# data[].attributes.attachment_link.title
Psychotic symptoms in children and adolescents

# data[].attributes.attachment_link.description
Some of the more disturbing behavioral symptoms to present are psychotic symptoms such as auditory or visual hallucination, delusions such as paranoia, or grossly disorganized thought content. Similar to the worry many families will have that a headache is the result of a brain tumor, concern that the psychotic symptoms represent the onset of schizophrenia often creates considerable alarm for families and primary care clinicians alike.

# data[].attributes.headline
Evaluation and Management for Children with Psychotic Disorders

# data[].attributes.subject
Evaluation and Management for Children with Psychotic Disorders

# data[].attributes.attachment_link.readable_text
Clinical Points

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

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

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

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

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

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

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

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

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

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

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

Table 1

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

WHAT ARE PRESENTING CHARACTERISTICS OF PSYCHOSIS IN CHILDREN AND ADOLESCENTS?

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

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

HOW ARE CHILDREN AND ADOLESCENTS DIAGNOSED WITH SCHIZOPHRENIA?

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

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

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

WHAT CAUSES SCHIZOPHRENIA IN CHILDHOOD AND ADOLESCENCE?

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

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

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

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

WHICH NEUROTRANSMITTERS ARE THOUGHT TO BE INVOLVED IN SCHIZOPHRENIA?

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

ARE THERE ENVIRONMENTAL RISKS FOR THE DEVELOPMENT OF SCHIZOPHRENIA?

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

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

HOW CAN ONE DISTINGUISH PRIMARY PSYCHOSIS FROM SECONDARY PSYCHOSIS?

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

Table 2

Infections

Creutzfeldt-Jakob disease

Herpes encephalitis

Human immunodeficiency virus infection

Lyme disease

Subacute bacterial endocarditis

Sydenham's chorea

Metabolic disturbances

Adrenocortical insufficiency

Cushing's disease

Hypercalcemia or hypocalcemia

Hypermagnesemia or hypomagnesemia

Hypernatremia or hyponatremia

Hyperthyroidism

Hypoglycemia

Hypokalemia

Hypophosphatemia

Lactic acidosis

Panhypopituitarism

Parathyroid disease

Thyroid storm

Neurologic

Cerebral neoplasms

Cerebrovascular disease

Cerebral lipidoses

Complex partial auras or seizures

Creutzfeldt-Jakob disease

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

Focal lesions of temporal and parietal lobe

Generalized seizures

Hepatic encephalopathy

Herpes encephalitis

Multiple sclerosis

Normal pressure hydrocephalus

Temporal arteritis

Postnoxic encephalopathy

Posttraumatic encephalopathy

Fragile X syndrome

Klinfelter's syndrome

Metachromic leukodystrophy

Prader-Willi syndrome

Velocardiofacial syndrome

Wilson's disease

Vitamin deficiencies

Folate deficiency

Niacin deficiency

Vitamin B ₁₂ deficiency

Vitamin D insufficiency

Medications

Drug classes that can cause hallucinations or delusions

Amphetamine-like drugs

Anabolic steroids

Angiotensin-converting enzyme inhibitors

Anticholinergics

Antidepressants (both tricyclic antidepressants and selective serotonin reuptake inhibitors)

Antiepileptics

Barbiturates

Benzodiazepines

β-adrenergic blockers

Calcium channel blockers

Cephalosporins

Corticosteroids (prednisone, cortisone, adrenocorticotropic hormone, others)

Dopamine receptor agonists

Fluoroquinolone antibiotics

Nonsteroidal antiinflammatory drugs

Procaine derivatives (procainamide, procaine, penicillin G)

Salicylates

Sulfonamides

Alcohol toxicity/withdrawal

Illicit use of drugs (including prescribed medications)

Amphetamines

Glue sniffing/ingestion

Lysergic acid diethylamide

Methamphetamine (crystal meth)

Phencyclidine hydrochloride (PCP)

Psilocybin (mushrooms)

Toxicologic causes

Carbon monoxide poisoning

Heavy metal poisoning (eg, mercury, lead)

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

Table 3

Electroencephalogram

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

Laboratory studies

Antinuclear antibodies

Blood urea nitrogen/creatinine

Calcium and phosphorus

Ceruloplasmin (for Wilson's disease)

Complete blood count

Electrolytes

Erythrocyte sedimentation rate

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

Human immunodeficiency virus screening

Liver function tests

Thyroid-stimulating hormone

Urinalysis

Urine (and/or serum) drug screen

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

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

WHAT DOES THE FIRST EPISODE OF PSYCHOSIS INVOLVE?

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

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

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

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

WHAT DOES THE PHARMACOTHERAPY OF SCHIZOPHRENIA IN YOUTH INVOLVE?

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

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

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

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

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

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

Table 4

Second-Generation Antipsychotics
(trade name)

Anticholinergic

Diabetes

Hyperlipidemia

Hyperprolactinemia

Hypotension

Sedation

Tardive Dyskinesia

Weight
Gain

WHAT ARE THE ADVERSE EFFECTS OF ANTIPSYCHOTICS?

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

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

Extrapyramidal Side Effects

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

Other Movement Disorders

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

Akathisia

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

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

Neuroleptic Malignant Syndrome

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

WHAT STRATEGIES ARE HELPFUL FOR NONRESPONDERS?

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

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

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

CONCLUSION

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

# data[].attributes.attachment_link.title
Psychotic Disorders in Children and Adolescents: A Primer on Contemporary Evaluation and Management

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

# data[].attributes.headline
Parental Roles for Children with Anxiety

# data[].attributes.subject
Parental Roles for Children with Anxiety

# data[].attributes.attachment_link.readable_text
When children are chronically anxious, even the most well-meaning parents, not wanting a child to suffer, can actually make the youngster's anxiety worse. It happens when parents try to protect kids from their fears. Here are pointers for helping children escape the cycle of anxiety.

None of us wants to see a child unhappy, but the best way to help kids overcome anxiety isn't to try to remove stressors that trigger it. It's to help them learn to tolerate their anxiety and function as well as they can, even when they're anxious. And as a byproduct of that, the anxiety will decrease over time.

Helping children avoid the things they are afraid of will make them feel better in the short term, but it reinforces the anxiety over the long run. Let's say a child in an uncomfortable situation gets upset and starts to cry - not to be manipulative, but just because that's how they feel. If their parents whisk them out of there, or remove the thing they're afraid of, the child has learned that coping mechanism. And that cycle has the potential to repeat itself.

You can't promise a child that their fears are unrealistic-that they won't fail a test, that they'll have fun ice skating, or that another child won't laugh at them during show & tell. But you can express confidence that they're going to be okay, that they will be able to manage it. And you can let them know that as they face those fears, the anxiety level will drop over time. This gives them confidence that your expectations are realistic, and that you're not going to ask them to do something they can't handle.

It's important to understand that validation doesn't always mean agreement. So if a child is terrified about going to the doctor because they're due for a shot, you don't want to belittle those fears, but you also don't want to amplify them. You want to listen and be empathetic, help them understand what they're anxious about, and encourage them to feel that they can face their fears. The message you want to send is, "I know you're scared, and that's okay, and I'm here, and I'm going to help you get through this."

Encourage your child to talk about their feelings, but try not to ask leading questions- "Are you anxious about the big test? Are you worried about the science fair?" To avoid feeding the cycle of anxiety, just ask open-ended questions: "How are you feeling about the science fair?"

What you don't want to do is be saying, with your tone of voice or body language: "Maybe this is something that you should be afraid of." Let's say a child has had a negative experience with a dog. Next time they're around a dog, you might be anxious about how they will respond, and you might unintentionally send a message that they should, indeed, be worried.

Let your child know that you appreciate the work it takes to tolerate anxiety in order to do what they want or need to do. It's really encouraging them to engage in life and to let the anxiety take its natural curve. We call it the "habituation curve." That means that it will drop over time as he continues to have contact with the stressor. It might not drop to zero, it might not drop as quickly as you would like, but that's how we get over our fears.

When we're afraid of something, the hardest time is really before we do it. So another rule of thumb for parents is to really try to eliminate or reduce the anticipatory period. If a child is nervous about going to a doctor's appointment, you don't want to launch into a discussion about it two hours before you go; that's likely to get your child more keyed up. So just try to shorten that period to a minimum.

Sometimes it helps to talk through what would happen if a child's fear came true-how would they handle it? A child who's anxious about separating from their parents might worry about what would happen if a parent didn't come to pick them up. So we talk about that. If your mom doesn't come at the end of soccer practice, what would you do? "Well I would tell the coach my mom's not here." And what do you think the coach would do? "Well he would call my mom. Or he would wait with me." A child who's afraid that a stranger might be sent to pick them up can have a code word from their parents that anyone they sent would know. For some kids, having a plan can reduce the uncertainty in a healthy, effective way.

There are multiple ways you can help kids handle anxiety by letting them see how you cope with anxiety yourself. Kids are perceptive, and they're going to take it in if you keep complaining on the phone to a friend that you can't handle the stress or the anxiety. I'm not saying to pretend that you don't have stress and anxiety, but let kids hear or see you managing it calmly, tolerating it, feeling good about getting through it.

# data[].attributes.attachment_link.title
What to Do (and Not Do) When Children Are Anxious - Child Mind Institute

# data[].attributes.attachment_link.description
How to help a child with anxiety? We bring expert parenting advice on assisting children to escape the cycle of anxiety. Learn what to do and not to do, anxiety treatments, and behavioral modification techniques.

# data[].attributes.headline
The Signs of OCD and Anxiety in Children

# data[].attributes.subject
The Signs of OCD and Anxiety in Children

# data[].attributes.attachment_link.title
OCD in Children - Are you Missing the Signs

# data[].attributes.attachment_link.readable_text
Children with obsessive-compulsive disorder (OCD) are plagued by unwanted and stressful thoughts and fears that they try to alleviate by performing compulsive rituals like counting or washing their hands. This guide explains how OCD impacts children, how it's diagnosed and the most effective treatments.

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

# data[].attributes.attachment_link.description
Children with obsessive-compulsive disorder (OCD) are plagued by unwanted and stressful thoughts and fears that they try to alleviate by performing compulsive rituals like counting or washing their hands. This guide explains how OCD impacts children, how it's diagnosed and the most effective treatments.

# data[].attributes.attachment_link.readable_text
Overview

Occasional anxiety is an expected part of life. You might feel anxious when faced with a problem at work, before taking a test, or before making an important decision. But anxiety disorders involve more than temporary worry or fear. For a person with an anxiety disorder, the anxiety does not go away and can get worse over time. The symptoms can interfere with daily activities such as job performance, school work, and relationships.

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

Signs and Symptoms

Risk Factors

Treatments and Therapies

Join a Study

# data[].attributes.attachment_link.description
Occasional anxiety is an expected part of life. You might feel anxious when faced with a problem at work, before taking a test, or before making an important decision. But anxiety disorders involve more than temporary worry or fear. For a person with an anxiety disorder, the anxiety does not go away and can get worse over time.

# data[].attributes.attachment_link.provider_name
National Institute of Mental Health (NIMH)

# data[].attributes.attachment_link.description
Learn about obsessive-compulsive disorder, including signs and symptoms, risk factors, treatments and therapies, and links to other resources to learn more.

# data[].attributes.headline
Individuals with Disabilities Education Act

# data[].attributes.subject
Individuals with Disabilities Education Act

# data[].attributes.attachment_link.description
The main intention for the Project IDEAL website is to better prepare teachers to work with students with disabilities.

# data[].attributes.attachment_link.provider_name
Individuals with Disabilities Education Act

# data[].attributes.attachment_link.readable_text
The Individuals with Disabilities Education Act (IDEA) is a law that makes available a free appropriate public education to eligible children with disabilities throughout the nation and ensures special education and related services to those children.

The IDEA governs how states and public agencies provide early intervention, special education, and related services to more than 8 million (as of school year 2022-23) eligible infants, toddlers, children, and youth with disabilities.

Infants and toddlers, birth through age 2, with disabilities and their families receive early intervention services under IDEA Part C. Children and youth ages 3 through 21 receive special education and related services under IDEA Part B.

Additionally, the IDEA authorizes:

Formula grants to states to support special education and related services and early intervention services.

Discretionary grants to state educational agencies, institutions of higher education, and other nonprofit organizations to support research, demonstrations, technical assistance and dissemination, technology development, personnel preparation and development, and parent-training and -information centers.

Congress reauthorized the IDEA in 2004 and most recently amended the IDEA through Public Law 114-95, the Every Student Succeeds Act, in December 2015.

In the law, Congress states:

Disability is a natural part of the human experience and in no way diminishes the right of individuals to participate in or contribute to society. Improving educational results for children with disabilities is an essential element of our national policy of ensuring equality of opportunity, full participation, independent living, and economic self-sufficiency for individuals with disabilities.

Other Laws for Children with Disabilities

The U.S. Department of Education's Office for Civil Rights (OCR) provides additional resources of interest for individuals with disabilities and their families.

OCR does not enforce the IDEA; however, OCR does enforce the Rehabilitation Act of 1973, Section 504 and Americans with Disabilities Act of 1990, Title II rights of IDEA-eligible students with disabilities.

To learn more, visit the OCR's Frequently Asked Questions About Section 504 and the Education of Children with Disabilities.

Visit OCR's website for additional resources.

# data[].attributes.attachment_link.title
About IDEA - Individuals with Disabilities Education Act

# data[].attributes.attachment_link.description
The IDEA is a law that makes available a free appropriate public education to eligible children with disabilities throughout the nation and ensures special education and related services to those children.

# data[].attributes.attachment_link.title
What is ODD? ODD meaning and Oppositional Defiant Disorder DSM 5  diagnosis

# data[].attributes.attachment_link.readable_text
When parents start googling behavior issues, one phrase tends to jump out: oppositional defiant disorder (ODD). It's easy to see why. "The words 'oppositional' and 'defiant' show up in parents' vocabulary fairly frequently," says David Anderson, PhD, a clinical psychologist at the Child Mind Institute. "It's one of the more aptly named diagnoses that exists."

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

What is Oppositional Defiant Disorder (ODD)?

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

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

Being unusually angry and irritable

Frequently losing their temper

Being easily annoyed

Arguing with authority figures

Refusing to follow rules

Deliberately annoying people

Blaming others for mistakes

Being vindictive

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

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

Parenting Under Fire

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

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

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

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

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

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

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

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

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

ADHD and Other Risk Factors

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

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

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

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

Why Treatment is Important

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

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

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

What Treatment for ODD Looks Like

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

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

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

Parent-Child Interaction Therapy (PCIT)

Parent Management Training (PMT)

Defiant Teens

Positive Parenting Program (Triple P)

The Incredible Years

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

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

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

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

# data[].attributes.attachment_link.title
What Is Oppositional Defiant Disorder (ODD)? - Child Mind Institute

# data[].attributes.attachment_link.description
Learn about the symptoms of ODD and how treatment can improve the parent-child relationship and improve a child's behavior.

# data[].attributes.attachment_link.title
Therapy for ODD, Oppositional and Defiant Disorder

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

# data[].attributes.headline
The Neuropsychology of Conduct Disorder in Children

# data[].attributes.subject
The Neuropsychology of Conduct Disorder in Children

# data[].attributes.attachment_link.title
The Neuropsychology of Conduct Disorder in Children | Kalina Michalska | TEDxUCR

# data[].attributes.attachment_link.readable_text
by Dinah Stacy

The paper presents a comprehensive analysis of current journal articles, research and literature on conduct disorder. The correlation of unproductive parenting, poor choices during pregnancy, etiology, childhood environment and the lack of disciplinary practices at home and at school are presented as key determinants of this disorder. The research supports this statement.Statistical data is provided to support the prevalence of this disorder in young children which escalates during the teen years.

When asked what developmental stage is diagnosed with conduct disorder the primary answer would be adolescent. However, based on research the greatest damage to society is the result of actions by delinquent adolescents but conduct disorder begins below the age of 7 (Scott, 2007). The researcher hypothesis suggests conduct disorder has a multi-factorial causation which includes biologic, psychosocial and numerous facets of the family unit. The research reveals a negative combination of these factors may predispose young children to exhibit symptoms of conduct disorder. The following questions will hopefully be answered: (1) What causes conduct disorder?(2) Can conduct disorder be prevented or predicted? (3) Does parenting style promote symptoms of conduct disorder? and (4) What are the interventions?

Definition

Conduct disorder is differentiated from other psychiatric disorders diagnosed in children by the following criteria: "persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated" American Psychiatric Association (as cited from Tehama, 2007). According to Sea right et al., (2001) conduct disorder is a psychiatric syndrome occurring in childhood and adolescence which characterized by a longstanding pattern of violations of rules and antisocial behaviors. They interpret conduct disorder as:

Conduct disorder is a common childhood psychiatric problem that has increased incidence in adolescence. The primary diagnostic features of conduct disorder include aggression, theft, vandalism, violation of rules and/or lying. For a diagnosis these behaviors must occur for a least a six-month period.

According to Evans (2003) conduct disorder is a steady pattern of harming others or their property, lying, stealing, or breaking societal rules of behavior. Remote instances of acute behavior, running away, or vandalism is not enough to merit a diagnosis of conduct disorder. Most children exhibit instances of poor judgment and bad behavior at least one time in their childhood. The distinction is children with conduct disorder break the rules over and over again, exhibit aggressive behavior, and show no regard for others. The behavior is not considered conduct disorder until the symptoms are displayed for one year or more. The disturbances in behavior result in significant clinical impairment with social skills, academics and occupational functioning (American Psychiatric Association, 1994).

Clinical Symptoms/Diagnosis

The clinical features of Conduct Disorder are:

The American Psychiatric Association (1994) provides further symptoms which support the clinician in diagnosis of conduct disorder. The child will often bully, threaten or intimidate others. They may intentionally set fires with the objective of harming others. The violation of rules would include: (1) often staying out late at night regardless of parental prohibitions which can begin before the age of 13; (2) has run away from home more than two times; and (3) the child is often truant from school which usually begins before the age of 13.

Additional features of conduct disorder include an indifference to the welfare of others and little if any remorse about harming others. Adolescents often verbalize outward remorse to avoid punishment but do not exhibit any guilt. They do not require an objective basis to conclude others are a threat to them. Because of this demeanor they may lash out aggressively without being provoked (Searight et al., 2001).

During normal child development aggression and fighting is pertinent for defensive issues which do not escalate into anti-social behaviors; but, persistent anti-social behavior collectively handicaps during childhood and leads to deprived adjustment during adulthood. The child often endures negative responses by their peers and high levels of disapproval from their parents (Scott et al., 2001).

Children who are diagnosed with conduct disorder judge the world as an antagonistic and intimidating place. They may tattle on friends or blame others for the harm they have caused. They have few if any friends because of their limited interpersonal skills. Peers and family members may view them as irritating because of their indifference to their actions. They often have low self-esteem internally but externally they appear tough, cocky or self-assured (Evans, 2003).

Statistics

Conduct disorder has become a major health and social problem; it is the most common psychiatric problem diagnosed among children. Around the world the prevalence of conduct disorder is 5% (Scott, 2007). A study conducted by Sujit et al., (2006) reveals 4.58% of boys and 4.5% of girls are diagnosed with conduct disorder worldwide. In their study of 240 students in four schools in Kanke childhood conduct disorder was found in 73% and in adolescent 27%. Mild conduct disorder was found in 36%, moderate in 64% and severe conduct disorder in none. Lying, bullying and cruelty to animals were the primary symptoms (Sujit, 2006).

Conduct disorder affects 1 to 4 percent of 9- to 17-year olds in the United States. The disorder is more predominate in boys than girls and more common in cities than in rural areas (U.S. Department of Health and Human Services, 1999). Between 6 to 16 percent of boys and 2 to 9 percent of girls meet the criteria to be diagnosed with conduct disorder. It is estimated 40 percent of these children will grow up to be adults with antisocial personality disorder (Searight, 2001).

Epidemiological studies state approximately 2% of girls and 9% of boys are afflicted with this disorder. Adolescents with more external signs and symptoms would amplify the percentage to one third or one half of all children and adolescent clinic referrals Kazdin et al., 1992 (as cited by McCabe et at., 2005).

Heredity, Prenatal Care & Other Aspects of Causation

The etiology of conduct disorder consists of the correlation of genetic, family and social factors. The child may inherit limited baseline autonomic nervous system activity, resulting in a need for greater stimulation to attain optimal arousal. This hereditary aspect may explain the high level of sensation-seeking activity associated with the disorder (Johnson et al., 2002). Several studies have revealed the role of autonomic under-arousal in conduct-disordered adolescents (Crowell et al., 2006). According to McBurnett & Lahey, 1994 & Scrapa & Raine, 1997 (as cited in Crowell et al., 2006) conduct disorder and antisocial behavior in adulthood are marked by autonomic under-arousal which included reduced electro-dermal responding (EDR) and heart rate. Beauchaine, 2003 & Beuchaine et al., 2001 (as cited in Crowell et al., 2006) revealed both elementary children and adolescents have reduced sympathetic and parasympathetic linked cardiac activity when diagnosed with conduct disorder.

The importance of this research is evident when considering the critical period of preschool when noradrenergic, serotonergic, and dopaminergic systems which administer behavioral control are susceptible to long-term changes in functioning Bremner & Vermetten, 2001 (as cited in Crowell et al., 2006). Parasympathetic nervous system (PNS)-linked cardiac activity has been associated with emotional regulation capabilities Porges, 1995 (as cited in Crowell et al., 2006) in contrast to deficiencies in sympathetic nervous system (SNS)-linked cardiac activity have been linked with reward inconsiderateness Beauchaine et al., 2001 (as cited in Crowell et al., 2006).

During gestation the brain is vulnerable to the effects of environmental stressors; this statement applies to both prenatal and postnatal development Dawson et al., 2000 & Hulzink et al., 2004 (as cited in Van Goozen et al., 2007). Environmental factors which can affect brain development are:

Baumrind (as cited in Marsiglia et al., 2007) classified three parenting styles: authoritarian, authoritative, and permissive. For the purpose of this research authoritarian parenting styles will be discussed. The characteristics of an authoritarian parent are extremely restrictive and demanding rules. Parents who utilize this style tend to hamper children's autonomy and force them to follow stringent rules by threatening harsh punishment (Marsiglia et al., 2007). This type of parenting may lead children to believe they are not responsible for their actions; by contrast, when actions are questions they assume it is not their fault. According to numerous psychological theories parent-child relationship can generate psychological disorders such as anxiety, identity confusion and conduct disorder (Dwairy, et al., 2006). Hoeve et al., (2008) concluded from their study a strong link between parenting styles and delinquency trajectories; therefore, they recommended future research include parenting styles in measuring serious behaviors which are classified as conduct disorders.

The link between exposure to violence in the home and community is a crucial risk factor for conduct disorder according to research by Elze et al., 1999; Fergusson & Horwood, 1998; Jouriles et al., 1989; Kaplan et al., 1998 (as cited in McCabe et al., 2005). Violence exposure can take place in many places within the child's environment including: (1) victimization and witnessing child abuse; (2) community violence; (3) parental abuse (McCabe et al., 2005).

Culture and societal norms make up the macro-system which is seen as the most distant factors; the exo-system is seen as a midlevel factor; and the micro-system is seen as the most proximal position to the child. Lynch & Cicchetti, 1998 (as cited in McCabe, et al., 2005) stress risk factors which have the most impact are the factors which are more proximal to the child.

Family stresses: (1) substance abuse; (2) violence; and (3) social isolation etc increase a child's risk of conduct disorder or other mental health disorders. Garrison et al., 1992 (as cited in Baker et al., 2007) reveals several studies have documented the relationship between childhood psychosocial issues and primary care visits. Pediatricians consistently under identify mental health problems in children. Behavioral problems have been linked to an increase in family stressors: (1) divorce; (2) relocation; and (3) financial issues Lavigne et al., 1998 (as cited in Baker et al., 2007). Pediatrician should be aware of these factors when addressing repetitive visits to the office or the emergency room for treatment (Baker et al., 2007).

Parental psychopathology and parenting behavior may be potentially important risk or protective factors in developmental outcomes for these children with concurrent conduct problems. Parental stress and maladaptive parenting may foster the development of conduct disorder Johnson & Mash, 2001 (as cited by Chronis et al., 2007).

The researchers propose maternal smoking is a significant factor in conduct disorder because nicotine may interrupt fetal brain development. Dr. Wakschalg stated, "Our study suggests that cigarette smoking may be one of the first prenatal risk factors for this very serious disorder" (University of Chicago Medical Center, 1997).

According to the ecological-transactional model child abuse has the greatest impact on child functioning. Kaplan et al., 1998 states several studies have correlated child maltreatment to an increase risk of conduct disorder (as cited in McCabe et al., 2005). A study at University of Chicago Medical Center (1997) reveals a link between smoking during pregnancy and the likelihood of having a son with conduct disorder. The researchers analyzed records of 177, 7-12 year-old boys who were referred for outpatient treatment for behavioral problems. The study indicated 24 percent of the mothers who reported smoking more than a half-pack of cigarettes per day during pregnancy, 80% of their sons had conduct disorder. This was in contrast to conduct disorder in 50% of the boys whose mothers did not smoke (University of Chicago Medical Center, 1997). Dr. Lauren Wakschlag stated "Our study indicates that regardless of other factors, smoking during pregnancy can have serious behavioral outcomes in children" (University of Chicago Medical Center, 1997).

The longitudinal and experimental studies on children who are raised in orphanages, children's homes, and foster homes have established the adverse effects of long-term institutional care on children's personality development according to the American Academy of Child and Adolescent Psychiatry, 2005 (as cited in Chronis et al., 2007). Consistent research has shown a correlation between institutional child rearing and hyperactivity and inattention. Both of these symptoms are precursors of conduct disorder Roy et al., 2000 (as cited in Chronis et al., 2007).

The research repeatedly exposes children who are diagnosed with ADHD and conduct disorder are predisposed for (1) risky sexual behavior; (2) substance abuse; (3) delinquency; and (4) driving risks Barkley et al., 1993 (as cited in Chronis et al., 2007). The most disturbing fact is children who are diagnosed with ADHD and conduct disorder are at a greater risk of chronic criminal offenses Lyman, 1998 (as cited in Chronis et al., 2007). Lynam 1996 (as cited in Chronis et al., 2007) identified children with conduct disorder at a greater jeopardy for continual offending and explained their perseverance by the correlation of their behavior, neuropsychological and physiological deficits are comparable to adult psychopaths.

Childhood conduct disorder is a major risk factor for adult disorders especially anti-social behavior. The key to diagnosing these children is to identify the origin of antisocial behavior which is found in (1) difficult temperament and (2) ineffective socialization (Van Goozen et al., 2007).

Conduct disorder in childhood which persists through adolescence is associated with co-morbidity, recurrence and resistance to treatment Moffit, 2005 (as cited in Jaffee et al., 2006). The study shows children and adolescence who struggle with signs and symptoms of conduct disorder continue to struggle throughout adulthood with psychosocial problems. The trajectories of antisocial behavior influence these children throughout adulthood and influence the childrearing environment (Jafee et al., 2006).

The influences of individual factors are multifaceted and confusion. Family dysfunction is repetitively identified as one of the crucial factor for conduct disorder in adolescence. Poor parental supervision is the preeminent predictor of violence and vandalism committed by boys. Psychosocial disturbances in children and adolescence bring together a comprehensive range of research to shed light on these young people who become parents of tomorrow; these parents who were diagnosed with conduct disorder predispose their child to the same disorder (Pearce, 1996).

The public debate concerning the relationship between family characteristics and children with conduct disorder continues to raise questions which researchers hope to answer. A longitudinal survey of children suggests ineffective parenting style is the strongest predictor of delinquent behavior in children between the ages of 8 and 11 years. In addition, aversion tactics, low socioeconomic status and the number of siblings in the home are associated with higher probability of children exhibiting conduct disorder (Stevenson, 1999). Somerstein (2007) reveals the common family dynamic in many individuals' histories of male terrorist is authoritarian parents.

Intervention

There are several factors noted by the research which can help with children who are exhibiting signs and symptoms of conduct disorder. Parents need to monitor their child's activities on a daily basis. Compliance with (1) curfew; (2) being a responsible parent; (3) monitoring your child's activities; and (4) quality time with your child are important aspects of parenting (Searight et al., 2001). Most of the parents are diagnosed with some type of psychological disorder and do not have the skills to implement this tips.

A productive intervention for parents is learning good communication skills. Parents should be able to communicate clear, direct and specific rules, request or expectations. Parents should expect the child to react in a concise manner. There should be respect from each party and rules need to be enforceable. Parents of children with conduct disorder rely on inconsistent coercion which increases the negative climate of the home (Searight et al., 2001).

School based intervention has begun to be implemented because of the increase in children who are diagnosed with conduct disorder. Ray (2007) compared the impact of child-centered play therapy, teacher interaction only and a combination of teacher-child relationship. The results were statistically significant for each treatment group, the indication was school based play therapy intervention was more effective in facilitating a positive rapport between the teacher and child.

Hoagwood et al. (2007) reported school-based mental health interventions have a positive effect on academic and mental health progress for children. The interventions were more productive when received long-term and addressed multiple needs in the child's lives. Community based agencies that provided services for children with conduct disorder in Great Britain were rated effective if they include:

Functional Family therapy is an empirically grounded, successful family intervention for kids with conduct order and other risk factors which hinder them from living a healthy life in society. The concept of FFT is to develop family member's strengths which can improve the environment. The characteristics of the program give the family a foundation for change which includes direct support from the therapist. The family is included in each phase of treatment: (1) goals i.e. reduce negativity and improve communication; and (2) risk and protective factors i.e. blaming (risk) and alliance (protective) (FFT, 2007).

The effectiveness of the intervention is based on the following factors: (1) engagement with the child and the family; (2) motivation; (3) clear/concise/understandable assessment; (4) teaching the family skills to change behaviors; and (5) being available for individualized needs from each member of the family.

The program's protocol suggests if the program is implemented successfully the child and family will show the following benefits:

According to the U.S. Department of Justice (U.S. Department of Justice, 2000):

Thirty years of clinical research indicate that FFT can prevent the onset of delinquency and reduce recidivism at a financial and human cost well below that exacted by the punitive approaches noted earlier.

If there is no change in the child's behavior pharmacotherapy may be added to the treatment. There are no formally approved medications for conduct disorder there are medication which can help with specific symptoms. Stimulants i.e. Dexedrine, Ritalin, are the most promising medication for the treatment of conduct disorder. There is limited research for the long-term effects of these medications on conduct disorder.

There is some controversy when administering antidepressants to children with ADHD and conduct disorder. There have been reports of improvement by parents but more studies are needed. Lithium has shown to reduce aggression but lithium requires regular blood level monitoring for toxicity. The use of lithium and anticonvulsants provides limitations in treatment. Several studies have shown significant improvement with Clonidine but the side effects interrupt the child's normal day i.e. drowsiness (Searight et al., 2001).

The parent may choose an outpatient mental health provider such as a community service board. The child would be assigned a case manager to assist with programs and concerns in the home and school. The case manager with the assistance of the parent would complete a treatment plan to notate long-term and short-term goals. Therapeutic interventions would include but not limited to: (1 psychological evaluation; (2) psycho-educational testing; (3) provide feedback to the parents and the teachers; (4) assist the parent and the child with establishing rule, boundaries and consequences; and (6) build a therapeutic rapport with the child (Jongsma et al., 1996).

Conclusion

Clearly the research reveals the correlation of diverse factors which promote conduct disorder. Parenting styles play a key role in promoting an environment which is conductive of this disorder. We (I) as new therapist need to education our clients, public, parents, families etc on the negative effects authoritarian parenting styles have on our children.

The research suggest children with conduct disorder become adults with anti-social behavior and others psychological problems. The disorder is more than a fussy child it is a serious issue which parents, teachers and the mental health profession needs to address.

The researcher has provided a brief look into the world of conduct disorder. Parents, caregivers, and clinicians need to be aware of the warning signs of conduct disorder. All three entity need to form a coalition to improve the environment these children endure everyday. Parents need to learn resources, interventions and build rapports with faculty at the schools.

Another aspect to consider is the link between nicotine and conduct disorder. Pregnant women need to be warned against smoking during and after pregnancy. There are significant risks with cigarette smoking during pregnancy but the research adds another aspect to the issue.

The statistics are staggering but the realization of what these children and their parents are enduring is more staggering. As a clinician at a community service board I witness daily these children who can not sit in a chair for five minutes. They need constant re-direction; as the research stated parents resort to coercion and threats instead of implementing good parental skills. Another aspect of the research is lack of communication; this is noticeable immediately.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual

(4 of mental disorders th ed. Text Revision). Washington D.C.: Author.

Barton, A. et al. (2007). Functional Family Therapy: blueprint for violence

Prevention. Institute of Behavioral Science . Retrieved June 19, 2007 from

http:www.colorado.edu/cspv/blueprints/model/programs/FFT.html

Functional Family Therapy Website. (2007). http://www.fftinc.om

Hoeve et al. (2008). Trajectories of delinquency and parenting styles. Journal

of Abnormal Child Psychology, 36 (2), 223-235. Retrieved April 28,

2008 from http://www.pubmedcentral.nih.gov/

Hoagwood, K., et al. (2007). Empirically-based school interventions targeted

Marsiglia et al. (2007). Impact of parenting styles and locus of control on emerging

Retrieved April 29, 2008 from:

http://www.scientificjournals.org

National Institute for Health & Clinical Excellence. (2007). Conduct disorder

Retrieved June 22, 2007

http://www.nice.org.uk/page.aspx?0=529846

Ray, D. (2007). Two counseling interventions to reduce teacher-child relationship

Stress {Electronic version}. Professional School Counseling, 10(4), 428-440.

http://www.goliath.ecnext.com/coms2

Scott, S. Conduct disorder in children. BMJ 2007. Retrieved July 13, 2007 from

Somerstein, L. (2007). I came with a sword on judgment day: a psychoanalytic look

Stevenson, K. (1999). Family characteristics of problem kids. Canadian Social

{Electronic Version} A report of the Surgeon General . Rockville, MD.

Retrieved July 12, 2007 from http://mentalhealth.samsha.gov/publications

Van Goozen et al. (2007). The evidence for a neurobiological model of childhood

antisocial behavior. Psychological Bulletin, Vol 1333(1), pp.149-182.

# data[].attributes.attachment_link.title
Conduct Disorder: Definition, Statistics, Parental Role and Intervention

# data[].attributes.attachment_link.description
by Dinah Stacy The paper presents a comprehensive analysis of current journal articles, research and literature on conduct disorder. The correlation of unproductive parenting, poor choices during pregnancy, etiology, childhood environment and the lack of disciplinary practices at home and at school are presented as key determinants of this disorder.

# data[].attributes.attachment_link.readable_text
Meet the Expert

Scott Carroll, MD

Scott Carroll, MD is the Director of Psychiatric Consultation Services at the University of New Mexico Children's Hospital and Carrie Tingley Children's Rehabilitation Hospital. He is currently an associate professor of Child and Adolescent Psychiatry at the University of New Mexico - School of Medicine.

Types of Eating Disorders: The Big 3

Social Interaction

May choose to eat alone or withdraw from interacting with others

Still has relationships with others, but may be more withdrawn than usual

Ranges from being overly defensive to avoiding confrontation at all costs

Q&A with an Eating Disorders Expert

Dr. Carroll offers some expertise and insight into how to spot eating disorders and how to get help.

Many individuals become quite adept at hiding their eating disorder. What are some of the more subtle signs friends and family should look for if they suspect an eating disorder?

Anorexia - warm baggy clothing, especially in the summer, think sweat pants and sweat shirts or coats. Sallow, tired looking skin. Increased comments about being fat despite being thin and coming up with excuses not to eat with family/friends like, "I just ate, but you go ahead." Alternatively, eating and then disappearing to the bathroom or working out excessively. Also, rapid weight loss, even if it seems healthy at first. Increasing OCD type behavior (technically Obsessive-Compulsive Personality Disorder) is also common.

Bulimia - any signs of binging, especially at night, finding lots of empty food containers, but never seeing them eat. Increased dental problems such as cavities and inflamed gums or scars on the backs of their hand from making themselves vomit. Also, buy/using lots of laxatives. Increasing depression is another common sign in Bulimia. Repeated attempts to lose weight unsuccessfully or being suddenly successful after numerous failed attempts.

Are eating disorders more prevalent in college, or do they manifest more often during those years? If so, why?

Bulimia typically starts in college, but anorexia typically starts in late puberty (~13yo) or late high school/early college age. Anorexia is moderately genetic and is also associated with high IQ and high educational levels so that is why you see more anorexia in college. Also, many women had anorexia has a young teen, get treated and do well, but the stress of college and being away from family often conspire to trigger a relapse.

What can friends and family do to help someone who has an eating disorder?

Professional treatment is absolutely necessary. Being supportive does little to help if someone really has an eating disorder. Probably the most important thing is to watch what a love one does and how they look and not be swayed by their attempts to conceal or deny their disorder.

When someone suffering from an eating disorder does choose to get help, what should they expect to happen next?

Anorexia under 18 years old, we often initiate treatment on an inpatient basis for weeks or even months at first if the disorder is severe enough. Adults with anorexia are harder to treat since they have more legal ability to refuse inpatient treatment (people with anorexia often don't think that anything is wrong with them). The important thing is that anorexia takes about 5 years to fully recover and many people never fully recover and have a waxing and waning course. Also, psychiatric medication is of modest benefit and specialized eating disorder therapy (1-3 times per week) over a few years is what it typically takes to recover on top of any inpatient treatment.

What else should we know about eating disorders?

Families often need to force the ill person in to treatment because a key feature of anorexia is to not be aware that you are sick (or even to like being emaciated). Also, even when people don't die from the anorexia, they still have severe, life-long health problems such as osteoporosis, infertility, heart problems and increased risk of dementia and learning problems.

Understanding Eating Disorders

Eating disorders are mental illnesses that manifest in some form concerning food. The most common symptoms include either excessive overeating, sometimes including binge eating and then purging, or severe restriction of calories. The obsession with eating and food, as well as weight and body image, can lead to significant distress; in fact, eating disorders can often go hand-in-hand with other problems, such as depression, anxiety and even substance abuse. Eating disorders might manifest in childhood, or they might surge to the forefront during the teenage years - more rarely, they manifest in adults.

What Causes an Eating Disorder?

Eating disorders have many causes, which are usually a complex interaction of genetic, psychological and social factors. However, social and psychological factors appear to be the leading causes. Specifically, many eating disorders relate to feelings of low self-esteem and poor body image.

Low self-esteem and/or poor body image often originate from societal pressure about how someone should look. There is also a link between certain personality traits and eating disorders. For example, those suffering from anorexia tend to be perfectionists, while those who have bulimia nervosa have impulsive tendencies. Combine a perfectionist personality with comments from friends, family members or the mainstream media telling someone they aren't "good enough" unless they lose some weight and it's no surprise if an eating disorder develops.

But keep in mind that the cause of an eating disorder is not always this simple. Eating disorders can be triggered by a wide variety of things, some of which is not well understood. Research is ongoing to learn more about what causes an eating disorder.

What Are the Most Common Eating Disorders?

The most common eating disorders include anorexia nervosa and bulimia nervosa. Binge-eating disorder is also a common problem for many people. Eating disorders not otherwise specified, often referred to as EDNOS, include eating disorders that don't fit neatly into the first three disorders.

Anorexia nervosa:

This often manifests as a desire to eat as little as possible, an obsession with counting calories, and sometimes excessive exercise in order to burn off any calories consumed.

Bulimia nervosa:

Bulimia usually takes the form of eating regularly or excessively, then purging - in other words, throwing up - in order to expel the calories.

Binge-eating:

This disorder often manifests in eating a great deal of food in one sitting, usually with an excessive amount of calories consumed.

EDNOS:

This might include any issues with food, including starving, binging, purging, serious food aversions, and much more. These issues don't fit neatly into the definition of binge-eating, bulimia or anorexia.

We will discuss these eating disorders in-depth in the following sections.

What's the Impact of an Eating Disorder?

The impacts of an eating disorder can be both immediate and long-term. In the short-term, eating disorders can cause tooth erosion, low heart rate, abnormally low or high blood pressure, muscle atrophy, hair loss, electrolyte imbalance, high cholesterol, peptic ulcers, inflamed esophagus, constipation and fatigue.

But keep in mind that these are simply the physical impact that might be experienced - the emotional and psychological impact can be just as devastating.

In the long-term, those who suffer from eating disorders might experience an increased risk of diabetes, osteoporosis, anemia, kidney failure, a drop in internal body temperature, infertility, organ failure, severe constipation, growth of fine hair over the body, brittle hair or finger nails, dry skin, heart disease and brain damage.

These long-term consequences can be deadly. In fact, research indicates that those who are anorexic have a mortality rate that is 18 times higher than those without an eating disorder.

Signs of an Eating Disorder

The signs of an eating disorder can sometimes be difficult to spot, especially in the earliest stages. That's because someone with an eating disorder often knows that they will be encouraged to eat or otherwise do things that they might not want to do, and so hiding the disorder becomes a priority. However, over time an eating disorder becomes much more difficult to hide, especially when someone begins to drop weight - or gain weight - at an alarming rate. Here are some of the most common signs that might tip off friends and family to those who have an eating disorder.

Tooth decay and/or tooth erosion

Change in color of the teeth

Constant sore throat

Acid reflux

Dehydration

Skewed body image ideas

Secretive food behaviors

Consumption of large amounts of food in a very short period of time

Purging behavior, such as frequent bathroom trips after meals, unusual use of diuretics and/or laxatives

Calluses or scars on hands and wrists due to purging

Extreme and rapid weight loss

Obsession with calories, weight loss and food

Refusing to eat normal amounts of food or avoiding food altogether

Refusing to eat in front of other people

Worry over weight gain, however slight

In a constant state of hunger

Withdrawal from friends and activities

Excessive exercise

Emaciation

Lack of menstruation or irregular menstruation

Dry or yellowing skin

Growth of fine hair over entire body

Unusual fatigue or lethargy

Anemia

Ulcers

Disordered Eating

What exactly turns disordered eating or a diet into an eating disorder? The simple answer is that it's a question of degree. A slightly more complex answer is that in addition to the degree to which someone controls what or how they eat, the person's motivation for the behavior can turn a "diet" into an eating disorder. We can start explaining the differences by defining what a diet, disordered eating and eating disorders are.

A diet is the regulation of food intake in order to modify the body. This is usually to lose weight or to meet some sort of health expectation, such as dieting in the hopes of reducing sodium intake or the like. A diet has a finite goal, whether it's to put on 15 pounds of muscle before the next sport season begins or lose 10 pounds before summer vacation starts. There usually is no compulsive or extreme behavior concerning food or exercise while on a diet - though intake might be strict, it is reasonable.

Also, choices made on a diet are usually universally accepted as beneficial. An example might be eating more fruit and vegetables and eating fewer hamburgers.

Disordered eating refers to abnormal eating that doesn't meet the criteria for an eating disorder. Put another way, someone suffering from disordered eating may have certain eating disorder criteria, such as binge eating, compulsive eating and purging. However, someone with disordered eating doesn't engage in these activities as often or in as extreme fashion as someone with an eating disorder. Another way of thinking of disordered eating is abnormal eating, but not bad enough to warrant calling it an eating disorder.

An eating disorder takes something like dieting or disordered eating to the extreme. Instead of replacing a chili cheeseburger with healthier options, such as a turkey sandwich on wheat toast, the person with the eating disorder skips the meal entirely.

One of the biggest differences between a diet and an eating disorder is the motivation for the eating behavior. Someone on a diet wants to lose a set amount of weight and once that goal is reached, the eating behavior stops. Someone with an eating disorder will never be satisfied with the weight they have lost. They may say they just want to lose 10 pounds, but once they reach that goal, they'll set another goal to lose weight. The eating habits become a compulsion, especially once that person suffering from an eating disorder sees the results of those habits.

Anorexia

Besides having an emaciated appearance, those who suffer from anorexia can face severe health problems. These can range from anemia to irregular periods to osteoporosis to death. When someone has anorexia, their body is being starved to death. Not only does the body not have enough energy to function, but the lack of nutrients causes serious medical complications.

One of the worst things about anorexia is that the person suffering from it believes they are fat or overweight, despite the fact that they are about extremely underweight and are on path to die from malnutrition. They also tend to express disbelief when someone suggests there might be something wrong. About 8% of those who suffer from anorexia will die, either from starvation or suicide.

As with other illnesses, the earlier treatment begins, the more likely it will be successful. Treatment will consist of several elements, depending on the individual and the severity of the problem.

If there are imminent medical problems, they will be addressed first. This can include medical treatment for osteoporosis or heart issues. Once medical complications have been treated or stabilized, the individual can receive counseling for proper eating habits and therapy to address the underlying cause of the anorexia. Individuals with anorexia usually suffer from anxiety, depression and body image issues.

Therapy can include psychotherapy and cognitive-behavioral therapy. Medication for mental health issues may be prescribed to help cope with things such as depression and anxiety.

The first step is to realize there is a problem. Visiting the websites listed below can help identify if you or someone you know has anorexia. They can also provide contact information for places to receive treatment as well as providing additional treatment information.

Once the problem is identified, a visit to your primary care physician will be an ideal next step. The primary care physician will be trained to treat and assess the eating disorder and can refer you to a specialist if necessary.

Resource List

Bulimia

Bulimia is a serious mental health condition that is especially hard on the digestive system. Repeated vomiting causes long-term damage to the esophagus, mouth and teeth. Use of laxatives can cause long-term problems with bowel movements. No matter the purging methods used, bulimics usually suffer from osteoporosis, electrolyte imbalance and low blood pressure.

Another serious problem with bulimia is that in addition to problems with eating habits and the constant desire for food, as well as the guilt that comes with eating it, vomiting can actually become addictive. Vomiting results in the release of endorphins, a "feel good" hormone. Therefore, bulimics may force themselves to vomit, just to achieve this euphoric feeling, even if they haven't eaten anything.

Depending on how long the individual has suffered from bulimia, treatment usually focuses on therapy, such as psychotherapy, interpersonal psychotherapy, family therapy or cognitive-behavioral therapy. Medical issues may need to be addressed such as tooth loss and esophageal damage. Prescription medication may also be needed to address feelings of depression and anxiety usually associated with bulimia.

First, identify the problem. Bulimia is one of the hardest eating disorders to treat because it is often undetected. It is usually done in secret, which makes it tough for friends or family members to spot the problem.

Second, seek treatment. This may ultimately require a trip to the hospital or to see a licensed mental health professional. Getting support from friends and family or support groups can also make things easier. If you have a doctor you see regularly, making an appointment will be the great first step in getting help. More information about where to get help can be found at any of the below websites.

Resource List

Binge Eating

Binge eating is much more than simply overeating on occasion - that's something all of us do. Binge eating becomes a disorder when it becomes an uncontrollable urge and interferes with everyday life. Binge eating can become a serious problem that leads to depression, social isolation, and medical complications such as obesity, heart disease, type 2 diabetes, sleep apnea, high blood pressure and joint problems.

The focal point for treating binge eating disorder will likely be therapy, whether it's family, group, cognitive-behavioral or psychotherapy. Therapy may be combined with prescription medications if deemed necessary by the treating therapist. If there are health problems caused by overeating, such as high blood pressure, type 2 diabetes or heart disease, inpatient care may be required.

As with bulimia, identifying a problem with binge eating can be difficult due to its inherently secret nature. However, once the problem has been identified, contacting a doctor is the best course of action. A physician will not only be able to assess the situation and refer to a specialist if needed, but may be able to begin treatment of certain medical complications. Additional information about binge eating can be found at the below websites.

Resource List

Other Disordered Eating

There are other types of eating disorders, usually classified under "eating disorders not otherwise specified," or ENDOS. These eating disorders might not get as much press as anorexia or bulimia, but they can be just as lethal. These are just a few examples of the wide range of eating disorders that might affect anyone of any age.

Orthorexia

Orthorexia is the compulsion to avoid eating foods that are perceived to be unhealthy or unpure. Orthorexia might also be defined as an unhealthy obsession with healthy eating or eating only pure foods.

What's the difference between orthorexia and being a picky eater or someone who is extra careful about what foods they eat? With orthorexia, the desire to avoid eating unhealthy foods is so extreme that it limits potential food selection to a very small amount of foods and/or creates isolation due to intolerance of other people's eating habits or beliefs. There may also be a connection of self-worth to the success in keeping up with the "healthy" eating habits, resulting in "punishments" for any mistakes in eating. It should be noted that orthorexia is not a clinical diagnosis under the DSM-5.

Yo-yo Dieting

Yo-yo dieting refers to the cycle of losing and gaining weight. Yo-yo dieting often occurs when someone decides to lose weight, is successful, but promptly gains the weight back. Another attempt to lose weight is initiated; weight is lost, but again gained back. This creates an up and down cycle, mimicking the up and down movements of a yo-yo toy.

Yo-yo dieting can be unhealthy because it alters the body's muscle-fat ratio. When weight is initially lost, a combination of muscle and fat is lost. When weight is gained back, usually from overeating, mostly fat returns instead of both the fat and muscle originally lost. When the cycle continues, more and more muscle is lost, only to be replaced with fat.

Many yo-yo dieters lose weight through food deprivation, rather than additional exercise and healthier food choices. However, because the differences in yo-yo dieting methods, there is still debate about the adverse consequences of yo-yo dieting.

Diabulimia

This unique form of bulimia is isolated to those with diabetes who are dependent upon insulin. Those with Type 1 diabetes are often diagnosed after they spot one of the key symptoms: severe weight loss. That's because when blood glucose is too high, the cells in the body are actually starving for energy. The eventual result is dropping weight quickly, among other symptoms, such as extreme thirst and frequent urination. A regimen of proper insulin dosage can keep those with Type 1 diabetes healthy.

However, some with Type 1 diabetes will choose to limit their insulin intake and let their blood sugar levels skyrocket. The result of this is rapid weight loss. Some take only enough insulin to keep them from falling into a diabetic coma, and continue to lose weight until they become ill from the many symptoms of anorexia or bulimia. This is a very dangerous practice: In addition to the problems that can be caused by an eating disorder, a person suffering from diabulimia also faces the issues of diabetic complications, including long-term kidney and vision problems, heart issues, and much more.

Eating Disorders by the Numbers

Approximatelyeight million Americans currently have an eating disorder.

Only 30-40%of anorexics will recover from their eating disorder.

42% of all first through third grade girls wish to be thinner.

Of the eight million Americans that have an eating disorder,seven million are female and one million are male.

Almost1 in 5 peoplewho suffer from anorexia will die within 20 years of becoming an anorexic.

About one in two peoplein the United States know someone who has an eating disorder.

The average cost of treating an eating disorder is $1,250 per day.

95% of those suffering from eating disorders are between the ages of 12 and 25.

Sources: Eatingdisorderhope.org, statisticbrain.com

College Students and Eating Disorders

College students often suffer from eating disorders at a rate much higher than the average population. Why are eating disorders so prevalent among those in college? Let's focus on the issues that surround college students and their healthy - or unhealthy - choices about food.

Eating Disorders on Campus

A Common Problem

Eating disorders are prevalent on college campuses for a variety of reasons. First and foremost, there is academic pressure and stress that is unlike anything many students have ever experienced. Students may need to maintain certain grades to keep scholarships or to avoid disappointing family members.

Second, there are social stresses. College students, especially women, are pressured to "fit-in" and become popular and accepted. Consequences for not fitting in may be especially harsh in college compared to high school due to the fact that students are away from home and their familiar environment and family support net. Combined this with society and the media's portrayal of an ideal body type or appearance, it's almost no surprise that eating disorders are so prevalent in college.

Third, there is a sense of shame college students feel when confronted with the fact that they may have an eating disorder. For example, 82% of those with eating disorders did not seek treatment because they were unwilling to get it and face the social stigma that might come along with it.

College Women and Eating Disorders

Women are the vast majority of college students who suffer from eating disorders. One of the reasons is the pressure to be a certain weight, which is related to larger social pressure to fit in, make friends and have romantic relationships. Women in general are more sensitive to media and societal pressures regarding body image and college is no different. This fact, coupled with increase in desire for acceptance, academic pressure and being away from home, results in a high percentage of women in college suffering from eating disorders.

Eating Disorders Surface in College

In addition to social and academic stresses, other factors of campus life can contribute to the development of eating disorders. One significant component is the increase alcohol use, which can lead to increase caloric intake and weight gain. There is then subsequent pressure to lose the weight, yet the social norm that encourages students to drink remains.

All-you-can-eat meal plans can contribute to eating disorders. A plethora of practically unlimited food choices can cause an increase in food consumption that goes without notice until a person steps on the scale and sees (often to their horror) that their weight has climbed dramatically. The result can be sudden crash dieting, which can eventually morph into an eating disorder.

Athletes, especially those that compete based on judging, are at a higher risk of developing an eating disorder. Some of the behaviors associated with eating disorders, such as excessive exercising, can be explained away as additional training for competition.

Even if an eating behavior does not qualify as an eating disorder, there may be rampant dieting and abnormal eating habits, such as disordered eating.

Signs of Disordered Eating

Feeling guilty after a meal

Having trouble being social

Frequent weight fluctuations

Emotionally driven eating

Occasional purging or binge eating

Feeling possessive of your food

Preoccupation with weight gain

Irregular eating patterns

How to Stop Disordered Eating

If you believe you or someone you know suffers from disordered eating or an eating disorder, one of the first steps is to contact or visit your campus medical/health center or your school's counseling center. All schools recognize the problem of eating disorders and have resources to help you seek treatment, either on campus or elsewhere.

Eating Disorders: Separating Fact from Fiction

Men don't have eating disorders as often as women.

Fact. However, about one in four people with an eating disorder are male.

Learn More: Eating Disorder Help and Resources

If you or someone you care about is facing an eating disorder, these resources can lead to valuable information and help.

NOTE: Beware of some blogs that promise "inspiration" to overcome an eating disorder. Unfortunately, there are numerous blogs out there that actually promote anorexia, bulimia and other disorders, but try to masquerade as "helpful."

About-Face
Exists to educate women and girls on the effect media has on their self-esteem and body image.

Academy for Eating Disorders
The primary goal is to provide information about eating disorders through the promotion of research and creation of expert knowledge.

ANAD
The National Association of Anorexia Nervosa and Associated Disorders is a non-profit organization which aims to prevent and stop eating disorders.

ANRED
A nonprofit organization focusing on self-help, prevention and recovery information.

American Psychological Association: Eating Disorders
An in-depth discussion of eating disorders, including how psychologists may be able to help.

Bulimia.com
Online resource for all eating disorders, including how to get treatment.

Caring Online
Provides a self-assessment tool for helping identify eating disorders, as well as ways to get immediate help.

Center for Eating Disorders
Provides treatment and support for people of all ages who are struggling with eating disorders and/or body image.

Center for Young Women's Health
Provides a wide array of health information useful, including what to do if a friend has an eating disorder.

EatingDisordersOnline
Providing news, videos, blogs, articles and support for those suffering from (or know someone who suffers from) eating disorders.

Eating Disorder Hope
Provides resources, education, treatment options and support for those with eating disorders.

Eating Disorders Recovery
A series of articles concerning body image and eating disorder recovery issues.

Eating Recovery Center
A center for eating disorder treatment and recovery. Also provides information about eating disorders.

E-D-Referral
Exists to prevent and treat eating disorders by providing a comprehensive resource of eating disorder treatments and information.

F.E.A.S.T.: Families Empowered and Supporting Treatment of Eating Disorders
An international organization designed to help those who are caregivers for those suffering from eating disorders.

MEDA
The Multi-Service Eating Disorder Association is a non-profit that prevents the continuing spread of eating disorders through educational awareness and early detection.

MedlinePlus
The National Institute of Health's online library of eating disorder information. Statistics, journals, research and references are all available here.

MGEDT
A British charitable organization with the goal of helping men who suffer from eating disorders.

Mindfullness
Provides an online community whose goal it is to support those who have body image issues and/or eating disorders. A list of events and resources is provided.

Mirror Mirror: Eating Disorders
Provides information and help to those who may have eating disorders.

N.A.M.E.D.
The National Association for Males with Eating Disorders: A nationwide organization focused on males who have eating disorders.

NIH
National Institute of Mental Health, Eating Disorders: The NIH's Health & Education discussion about eating disorders, including what they are, causes, symptoms and treatments.

NEDA
A non-profit organization which advocates and supports those who suffer from eating disorders as well as their families.

NEDIC: National Eating Disorder Information Center
A non-profit Canadian website with comprehensive information about eating disorders and weight issues.

Nourishing Connections
This website promotes "attuned eating" and provides plenty of resources.

Nova: Dying to Be Thin
Presented by PBS, this website provides the full television aired Nova episode called "Dying to Be Thin." Additional information about eating disorders is also provided.

# data[].attributes.attachment_link.title
Eating Disorder Awareness Guide | LearnPsychology.org

# data[].attributes.attachment_link.description
For some students, eating disorders may surface or become exacerbated during the college years. Learn how to spot eating disorders, the types of eating disorders that exist, and how to get help for disordered eating with our comprehensive Guide to Eating Disorder Awareness.

# data[].attributes.attachment_link.readable_text
Today, I would recognize the signs: the 11 year old girl in the sixth grade class spending her entire recess and lunch-break running in the schoolyard and doing circuits in the gym; every day, exercising more; the same girl continuing to get top marks with her school work, always punctual, eager to please, but becoming withdrawn; her bubbly personality disappearing; she is not eating her lunch - she offers it to her playmates. She keeps only the apple and eats this very, very slowly, one nibble at a time. Today I would recognize these signs as symptoms of anorexia nervosa, for this child was me.

Teachers are in a prime position to be among the first people to notice a child is developing an eating disorder. I certainly wish my teacher had recognized the symptoms and intervened. But that was 50 years ago. Today, I like to think that all teachers are aware of the signs of anorexia nervosa, and that they know how to respond. Sometimes, friends of the child will notice the symptoms, and confide in the teacher. Or perhaps the coach or dance instructor may notice behavioral changes.

Teachers often want to help when they suspect a child is suffering symptoms of anorexia nervosa, but don't know when to say something, what to say or how to say it. They might even decide that it is better to say nothing than say the wrong thing. This just goes to show how important it is for school staff to be educated and informed about eating disorders - so that they feel confident and more able to help. A teacher's attitude and response can greatly influence whether the illness is 'nipped in the bud' and stopped in its tracks or gathers pace and becomes entrenched.

School staff are well placed to spot the early signs of anorexia nervosa, enabling early diagnosis, early intervention and a far better prognosis. A child may feel more comfortable talking about food difficulties with a teacher rather than someone in their immediate family. The school can provide a bridge between the child, their family and other care providers to ensure the best possible outcome.

How the teacher responds - how they offer support - can greatly influence what happens next. The clues below on what to say, and when to say it, are drawn from my latest book with Professor Janet Treasure: Anorexia Nervosa: A Recovery Guide for Sufferers, Families and Friends. This updated version includes information for teachers and others whose daily work involves the care of children.

School-specific warning signs
Some anorexia nervosa warning signs are more easily noticed at school. Observing me at age 11, the teacher would have ticked a box in each of the following:

Weight loss (not because I did not want to eat, but was afraid to eat)

Avoidance of PE or swimming (because it involved undressing)

Excessive exercise (I felt driven to do more each day)

Busy during lunch breaks (to avoid questions like 'why aren't you eating?')

Wearing extra clothing (to keep warm and hide the body)

Perfectionism (important to get everything right to avoid anxiety)

Inability to focus in class (when the brain is starved, concentration is more difficult)

Loss of friends (because food thoughts increasingly dominate thinking time)

When a child is causing concern
When a teacher suspects a child may be suffering from anorexia nervosa, they should tell the person responsible for pastoral care within the school. They may already be aware of the problem, or they may enlist your help.

Creating opportunities for confiding
A child feels more comfortable when they 'make the first move' with regards to talking about their eating disorder as this helps them to feel in control of the situation. To facilitate this, a teacher can create situations for one on one time such as suggesting they stay after class to discuss their homework. Often, a child with an eating disorder feels scared and alone, and during the early stages may welcome the chance to offload to someone.

Remain calm and don't judge. Encourage the child to share their fears with questions such as: 'You don't seem quite yourself lately, how can I help you?' Avoid talking about food or weight directly as this is likely to frighten the child. Take this first meeting gently and accept that you are unlikely to get to the crux of the issue immediately. Focus on listening to the child. Work on building a trusting relationship and ensure that they know when and where they can talk to you further about what's on their mind.

* For more information, see Anorexia Nervosa: A Recovery Guide for Sufferers, Families and Friends. Pooky Knightsmith writes the chapter 'Guidelines for School Staff'.

# data[].attributes.attachment_link.title
A Lesson for Teachers in Addressing the Eating Disorder Bully

# data[].attributes.attachment_link.description
Today, I would recognize the signs: the 11 year old girl in the sixth grade class spending her entire recess and lunch-break running in the schoolyard and doing circuits in the gym; every day, exercising more; the same girl continuing to get top marks with her school work, always punctual, eager to please, but becoming withdrawn; her bubbly personality disappearing; she is not eating her lunch - she offers it to her playmates.

# data[].attributes.headline
Help for Parents with Children with Bipolar Disorder

# data[].attributes.subject
Help for Parents with Children with Bipolar Disorder

# data[].attributes.attachment_link.readable_text
During manic episodes, children with bipolar disorder will feel anger and rage-and with greater intensity-rather than elation or euphoria that is common in adults. Bipolar in children combine the depressive and manic states together to form 'aggressive depression.' However, because they lack the emotional maturity to manage these outbursts, they require personalized help. Here's a look into bipolar rage and the best strategies for parents and caregivers:

#1 What is rage in children with bipolar?

The nerve centers responsible for rage are located in the limbic system or "animal brain" that contains structures essential to our survival through the " fight or flight " response, explains George T. Lynn, MA, a Licensed Mental Health Counselor in Bellevue, Washington. "To the child in rage, it is a life and death struggle. As the limbic system flares on, adrenaline spikes, the child becomes stronger, and the thinking brain shuts down."

#2 Know what you're dealing with

These temper tantrums can turn into rages lasting for hours. Children with bipolar are often intentionally "dare-devilish" and tend to be risk-takers. In addition to severe anger episodes, irritability is common, especially when first waking up in the morning. Also, these kids don't have a normally developed emotional regulation so they may be constantly anxious, irritable, have trouble sleeping, have fear issues and are rarely in a calm state.

#3 Understand the disease

"Children with bipolar-like problems with rage and violence do have personal boundaries," believes Lynn, who has pioneered the use of psychotherapy for adults and children with neuropsychological issues such as bipolar disorder. "Many children with bipolar challenges punch holes in walls, but few will put their fists through a window. This behavior suggests that these children are able to control themselves somewhat. But given the limitations they possess in terms of ability to see the big picture, to form valid conclusions about it, and to manage their own stress and mood swing, it takes enormous strength to exercise this control. "

#4 How to view the behavior...

Think of it as reacting to a child who has diabetes and is in a state of agitation due to high blood sugar level. You would accept that his off-behavior temper is due to something medical and you would treat it with medication or food. It's important to remember that because your child has a brain disorder, it is the chemistry of their brain that drives their rage. That doesn't preclude setting boundaries, but it's an important distinction to make, especially when there are other children in the household without bipolar symptoms and require different parenting techniques.

#5 Get proper medication

Rage in children who have bipolar is actually closer to a seizure than an emotional event and in fact the National Institute of Mental Health is studying whether bipolar and seizure disorders are directly related. In the meantime, this anger and other symptoms of the disorder are usually effectively treated with anti-seizure medication, or mood stabilizers. Medication can balance brain chemicals that control emotions and stabilize the child.

#6 Monitor meds and chart the moods

Mood-stabilizing medications can restore the brain to a more normal level, reducing the likelihood of chemicals flooding in to cause the anger and fury. However, sometimes it takes some trial and error to find the precise dosage for success in stabilizing your child. In order to properly communicate the effects of the meds to your child's health professional, it's important to keep an accurate and detailed mood and behavioral chart so you can monitor the effects.

#7 Seek family-focused therapy

Family-focused therapy and individual psychotherapy tailored for children can also help control feelings of rage in children with bipolar. "These therapies help bipolar children tolerate frustration and express angry thoughts and feelings in ways that are less disruptive and destructive," says David Fassler, MD, clinical professor of psychiatry at the University of Vermont College of Medicine. Additionally, family therapy sessions teach parents how to implement techniques at home that can reinforce positive behavior and reduce the frequency of these angry outbursts.

#8 Control stress

Anger in children with bipolar is often triggered by stress. "It's known that bipolar children and teens have more rapid mood changes than adults with bipolar disorder," says Fassler. These mood changes often manifest themselves as anger episodes. It's extremely beneficial for parents to first control stress in themselves and this will naturally transfer to their children. Better yet, have your child participate in your own mindfulness strategies together, such as yoga and meditation.

#9 Instill and enforce boundaries

It's essential for parents to establish boundaries and consequences for inappropriate behavior for these children and then stick to it. By letting the kids run the house or manipulate them, because at times it's just easier to give in, is actually doing these kids a disservice as future adults, explains Lynn. Children with bipolar will benefit from strong, but loving parents who don't let the child spin free because there are no consistent consequences.

#10 Consequences, not punishment

Punishment of a furious child with bipolar is more delicate and comes with its own drawbacks. They should certainly be taught, while in a calm state, that there are specific consequence s for certain behavior. Talk with your child about rules that cannot be broken regardless of their brain illness i.e. it is unacceptable behavior to harm others or destroy property. Explain what the consequence will be so he knows prior to any meltdown what will happen. Remember to wait until your child is stable and calm before delivering the consequence.

#11 Reinforce positive behaviors

"Parents help the child to the degree that they reward even little gestures of moderation and reasonable behavior," Lynn writes in his book: ' Survival Strategies for Parenting Children with Bipolar Disorder.' "They help her develop character strength when they note and affirm every time she is able to put boundaries around her own wild emotional reaction. And they stick to their consequences ... and compliment her for doing a good job."

#12 Check your emotions

It's crucial to master techniques to manage your own stress first. Children with bipolar are sensitive to the emotions of others around them, especially stress, so it's important to practice stress management. If you are stressed and you are irritable and frustrated, you will make things worse. Also, remember that timing is everything; it's important to wait until your child is calm before dealing with the consequences of the negative behavior.

#13 Don't argue back

Arguing or even trying to reason with a child when he is unstable or during a manic phase is pointless and will likely end up causing further frustration for both sides. Lynn describes this mindset: "Children with bipolar disorder seem incapable of seeing the other's perspective in a situation. They will argue incessantly or deliberately twist an argument to justify their position on any issue."

#14 Listen with your heart and your head

Lynn writes that your best bet is to get on problems early, keep your cool, and take your child's bipolar-related challenges seriously. Try and do what you need to keep your heart open and see the soul of a very young child in her. She is disabled for the time being. "One must be 'very quiet' in one's heart so as to allow the child to express the pain she feels inside. Try to approach the situation with this sense of peace and presence while you maintain the proper boundaries and consequences..."

#15 Sibling communication

Communication is key for the siblings of a child with bipolar. While they may grasp their brother or sister has a brain illness, it may still be confusing as to why they are being treated differently for their anger issues or the punishment and consequences aren't the same. They will be required to understand this so as to help calm down their sibling. It may be beneficial for them to talk with a therapist as well for help adjusting.
code:bphopekids

# data[].attributes.attachment_link.title
15 Rules For Parents to Manage Bipolar Rage in Their Children | bpHope

# data[].attributes.attachment_link.description
During manic episodes, children with bipolar disorder will feel anger and rage-and with greater intensity-rather than elation or euphoria that is common in adults. Bipolar in children combine the depressive and manic states together to form 'aggressive depression.' However, because they lack the emotional maturity to manage these outbursts, they require personalized help.

# data[].attributes.attachment_link.title
Family Center - Depression and Bipolar Support Alliance

# data[].attributes.attachment_link.readable_text
Here are things you can do at home to help your child manage his or her anxiety disorder:

Pay attention to your child's feelings.

Stay calm when your child becomes anxious about a situation or event.

Recognize and praise small accomplishments.

Don't punish mistakes or lack of progress.

Be flexible, but try to maintain a normal routine.

Modify expectations during stressful periods.

Plan for transitions (For example, allow extra time in the morning if getting to school is difficult).

Keep in mind that your child's anxiety disorder diagnosis is not a sign of poor parenting. It may add stress to family life, however. It is helpful to build a support network of relatives and friends.

It's important that you have the same expectations of your anxious child that you would of another child, according to psychologist Lynn Siqueland, PhD. She has specialized in treating children and adolescents with anxiety disorders for more than 15 years. She offers these parenting tips for anxious kids, as well as ways to manage siblings, whose lives are also affected.

SAMHSA Report: how to help children who have experienced traumatic events.

Other Resources

Keep reading about the important role of parenting at BetterHelp.

# data[].attributes.attachment_link.description
Here are things you can do at home to help your child manage his or her anxiety disorder: Pay attention to your child's feelings. Stay calm when your child becomes anxious about a situation or event. Recognize and praise small accomplishments. Don't punish mistakes or lack of progress.

# data[].attributes.attachment_link.readable_text
When kids are young, parents are used to swooping in and rescuing them whenever they need help. As your kids get older and their problems become more complex, you have to transition into more of a supporting role, and that can be difficult. This is especially true with teens who are struggling with depression. They need help to get better, but first they have to want that help.

Signs your child is depressed:

Have they been sad or irritable most of the day, most days in a week for at least two weeks?

Have they lost interest in things that they used to really enjoy?

Have their eating or sleeping habits changed?

Do they have very little energy, very little motivation to do much of anything?

Are they feeling worthless, hopeless about their future, or guilty about things that aren't their fault?

Have their grades dropped, or are they finding it difficult to concentrate?

Have they had thoughts of suicide? If so it's crucial you have them evaluated by a mental health professional immediately. If the thoughts are really serious and there is imminent threat, you will need to take them to an ER.

If your teen shows more than a few of these signs they may have depression that warrants professional attention. While you can't make them want to get better, there are some things that you as their parent can do. And it starts with simply being there for them.

Be supportive

One of the most important things you can do for your teen is to work on strengthening your relationship. Try to build empathy and understanding by putting yourself in their shoes. You might be frustrated that they seem down and irritable a lot of the time and don't seem to be doing much of anything to help themselves. But if there isn't much in their life that is making them happy, or something intensely disappointing has happened to them, it's understandable that they might avoid things they used to enjoy and retreat to their room. Depression makes even doing the smallest things more difficult.

Try to validate their emotions, not their unhealthy behavior. For example, you could say, "It seems as though you've been really down lately. Is that true?" Make it clear that you want to try to understand what's troubling them without trying to problem solve.

Be compassionately curious. Ask them questions about their mood gently, without being emotional. Even parents with the best intentions often don't realize that their concern can come across as critical rather than loving. Do not be judgmental or try to solve their problems, even if you disagree with their point of view. Listening to them talk about their problems might seem as though you're highlighting the negative, but in fact, you're letting them know that you hear them, you see them, and you're trying to understand - not fix them. People don't like to be fixed. Listening without judgment will actually make them more likely to view you as an ally and someone they can turn to when they're ready to talk.

Try also to give them opportunities to do things without being critical of them. Instead of saying, "Honey, you should really get up and do something. How about calling an old friend?" you might say, "I'm going to the mall to do an errand. Let me know if you want to come with me, and maybe we can get lunch together."

For some parents, this can feel passive, as though you're not doing enough. But being there for them and communicating your acceptance is exactly what they needs from you right now. It's actually a very active way to strengthen your relationship.

Accentuate the positive

Make sure you're noticing the positive things your teen does, too. Going to school, holding down a part-time job, doing the dishes or picking up their brother from soccer practice: These are all good things they're doing, and it's important to recognize them rather than thinking, "This is what they should be doing." We all like to be appreciated and recognized for doing a good job even when it's expected of us.

Ask yourself how many positive things have you said to them today? How many negative things have you said? How many times have you highlighted their problems or tried to fix them? The positive should outweigh the negative. Let them know that you're proud of them, that they're doing a good job if you see them taking care of themselves, doing homework, interacting with the family, or doing other things that take effort. They'll likely appreciate that you noticed.

Likewise, you don't need to mention that you're disappointed they aren't hanging out with friends as much or taking the interest they used to in guitar, for example. They probably feel disappointed, too, and don't need to be reminded of what's not going well in their life. They don't want to feel this way. If they could snap their fingers and feel better, they would.

Helping kids with depression get treatment

Some teens will want to go to therapy when you ask them and some won't. For those who are resistant, know that they aren't going to suddenly open up to the idea of therapy (or to you) quickly, but you can help guide them towards treatment by opening the door and then waiting patiently for them to walk through it.

Try saying, "I know you're having a hard time, and I have some ideas of things that could help. If you'd like to talk with me about them, let me know. I'm here for you." It's also a good idea to ask them if they has any suggestions on how you might be able to help. You might be surprised with what they have to say.

Be aware that your teen might tell you to back off. That's fine; it's their way - albeit a slightly irritable one - of telling you that they need space. It's normal for teenagers to want independence, and it's important for you to respect that. You can respond by saying, "I'll give you more space, but know that I'm here for you if you ever want to talk or hear my suggestions."

If they do come to you wanting help, be prepared. Do your research. Find two or three therapists they can interview and tell them that they can choose the one that they feel most comfortable with, and think will help the most. Finding a therapist who is a good fit is extremely important, and making the choice theirs will help them feel ownership over their own treatment, which is extremely important to teens and sets the stage for effective therapy.

It's also important to know that there are several different kinds of therapy that might be helpful for your teen, including some well-studied behavioral therapies. Interpersonal therapy (IPT), cognitive behavioral therapy (CBT), and dialectical behavioral therapy (DBT) have all been shown to be helpful for teenagers with depression. Make sure that your child has had a thorough evaluation that includes treatment recommendations to help guide you.

Many teens with depression benefit from medication, such as an anti-depressant. While therapy alone may be effective with mild to moderate depression, the best results are usually gained with a combination of medication and therapy. If depression medication is a consideration, it is strongly recommended that you make an appointment with a board certified child and adolescent psychiatrist (rather than a general physician) for a consultation.

Why depression treatment might not be working

If your child already is in treatment but it isn't helping, ask them why they think that is. What isn't helpful or what don't they like about therapy? Are there things about therapy they do like? Maybe you can work together to find a therapist who does more of the things they like. If you do consider changing therapists, it's important to discuss this with their current therapist before the decision to change is made. Many times, the therapy and/or the therapeutic relationship can be improved.

Keep in mind that therapy usually isn't effective if the person in treatment isn't committed to it, or is doing it to please someone else. Your child should want to get better for themselves. Unfortunately, sometimes people have to get worse before they want help. But the good news is that if you lay the groundwork by strengthening your connection now, they'll be more likely to turn to you for support when they're finally ready.

Taking care of yourself

Lastly, it's important to make sure that you're taking care of yourself. It can be emotionally and physically exhausting to be a parent of someone who is struggling with depression. Know that you are not alone, and get support for yourself. Make sure that you make time to do things you enjoy and go out with friends. The phrase: happy mommy (or daddy) = happy baby (read: teenager) still applies!

# data[].attributes.attachment_link.description
When kids are young, parents are used to swooping in and rescuing them whenever they need help. As your kids get older and their problems become more complex, you have to transition into more of a supporting role, and that can be difficult. This is especially true with teens who are struggling with depression.

# data[].attributes.attachment_link.provider_name
National Institute of Mental Health (NIMH)

# data[].attributes.attachment_link.description
Learn about depression, including types, signs and symptoms, risk factors, treatments and therapies, and things you can do to help during treatment.

# data[].attributes.attachment_link.provider_name
National Institute of Mental Health (NIMH)

# data[].attributes.attachment_link.readable_text
Overview

Bipolar disorder (formerly called manic-depressive illness or manic depression) is a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks.

There are three types of bipolar disorder. All three types involve clear changes in mood, energy, and activity levels. These moods range from periods of extremely "up," elated, irritable, or energized behavior (known as manic episodes) to very "down," sad, indifferent, or hopeless periods (known as depressive episodes). Less severe manic periods are known as hypomanic episodes.

Bipolar I Disorder- defined by manic episodes that last at least 7 days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, depressive episodes occur as well, typically lasting at least 2 weeks. Episodes of depression with mixed features (having depressive symptoms and manic symptoms at the same time) are also possible.

Bipolar II Disorder- defined by a pattern of depressive episodes and hypomanic episodes, but not the full-blown manic episodes that are typical of Bipolar I Disorder.

Cyclothymic Disorder (also called Cyclothymia)- defined by periods of hypomanic symptoms as well as periods of depressive symptoms lasting for at least 2 years (1 year in children and adolescents). However, the symptoms do not meet the diagnostic requirements for a hypomanic episode and a depressive episode.

Sometimes a person might experience symptoms of bipolar disorder that do not match the three categories listed above, which is referred to as "other specified and unspecified bipolar and related disorders."

Bipolar disorder is typically diagnosed during late adolescence (teen years) or early adulthood. Occasionally, bipolar symptoms can appear in children. Bipolar disorder can also first appear during a woman's pregnancy or following childbirth. Although the symptoms may vary over time, bipolar disorder usually requires lifelong treatment. Following a prescribed treatment plan can help people manage their symptoms and improve their quality of life.

Signs and Symptoms

Risk Factors

Treatments and Therapies

Join a Study

# data[].attributes.attachment_link.description
Bipolar disorder (formerly called manic-depressive illness or manic depression) is a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks. There are three types of bipolar disorder. All three types involve clear changes in mood, energy, and activity levels.

# data[].attributes.attachment_link.readable_text
Overview

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

Signs and Symptoms

Risk Factors

Treatments and Therapies

Join a Study

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

# data[].attributes.attachment_link.title
Eating Disorders - What You Need To Know