2017

Article in press: December 5, 2017

Specialty type: Pediatrics

Country of origin: United Kingdom

Peer-review report classification

Grade A (Excellent): A, A

Grade B (Very good): 0

Grade C (Good): 0

Grade D (Fair): D

Grade E (Poor): 0

P- Reviewer: Ho RCM, Yellanthoor RB, Yucel O S- Editor: Ji FF L- Editor: A E- Editor: Li RF

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24. Centers for Disease Control and Prevention (CDC) Perou RH, Bitsko SJ, Blumberg P, Pastor RM, Ghandour JC, Gfoerer SL. Mental Health Surveillance among Children - United States 2005-2011. Morbidity and Mortality Weekly Report (MMWR) 2013;62(Suppl 2):1-35. Available from: [ https://www.cdc.gov/mmwr/pdf/other/su6202.pdf. [ PubMed] Google Scholar]

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# data[].attributes.attachment_link.title
Behavioural and emotional disorders in childhood: A brief overview for paediatricians

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Mental health problems in children and adolescents include several types of emotional and behavioural disorders, including disruptive, depression, anxiety and pervasive developmental (autism) disorders, characterized as either internalizing or externalizing problems. Disruptive behavioural problems such as temper tantrums, attention deficit hyperactivity disorder, oppositional, defiant or conduct disorders are the commonest behavioural problems in preschool and school age children.

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What is Emotional and Behavioral Disorder?

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What is Emotional and Behavioral Disorder?

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Emotional and behavioral disorders refer to distinct mental health conditions characterized by challenges in managing both emotions and behaviors. These disorders impact a child's functioning their whole life. Individuals with emotional and behavioral disorders struggle to regulate their emotions and to express their behaviors appropriately.

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Rules and routines

Work on behaviors

Being supportive to the students with EBD

Making choice making opportunities

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Characteristics seen in Children with EBD:

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Characteristics seen in Children with EBD:

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Aggression to others or even self harming (fighting)

Inappropriate crying

Temper tantrums

Learning difficulty (unable to learn in an academic setting)

Anxiety

Inability to communicate with others or to be social

Hyperactivity

Refusal to follow rules

Difficulty handling frustration

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EBD- Emotional and Behavioral Disorder

3 other types of EBD acronyms:

OCD- Obsessive Compulsive Disorder

ODD- Oppositional defiant disorder

CD-Conduct disorder

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Naset.org home page. NASET News Alert RSS. (2008, January 18). https://www.naset.org/professional-resources/exceptional-students-and-disability-information/emotional-and-behavioral-disorders#c9032

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Dr. Sruthi M., M., & Shaziya Allarakha, M. (2022, November 3). What are the different types of behavior disorders? 7 types. MedicineNet. https://www.medicinenet.com/what_are_the_different_types_of_behavior_disorders/article.htm

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This website shows signs and ways to help provide students with EBD the right help they need. It has a section for teachers and great strategies.

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

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

1. Emotional and Behavior Disorders (EBD)

2. Emotional Conflict (EC)

3. Serious Emotional Disturbance (SED)

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

General Strategies

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

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

Teacher Presentation

Laboratory

Group Interaction and Discussion

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

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

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

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

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

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

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

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

Reading

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

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

2. Reading in group or with others.

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

4. Demonstrating appropriate reading

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

Research

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

2. Use appropriate laboratory and field strategies.

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

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

Field Experiences

1. Use appropriate general strategies.

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

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

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

5. Use a buddy system.

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

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

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

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

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

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

Testing

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

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

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

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

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

Organizations

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

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

Resources

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

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

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

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This website provides strategies for teachers with kids that have EBD. The strategies have explain ways on how to set up a routine for these students.

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This website shows all of the things that teachers and parents need to know about EBD. It has of chart on what to do and the ways you can help.

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The topics listed are individual websites that can be accessed by members of The American Academy of Special Education Professionals (). If you are not a member of AASEP, and would like to join , click on the following link: Join AASEP to Register .

Members of AASEP , please login (member login and password) to have full access to all the information and other websites links, in our database.

Click Here to go to AASEP's comprehensive overview of Emotional and Behavioral Disorders. For numerous other links related to this topic, refer to the variety of topics below.

Modifying the learning environment : Educators have long understood that behavior difficulties can keep students from functioning productively in class. Many school personnel have been considering the effects of behavior on learning for some time.

A short guide to understanding accomodations: short guide to explain accommodations and to help you determine if you need one

A listing of books and journal articles for students with disabilities: This Resources You Can Use is intended to help professionals and others find information that can guide them in making appropriate changes in the classroom based on what their students need. All of the resources are rich with suggestions and techniques that can help professionals and, ultimately, students.

Testing accomodations for students with bi-polar disorder-Pdf file:The suggestions or ideas that follow assume that the student can be maintained in the mainstream building. In actuality, some students with severe symptoms may require home instruction, hospitalization, a self-contained program, day treatment, or residential setting. That said, and while many students with Bipolar Disorder may need special education, some student

Accomodations for persons with anxiety and emotional disorders: A person managing an online program, either a virtual volunteering program or one that provides online service delivery for an agency, needs to have a general understanding of various learning styles, working styles and information-processing styles. Volunteer management is not "one-size-fits-all," and simple adjustments in management style can be made to effectively channel talents and resources of the greatest number of people.

IEP's and 504 Plans: Similarities and differences: This article discusses the differences in IEP's and 504 plans in terms of requirements, accommodations and modifications.

Symptoms and Accommodations for Students with Bipolar Disorder:Children with bipolar disorder often need classroom accommodations to help them benefit from their education. The extent of the accommodations needed by an individual student will depend on the nature, frequency, severity, and duration of his or her symptoms.

Factors associated with community adjustment of young adults with serious emotional disturbance: a longitudinal analysis: From their teens to their early twenties, young adults experience dramatic changes across all realms of development. Emerging adulthood, as defined by Arnett (2000), marks the period of development (ages 18 years to 25 years) when individuals explore life possibilities and make choices that set the foundation for the remainder of their lives.

Definitions of adults with serious emotional disturbance: A thorough explanation of the definitions and characteristics that are exhibited by adults with emotional disturbance.

Recovery and rehabilitation of persons with severe mental illness: a vision: Although some progress has been made to counteract the myths, misperceptions, and stereotypes surrounding mental illness, stigma still prevents many people from seeking treatment and causes countless others to keep their conditions secret for fear of losing their jobs, health insurance, or homes.

Facts on Transitional Services for Youth with Mental Illnesses Transitioning to Adulthood: Providing comprehensive support services to youth with mental illnesses transitioning into adulthood is critical to their success. Many youth age out of children's services without any transitional planning and lack skills necessary to manage their illnesses and accomplish their goals.

Chartbook on Mental Health and Disability: The Chartbook on Mental Health and Disability in the United States is a reference on disability and mental health in the United States, created for both non-technical and technical audiences. The book is a resource for agencies, employers, organizations, policymakers, researchers and others concerned with the relationship between mental health and disability. An excellent source for information and statistics on adults with emotional disabilities.

Advocacy and learning center: a great souce of information, links and tips for meeting with officials to discuss your child's situation.

American academy of child and adolescent psychiatry: Throughout the evaluation process, parents should be directly involved and ask many questions. It's important to make sure you understand the results of the evaluation, your child's diagnosis, and the full range of treatment options.

Parent advocacy coalition: This article provides tips for parents on becoming effective advocates for their children.

Accessing parent groups: Families with a child who has a disability have special concerns and often need a great deal of information: information about the disability of their child, about school services, therapy, local policies, funding sources, transportation, medical facilities, and much more. Many families find it very useful to join a parent group, where they can meet other families with similar needs. Parent groups can serve many purposes, but primarily they offer parents a place and a means

Parent information: If your child is diagnosed with an emotional disability you'll have lots of questions: Which one does your child have? What can you do to help your child? What are your rights as a parent? There are plenty of techniques and research on how to deal with and overcome emotional disabilities. These steps will help you get started on your information search.

Overview - Anxiety is a normal reaction to stress. It helps one deal with a tense situation in the office, study harder for an exam, keep focused on an important speech. In general, it helps one cope. But when anxiety becomes an excessive, irrational dread of everyday situations, it has become a disabling disorder.

Booklet that describes the symptoms, causes, and treatments of the major anxiety disorders, with information on getting help and coping - A detailed booklet that describes the symptoms, causes, and treatments of the major anxiety disorders, with information on getting help and coping.

A fact sheet on anxiety disorders - A fact sheet with descriptions of the major types of anxiety disorders and their treatments.

Information About Coping with Traumatic Events - Most people have intense feelings after a traumatic event. Most will completely recover from the trauma; others are more vulnerable, especially those who have had previous traumatic experiences, and will need additional help.

Anxiety Disorders (Center for Mental Health Services, Substance Abuse and Mental Health Services Administration) - Anxiety disorders range from feelings of uneasiness to immobilizing bouts of terror. This fact sheet briefly describes the different types of anxiety disorders.

Statistics and Facts about Anxiety Disorders (Anxiety Disorders Association of America)

Reasearch on Anxiety Disorders - About half of adults with an anxiety disorder had symptoms of some type of psychiatric illness by age 15, a NIMH-funded study shows.

Specific Conditions (Anxiety Disorders)

Generalized Anxiety Disorder (GAD) - Generalized Anxiety Disorder, GAD, is an anxiety disorder characterized by chronic anxiety, exaggerated worry and tension, even when there is little or nothing to provoke it.

Obsessive-Compulsive Disorder - Obsessive-Compulsive Disorder, OCD, is an anxiety disorder and is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions).

Panic Disorder: Panic disorder is an anxiety disorder and is characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness, or abdominal distress.

Post-Traumatic Stress Disorder : Post-Traumatic Stress Disorder, PTSD, is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Traumatic events that may trigger PTSD include violent personal assaults, natural or human-caused disasters, accidents, or military combat. more>>

Social Phobia - Social Phobia, or Social Anxiety Disorder, is an anxiety disorder characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations. Social phobia can be limited to only one type of situation?such as a fear of speaking in formal or informal situations, or eating or drinking in front of others?or, in its most severe form, may be so broad that a person experiences symptoms almost anytime they are around other people. more>>

Conversion Disorder (Mayo Foundation for Medical Education and Research) - Conversion disorder is a type of somatoform disorder. Somatoform disorders are characterized by physical symptoms that suggest a medical condition. But a thorough medical evaluation doesn't reveal any underlying medical cause for the physical symptoms.

Separation Anxiety (Nemours Foundation) - You've always dropped off your 1-year-old child at day care without a problem - until today. She's anxious and distressed, she's clinging to you for dear life, and she's making it clear she doesn't want you to leave. She resists the professionals' attempts to calm her and seems to want nothing to do with the other kids. All she wants is you, and she screams and cries every time you try to walk out the door. Finally, you make one last attempt to comfort her and head to the car, feeling guilty, upset, and confused. And the same scenario plays out every day for the entire week.

Treatment of Anxiety Disorders

Treatment of Anxiety Disorders - Effective treatments for each of the anxiety disorders have been developed through research.19 In general, two types of treatment are available for an anxiety disorder—medication and specific types of psychotherapy (sometimes called "talk therapy"). Both approaches can be effective for most disorders.

Getting Help: Locate Services - If unsure where to go for help, talk to someone you trust who has experience in mental health—for example, a doctor, nurse, social worker, or religious counselor.

Anxiety Screening Tools (Anxiety Disorders Association of America) - One of the quickest and easiest ways to determine whether you have symptoms of an anxiety disorder is by taking a Self Test. Self Tests,
or screening tests, are developed to help you recognize the signs of an anxiety disorder.

Anxiety Disorders Information: Guide to Treatment (Anxiety Disorders Association of America) - Anxiety disorders are real, serious and treatable. Experts believe that anxiety disorders are caused by a combination of biological and environmental factors, much like other disorders, such as heart disease and diabetes.

Anxiety Disorders Information: Medications (Anxiety Disorders Association of America) - Medication can be very useful in treating anxiety disorders and is often used in combination with other forms of therapy, such as cognitive-behavioral therapy. The most important aspect of the process of beginning a medication is to have an open and honest discussion with your physician, followed by ongoing evaluation and monitoring.

Anxiety Disorders: The Role of Psychotherapy in Effective Treatment (American Psychological Association) - Everyone feels anxious and under stress from time to time. Situations such as meeting tight deadlines, important social obligations or driving in heavy traffic, often bring about anxious feelings. Such mild anxiety may help make you alert and focused on facing threatening or challenging circumstances. On the other hand, anxiety disorders cause severe distress over a period of time and disrupt the lives of individuals suffering from them.

Medications - A very detailed summary that describes mental disorders and the medications for treating them -- includes a comprehensive list of medications.

Coping (Anxiety Disorders)

Anxiety Disorders Information: Helping a Family Member (Anxiety Disorders Association of America) - Sufferers of anxiety disorders and their families may spend months, even years, without knowing what is wrong. It can be frustrating and can put a strain on relationships; this strain is not necessarily alleviated once there is a diagnosis. Recovery can be a long process.

Successful Strategies for Test Anxiety (Freedom from Fear) - We all experience some level of anxiety before a test. A little nervousness can actually help motivate us to perform our best. Too much anxiety can become a problem if it interferes with your performance on tests. Some strategies for dealing with test anxiety:

Coping with Anxiety, Fears and Phobias (Nemours Foundation) - Everyone, from the youngest child to the oldest adult, experiences anxieties and fears at one time or another. Feeling anxious in a particularly uncomfortable situation never feels very good. However, with children, such feelings are not only normal, they are also necessary.

How Families Can Help Children Cope with Fear and Anxiety (Substance Abuse and Mental Health Services Administration) - Whether tragic events touch your family personally or are brought into your home via newspapers and television, you can help children cope with the anxiety that violence, death, and disasters can cause.

Organizations (Anxiety Disorders)

American Academy of Child and Adolescent Psychiatry

American Psychiatric Association

Anxiety Disorders Association of America

National Institute of Mental Health

Children and Anxiety Disoders

Anxiety Disorders in Children and Adolescents (Anxiety Disorders Association of America) - Taking your child to the doctor for a mental health problem is as important as visiting the doctor for an ear infection or broken arm. But knowing when and where to seek mental health care can be difficult. Here are some these tips for parents to make the process easier.

Anxiety Medication and Kids (Anxiety Disorders Association of America) - <font face="Verdana, Arial, Helvetica, sans-serif" size="2">The use of medication is just one of the many treatment options available to manage the symptoms of anxiety disorders. Parents are understandably hesitant about putting their children on medications without knowing which ones are appropriate, how they will affect their child, and if and when they are safe to use.</font>

Being Afraid (Nemours Foundation) - The use of medication is just one of the many treatment options available to manage the symptoms of anxiety disorders. Parents are understandably hesitant about putting their children on medications without knowing which ones are appropriate, how they will affect their child, and if and when they are safe to use.
Frequently asked questions* about treating anxiety disorders in children with medication:

Children and Adolescents with Anxiety Disorders (Center for Mental Health Services, Substance Abuse and Mental Health Services Administration) - Have you ever been afraid? Everyone gets scared sometimes. Do thunder and lightning make your heart beat faster? Maybe your mouth goes dry when your professional announces a pop quiz, or your palms sweat when it's your turn to give your report in front of the class. Perhaps you get butterflies in your stomach when you see the bully that picks on you.

Teenagers and Anxiety Disorders

Why functional assessment of behavior is important: Educators have long understood that behavior difficulties can keep students from functioning productively in class. Many school personnel have been considering the effects of behavior on learning for some time. The 1997 Amendments to the IDEA take that consideration one step further: the relationship between behavior and learning must not only be considered but acted upon.

Behavioral recording : Another method of evaluating a student's behavior that provides you with a very precise picture of its severity is behavioral recording. The professional or aide observes the student directly and records how long or how often a certain behavior occurs. Using this method, you can compare the degree of occurrence of the behavior with the degree to which it is exhibited by other students.

Conducting a functional behavioral assessment : Identifying the underlying causes of behavior may take many forms; and, while the Amendments to IDEA advise a functional behavioral assessment approach (which could determine specificcontributors to behavior), they do not require or suggest specific techniques or strategies to use when assessing that behavior. While there are a variety of techniques available to conduct a functional behavioral assessment, the first step in the process is to define the behavior in concrete terms. In the following section we will discuss techniques to define behavior.

Sociograms : A sociogram is a professional-made device that is used to provide additional information regarding a student and how s/he interacts with peers. It is a valuable tool for determining how a student is viewed by his/her classmates. Students respond to a professional-provided direction such as "List the two classmates with whom you would most like to sit", "Write the name of the person with whom you would enjoy working on a project.", "If you were going on a vacation, which of your classmates would be nice to have along, and why?"

Manifestation determination: It is a process conducted by the IEP team (along with other necessary qualified personnel) to investigate whether there is a relationship between the student's action(s) of concern and his/her disability. The team must decide whether the student's action(s) were a reflection of his/her disability or perhaps the result of it.

Overview-Bipolar Disorder

Bipolar Disorder - A general overview of bipolar disorder from the NIMH

Going to Extremes: Bipolar Disorder (National Institute of Mental Health) - A brief overview of the symptoms, treatments, and research findings.

Overview (American Academy of Family Physicians) - Bipolar disorder is a mental illness that causes extreme mood swings. This condition is also called manic-depressive illness. It may be caused by a chemical imbalance in the brain.

Diagnosis/Symptoms-Bipolar Disorder

Treatment-Bipolar Disorder

Lithium (National Alliance for the Mentally Ill) - Drug information on lithium, used for treating bipolar disorder

Mental Health Providers: Making the Right Choice (Mayo Foundation for Medical Education and Research) - Seeking mental health treatment can be a big decision. But acknowledging your need for treatment is only the first step. You must also find a doctor or therapist to see.

Prevention/Screening-Bipolar Disorder

Mood Disorder Questionnaire (Depression and Bipolar Support Alliance) - This questionnaire is a good first step in discovering if you might have this illness but it is not meant to take the place of an evaluation by a physician or a mental health professional.

Coping-Bipolar Disorder

Dealing Effectively with Bipolar Disorder (Depression and Bipolar Support Alliance) - PDF file of informational pamphlet providing guidance and information on coping with bipolar disorder

Healthy Lifestyles: Improving and Maintaining the Quality of Your Life - PDF file of a pamphlet on improving the quality of life living with bipolar disorder.

Directories

Find a Support Group in Your Community (Depression and Bipolar Support Alliance) - This map of the united states provides links to bipolar and depression support groups by region

Organizations-Bipolar Disorder

Child & Adolescent Bipolar Foundation - A trusted source of vital information on Pediatric Bipolar Disorder, resources at your fingertips, and a network of parents and experts who can help.

Depression and Bipolar Alliance - The Depression and Bipolar Support Alliance (DBSA) is the nation's leading patient-directed organization focusing on the most prevalent mental illnesses – depression and bipolar disorder. The organization fosters an understanding about the impact and management of these life-threatening illnesses by providing up-to-date, scientifically-based tools and information written in language the general public can understand.

National Alliance for the Mentally Ill - NAMI (the National Alliance on Mental Illness) is the nation's largest grassroots mental health organization dedicated to improving the lives of persons living with serious mental illness and their families. Founded in 1979, NAMI has become the nation's voice on mental illness, a national organization including NAMI organizations in every state and in over 1100 local communities across the country who join together to meet the NAMI mission through advocacy, research, support, and education.

National Institute of Mental Health - The National Institute of Mental Health (NIMH) is one of 27 components of the National Institutes of Health (NIH), the Federal government's principal biomedical and behavioral research agency. NIH is part of the U.S. Department of Health and Human Services.

National Mental Health Association - The National Mental Health Association (NMHA) is the country's oldest and largest nonprofit organization addressing all aspects of mental health and mental illness. With more than 340 affiliates nationwide. NMHA works to improve the mental health of all Americans, especially the 54 million individuals with mental disorders, through advocacy, education, research and service.

Children and Bipolar Disorder

Child and Adolescent Bipolar Disorder (National Alliance for the Mentally Ill) - One of the biggest challenges has been to differentiate children with mania from those with attention deficit hyperactivity disorder. Both groups of children present with irritability, hyperactivity and distractibility.

Child and Adolescent Bipolar Disorder: An Update from the National Institute of Mental Health - Research findings, clinical experience, and family accounts provide substantial evidence that bipolar disorder, also called manic-depressive illness, can occur in children and adolescents. Bipolar disorder is difficult to recognize and diagnose in youth, however, because it does not fit precisely the symptom criteria established for adults, and because its symptoms can resemble or co-occur with those of other common childhood-onset mental disorders.

Storm in My Brain:Kids and Mood Disorders (Bipolar Disorder and Depression) - PDF file targeted to children with information on bipolar disorders and depression, from the Depression and Bipolar Support Alliance

Teenagers and Bipolar Disorder

Bipolar Disorder (Nemours Foundation) - Page targeted to teens with information on bipolar disorder

Bipolar Disorder (Manic-Depressive Illness) in Teens (American Academy of Child and Adolescent Psychiatry) - Research has improved the ability to diagnose Bipolar Disorder in children and teens. Bipolar Disorder can begin in childhood and during the teenage years, although it is usually diagnosed in adult life. The illness can affect anyone. However, if one or both parents have Bipolar Disorder, the chances are greater that their children may develop the disorder.

Behavior management checklist - Research shows that while a punitive, coersive approach toward behavior management may gain superficial compliance, students feel alienated from those teachers (and school in general), lose motivation to achieve, and resist changing the undesireable behavior.

Managing group behavior - Use these suggestions as a checklist to determine your skill in managing the behavior of groups of students.

Helping kids develop self management - These simple techniques (so simple that a lot of teachers don't believe that they'll work until they give them a try) are nice things to try before going to your penalties for non-compliance and misbehavior.

Best practices for behavior disorders - Best Practices for Behavior Disorders in the Classroom

Addressing skill deficits - If the student does not know what the behavioral expectations are, the plan can be formulated to teach expectations, and would include the supports, aids, strategies, and modifications necessary to accomplish this instruction, with expectations explained in concrete terms.

Giving and getting respect - When students feel valued, respected and welcomed in their classroom, they are more likely to behave better and demonstrate respect toward you. Here are a few tips for creating the optimal classroom environment.

Token economies - A token economy involves awarding tokens, chips, stickers, check marks, points, or other items/markings to students who demonstrate desired behaviors identified by the teacher.

Addressing performance deficits - If a functional behavioral assessment reveals that the student knows the skills necessary to perform the behavior, but does not consistently use them, the intervention plan may include techniques, strategies, and supports designed to increase motivation to perform the skills.

Primer on behavior management - how well you manage student behavior is crucial to your success as a teacher. The behavior that is exhibited in your classroom affects how administrators, colleagues, kids, parents, and YOU view your competence as a teacher.

Primer for beginning professionals - Our first year of teaching has a tremendous impact on our personal and professional life. A positive experience leads to a long and rewarding career. A negative one promotes feelings of frustration, embarrassment, and isolation. The greatest threat to a long and successful teaching career is student misbehavior. Teachers report it to be their primary source of career-based stress, and former teachers report it to be the number one reason that they left the field. Nationally, over 1/5 of new teachers leave the profession in the first three years (the rate is higher in low income urban areas).

Ways to catch kids being good - The most effective behavior management technique is the easiest to implement..."catching 'em being good". Research shows us that the quickest and most effective way to promote the display of appropriate behaviors is to reward them (e.g., touch, a smile, a "thank you", praise, points, food,...whatever would be reinforcing to those youngsters). We all like to have our efforts acknowledged, and will show more of that behavior if it brings us rewards.

How your teaching style affects the managing of behavior - A great deal of misbehavior occurs because the students are not interested in the lesson. Kids who are bored will create their own entertainment. Here are some ways to engage youngsters in your lessons.

Promoting positive peer pressure - This page contains ideas that bring about cooperation on the part of your class and promote "positive peer pressure" (students motivating others to behave appropriately).

Assertive discipline - Lee and Marlene Canter, when consulting for school systems, found that many teachers were unable to control undesirable behavior that occurred in their classrooms. The Cantors, rightfully so, attributed this to a lack of training in the area of behavior management. Based on their research and the foundations of assertiveness training and applied behavior analysis, they developed a common sense, easy-to-learn approach to help teachers become the captains of their classrooms and positively influence their students' behavior. Today, it is the most widely used "canned" (prepared/packaged) behavior management program. Assertive discipline has evolved since the mid 70's from an authoritarian approach to one that is more democratic and cooperative.

Cooperative learning - Cooperative learning is not having students merely sitting together, helping the others do their work. Having students who finish their work first assist others is also not a form of cooperative learning either. Neither is assigning a group of students to work together without assuring that all contribute to the product.

Differential reinforcement procedures - DR interventions are structured versions of "catching 'em being good". Instead of punishing the "bad behavior" to decrease it's occurrence, you get rid of it by using positive reinforcement in a structured manner.

Schedules of reinforcement - Given the precise and structured nature of the procedures of applied behavior analysis, you can be sure that any self-respecting behaviorist would make sure to "catch kids being good" only under certain circumstances (like in the Differential Reinforcement procedures) and on a particular schedule. By implementing a certain schedule when first building a behavior, and later changing to other schedules, you can promote stronger, more ingrained versions of appropriate behavior while "weaning" kids from rewards. Here, you'll find information on the different schedules and when you might make use of them.

Shaping - The practice of shaping (also known as "successive approximation") is not, in and of itself, a method for managing inappropriate behavior. Instead, it is a method that assists you in setting goals for the behavior of a certain student. Shaping will provide guidance and direction for your behavior change program, and will help you assess its effectiveness. It can assist you in changing an aberrant behavior or creating an appropriate behavior that is not yet in the student's repertoire.

Task analysis - Many of the day-to-day behaviors in which we engage without even thinking about them are really quite complex, comprised of many smaller, discrete, singular, specific sub-behaviors that we perform in a certain order.

Time out - An intervention in which you remove a misbehaving youngster from a situation or environment that is reinforcing the inappropriate behavior.

The really big list of classroom management resources - A collection of classroom management and discipline websites, still (probably) the biggest on the World Wide Web. Originally created by a bleary-eyed and courageous band of Monmouth University graduate students who gave up one week of their lives scouring the entire Internet (well almost), this site has many of the best that cyberspace has to offer.

Council for children with behavior disorders - The Council for Children with Behavioral Disorders (CCBD) is the official division of the Council for Exceptional Children (CEC) committed to promoting and facilitating the education and general welfare of children and youth with emotional or behavioral disorders.

Overview

Depression: A Treatable Illness - A fact sheet that describes the symptoms and types of depression and effective treatments.

Overview of Depression - An overveiw of depression from the National Institute of Mental Health

Clinical Depression: What You Need to Know (National Mental Health Association) - Clinical depression is very treatable, with more than 80% of those who seek treatment showing improvement. The most commonly used treatments are antidepressant medication, psychotherapy or a combination of the two. The choice of treatment depends on the pattern, severity, persistence of depressive symptoms and the history of the illness...

JAMA Patient Page: Depression (American Medical Association) - A person who feels sad all the time, has unexplained crying spells or loses interest in usual activities may have major depression, a serious medical illness that should be distinguished from normal temporary feelings of sadness after a loss, such as the death of a relative or friend.

Diagnosis/Symptoms-Depression

Symptoms: Learning to Recognize Clinical Depression in the Workplace (National Mental Health Association) - No two people experience clinical depression in the same manner. Symptoms will vary in severity and duration among different people.

Treatment-Depression

Depression: Electroconvulsive Therapy (American Academy of Family Physicians) - It is believed that ECT works by using an electrical shock to cause a seizure (a short period of irregular brain activity). This seizure releases many chemicals in the brain. These chemicals, called neurotransmitters, deliver messages from one brain cell to another. The release of these chemicals makes the brain cells work better. A person's mood will improve when his or her brain cells and chemical messengers work better

Electroconvulsive Therapy May Relieve Severe Depression, Other Disorders (Mayo Foundation for Medical Education and Research) - In certain cases ECT may be the best treatment option, sometimes offering fast and dramatic benefits. In severe depression, for instance, the risk of suicide may be high, requiring treatment that can quickly alleviate symptoms. And for some people, antidepressant medications aren't effective.

How to Find Help Through Psychotherapy (American Psychological Association) - Millions of Americans have found relief from depression and other emotional difficulties through psychotherapy. Even so, some people find it hard to get started or stay in psychotherapy. This brief question-and-answer guide provides some basic information to help individuals take advantage of outpatient (non-hospital) psychotherapy.

Medications (National Institute of Mental Health) - A detailed booklet that describes mental disorders and the medications for treating them -- includes a comprehensive list of medications.

Questions and Answers on Antidepressant Use in Children, Adolescents, and Adults (Center for Drug Evaluation and Research) - FDA is announcing a request to the manufacturers of ten antidepressant drugs that they strengthen the "Warnings" section of the package insert to encourage close observation for worsening depression or the emergence of suicidal thinking and behavior in both adult and pediatric patients being treated with these agents, particularly for depression but also for other psychiatric and nonpsychiatric disorders.

Types of Treatment: Clinical Depression is a Treatable Illness (National Mental Health Association) - If you or someone you know may benefit from a counselor or mental health center, here are some questions and guidelines to help you find the right care.

Alternative Therapy-Depression

Research on Adolescence and Depression-Depression

As Antidepressant Medication Treatment Increases, Adolescent Suicide Rates Decrease (American Medical Association) - Increases in antidepressant medication use are associated with decreases in rates of suicide among older adolescents and adolescent males, according to an article in the October issue of The Archives of General Psychiatry, a journal of the American Medical Association.

Combination Treatment Most Effective in Adolescents with Depression (National Institute of Mental Health) - A clinical trial of 439 adolescents with major depression has found a combination of medication and psychotherapy to be the most effective treatment.

Directories-Depression

Getting Help: Locate Services (National Institute of Mental Health) - If unsure where to go for help, talk to someone you trust who has experience in mental health—for example, a doctor, nurse, social worker, or religious counselor.

Organizations Involved With Depression

American Psychiatric Association

Center for Mental Health Services

Depression and Bipolar Support Alliance

National Institute of Mental Health

National Mental Health Association

Children and Depression

Antidepressant Medications for Children: Information for Parents and Caregivers (National Institute of Mental Health) - Research has shown that, as in adults, depression in children and adolescents can be treated. In particular, antidepressant medications — called selective serotonin reuptake inhibitors (SSRIs) because they specifically target the neurotransmitter serotonin — have been shown to be of benefit to children and adolescents with major depressive disorder. Certain types of psychological therapies have also been shown to be beneficial.

Depression in Kids: How Is It Treated? (Mayo Foundation for Medical Education and Research) - At one time, doctors didn't believe that children could experience depression. But researchers have found that depression is quite common in kids. Treatment may include psychotherapy and medication.

When Your Child is Depressed - Not everyone recognizes depression when it happens to someone they know. And some people have incorrect ideas about what it means to be depressed. People who don't understand may react to the depressed person's low energy with criticism, scolding them for acting lazy or not trying.

Childhood onset anxiety disorders - PDF file. After attention-deficit hyperactivity disorder and oppositional-defiant disorder, the anxiety disorders are the most common psychiatric illnesses in children and adolescents. As many as 3-5% of children suffer from anxiety disorders, not counting obsessive-compulsive disorder which affects another 0.5-1.0% of children.

Dual Diagnosis and Treatment for Co-occurring Disorders - A dual diagnosis occurs when an individual is affected by both chemical dependency and psychiatric/emotional illness. Both illnesses may affect a person physically, socially, psychologically, and spiritually. Each illness has symptoms that interfere with a person's ability to function effectively.

Double diagnosis: - Drug and alcohol abuse: More and more research is now showing that one reason many substance abusers have so many setbacks is that they also have an untreated, co-occurring psychiatric illness.

Extrem Irritability: Is It Childhood Bipolar Disorder? - Results of a new study may help improve the diagnosis and treatment of two debilitating childhood mental disorders

Eating Disorders: Facts About Eating Disorders and the Search for Solutions:A detailed summary that describes symptoms, causes, and treatments, with information on getting help and coping.

Study Tracks Prevalence of Eating Disorders - Results from a large-scale national survey suggest that binge-eating disorder is more prevalent than both anorexia nervosa and bulimia nervosa.

FAQ about attachment disorder - An attachment disorder is a mental and emotional condition occurring in the first two years of life that causes a child not to attach, to bond, or to trust his primary caretaker.

FAQ about child abuse - Frequently asked questions about child abuse from The National Exchange Club Foundation

FAQ about child bullying, school bullying and bullycide - Frequently asked questions about bullying and bullycide from bullyonline.org

FAQ about suicide - Attempts at suicide, and suicidal thoughts or feelings are usually a symptom indicating that a person isn't coping, often as a result of some event orseries of events that they personally find overwhelmingly traumatic or distressing.

FAQ about the President's New Freedom Commission on Mental Health - President George W. Bush established the Commission by presidential Executive Order 13263 on April 29, 2002. This President's Commission was the first comprehensive study of the nation's public and private mental health service delivery systems in nearly 25 years.

FAQ about anxiety and teens - Anxiety disorder is a real emotional disturbance; it's not just simply worrying, and it can be treated to help a person have a healthy and full life. From time to time, everyone worries about his or her health, family, money, and school. However, when a person has anxiety, they worry all the time, even when nothing is wrong. A person with anxiety always expects the worst will happen, can't relax, and feels tense most of the time.

FAQ about mental illness in persons with mental retardation - Mental health is a goal for all people, including those with mental retardation, not just those having difficulties. Mental health is an essential ingredient in the quality of life. The two main aspects of mental health are emotional well-being and rewarding social and interpersonal relationships.

History of mental health care: What is striking in looking at the history of mental health care is that at periods through the centuries, indeed through the millennia, there has been an accepted way of dealing with people with mental health problems, conventional for the time, that, however well-intentioned, has more often than not been inhumane, punitive, and largely unsuccessful, while alongside the orthodox practitioners there have been others with more enlightened approaches, attempting to do things differently.

History of modern mental health policy: An excellent history of mental health policy in the United States in the first half of the 20th century.

History of Occupational Therapy in mental health: The history of Occupational Therapy(OT) had it's origin in the 1700's during Europe's "Age of Enlightenment". At this time, radical new ideas were emerging for the infirm and mentally ill.

Medications chart - This chart lists the common medications used with children and adolescence with emotional issues. It provides the brand names, generic names and approved ages for the medications.

Promoting Appropriate Use Of Psychotropic Medications For Children And Adolescents - Since all children's treatment and services should be guided by CASSP Principles, this should include the use of psychotropic medication for children and adolescents, when clinically indicated. Unfortunately, for a variety of reasons, this in not always the case.

Children and psychotrophic drugs - Traditionally, mental health treatment for children relied upon behavioral or talk therapy, often coupled with an attitude of "waiting until they grow out of it." However, treatment options have changed dramatically since the 1970s. For today's children suffering from mental or behavioral disorders, psychotropic medications can work miracles.

Children and medications - One in ten of America's children has an emotional disturbance such as attention deficit hyperactivity disorder, depression or anxiety, that can cause unhappiness for the child and problems at home, at play, and at school. Many of these children will be taken by their parents to their family physician or pediatrician, or, in many cases, a specialist in child mental health. The child will be carefully evaluated and may begin some type of therapy.

Psychopharmacologic Medication: What Teachers Need to Know - Forness & Kavale (1988) and (Forness, Swanson, Cantwell, Guthrie, & Sena (1992) have also noted a decrease in classroom performance among children treated with psychostimulants for ADHD and disruptive classroom behavior. They have questioned whether the resultant decrease in behavior or relative gains in attention are worth the greater loss of learning performance in some children.

Handling children's fears: Some more common childhood fears are of darkness, animals, storms, fire, water, or strangers. Many children have fears that they or their parents will be hurt or killed. Also common is the child's fear of new situations, such as starting a new school.

Coping with child's stress: Stress is the body's physical, chemical, and emotional reaction to an overwhelming, confusing, or exciting situation.

Child discipline series-very extensive: The topic of child discipline causes heated arguments on 'Net discussion boards, as the proponents of spanking clash with those who are completely opposed. The fact is, child discipline is an important and emotional issue for us. We worry about our child's misbehavior and how we should handle it.

Parenting How To's: Simple strategies for better family communication and child discipline.

Parent's index to childhood and emotional disabilities: excellent overview of the many common emotional disorders found in childhood and adolescence.

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The topics listed are individual websites that can be accessed by members of The American Academy of Special Education Professionals (). If you are not a member of AASEP, and would like to join , click on the following link: Join AASEP to Register .

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Characteristics/Obsessions/ compulsions of a child with OCD:

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Characteristics/Obsessions/ compulsions of a child with OCD:

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Fear (fear of being dirty)

Anxiety (unwelcomed thoughts)

Concerns (concerns of not doing something)

Compulsions:

Cleaning

Repeating or phrases words

repeating actions

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Easily angered or irritated

Temper tantrums

Low self esteem

Refusal of rules

Argues more often

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Difficulty following rules

Aggression

Violating others

Bullying

Lying

Cheating

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3 step approach to identifying students with EBD: 

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3 step approach to identifying students with EBD: 

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Screening: Teachers evaluate the students based on the classrooms behaviors, interpersonal skills, and engagement. Those at the opposite or extreme ends may be recommended for further evaluation/ additional testing.

Identification: Students are directed to a diverse group of experts for structured assessment. They are evaluated based on behavioral and personality based methods. While behavior methods are most common in schools and personally focused techniques are most commonly used in clinical contexts.

Functional Behavioral Assessment: Following the identification of a student with EBD, a comprehensive analysis is taken to plan for instructions.

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Behavioral and Emotional Screening System (BESS)

The Behavioral and Emotional screening system aids educators and parents in evaluating the strengths and weaknesses of behavior and emotions among students aged 3-18.

Social, Academic, and Emotional Behavior Risk Screener (SAEBRS)

The SAEBRS is an assessment tool backed by research intended for universal behavioral and emotional vulnerability screening.

Strengths and Difficulties Questionnaire (SDQ)

The SDQ, created by Goodman in 1997, is a behavioral screening tool for individuals aged 4-17. It searches for potential psychiatric disorders and examines both traits and symptoms related to the child's behavior over the preceding six months.

Student Risk Screening Scale (SRSS)

The SRSS is an accessible and cost-free screening instrument created to pinpoint school-aged students exhibiting underlying issues.

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Cognitive behavior therapy

Family Psychoeducation

Social skill training

Interpersonal Psychotherapy

Relaxation Training

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Might cause disruption in the classroom

Might show aggression towards others in the classroom

Patterns of disruptive behaviors

Intense emotions circulating

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How to help outside of the classroom and in the classroom: 

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How to help outside of the classroom and in the classroom: 

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Emotional check ins

Provide a place for them to calm down peacefully

Create a routine

Provide coping skills

Positive communication

Behavior plans

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Giving clear instructions onto what is going on or what to do

Breaking down tasks into smaller pieces

Offer other choices or different choices

Giving extra time to complete an assignment

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pathway2success, says, K. W., & Webb, K. (2022, December 19). Executive functioning accommodations for emotions and behavior. The Pathway 2 Success. https://www.thepathway2success.com/executive-functioning-accommodations-for-emotions-and-behavior/

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9 effective teaching strategies for students with emotional and behavioral disorders. (n.d.). https://www.positiveaction.net/blog/teaching-strategies-for-emotional-and-behavioral-disorders

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Evidence based intervention network. Behavior – Screening – Evidence Based Intervention Network. (n.d.). https://cehd.missouri.edu/ebi/behavior-screening/

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Emotional disturbance therapy: Offices of Paul Dalton. Lexington Counseling & Psychiatry Near Lexington, Frankfort, and Richmond, Kentucky (KY). (n.d.). https://www.counselinglexingtonky.com/emotional-disturbance#:~:text=Emotional%20disorders%20are%20typically%20treated,interpersonal%20psychotherapy%2C%20or%20relaxation%20training.

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Identification of EBD. Informational Resources on Disabilties. (n.d.). https://disabilityinformationalresources.weebly.com/identification-of-ebd.html

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Obsessive-compulsive. Mental Health Foundation. (2023, May 26). https://mentalhealthfoundation.org/health-conditions/anxiety-disorders/obsessive-compulsive/?gad_source=1&gclid=Cj0KCQjwncWvBhD_ARIsAEb2HW_ch9dXCTGifR1cUDD1b-cpip93Aqa5KKJgGrx5HuzgC6nBwqGRPX4aAqvFEALw_wcB

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Department of Health & Human Services. (2002, March 12). Oppositional defiant disorder (ODD). Better Health Channel. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/oppositional-defiant-disorder-odd

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9 effective teaching strategies for students with emotional and behavioral disorders. (n.d.). https://www.positiveaction.net/blog/teaching-strategies-for-emotional-and-behavioral-disorders

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Yourtherapysource. (2023, June 3). Accommodations for students with emotional and behavioral disorders. Your Therapy Source. https://www.yourtherapysource.com/blog1/2022/03/11/accommodations-for-students-with-emotional-and-behavioral-disorders/

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Cummings, E. (2022, October 2). Emotional and behavioral disorder EBD diagnosis and special education. Behaviorist. https://www.behaviorist.com/emotional-and-behavioral-disorder-ebd-diagnosis-and-special-education/#:~:text=By%20definition%2C%20children%20diagnosed%20with,at%20school%2C%20and%20home%20settings.