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In the mental health world, I am best known as a parent advocate for children with mental illness. But in my professional life as an instructor at an open-access community college, I've had multiple opportunities to connect students in mental health crisis with the right resources. In this article, I'll share some things I've learned about managing psychosis in the classroom and explain why it's so important for educators to know the signs and be ready to help. In fact, teachers at all levels are on the front lines of mental health care. Education, empathy and advocacy are critical to ensuring that your students are able to succeed in the classroom and beyond.

Education

Students with serious mental illness face special challenges in the academic environment. Not only can the illness impede their cognitive function, but they may also face the fear and stigma that too often accompany diagnoses like schizophrenia and bipolar disorder. While these illnesses are rare - schizophrenia occurs in just 1 percent of the population - the first serious symptoms often occur right at the age when students are leaving home for the first time and attending college. This is why it's so important for educators to learn about psychosis and how it can manifest in the classroom.

My school has instituted mental health awareness training for all faculty members, but not everyone is so fortunate. I recommend that all educators take a Mental Health First Aid Course. You'll learn how to recognize the signs of mental illness and explore effective strategies for connecting students with appropriate resources.

Some signs that educators can watch for include:

Social withdrawal and isolation.

Sudden decline in school performance.

Expression of extreme fear (perhaps refusing to attend class or other school functions).

Odd behaviors or statements.

Sudden preoccupation with a narrow topic.

Clear changes in personal hygiene.

Difficulty in attending class and completing assignments (Back to School, p. 9).

You may also want to participate in some form of psychosis simulation. If you have not experienced psychosis, it can be hard to imagine how frightening and disorienting this condition can be for a young person who is experiencing it for the first time. The Mental Health First Aid course includes a simulation exercise, and I have linked to some in the Resources section below.

Empathy

If you see one or more warning signs, don't be afraid to approach the student. Ask open-ended questions, and be willing to listen. When I notice that a student is behaving in an uncharacteristic way, I try to take the student aside and ask a few questions using a communication model developed by Dr. Xavier Amador, who has dedicated his professional life to helping caregivers to communicate with people in psychosis. His LEAP model is a good guideline for educators: Listen-Empathize-Agree-Partner.

Educators who can recognize symptoms and connect students with mental healthcare have a unique opportunity to promote better outcomes for their students. The RAISE project in the United States has focused on getting help to patients after the first episode of psychosis. Early intervention can be critical to long-term positive outcomes, and in fact, many people can and do live in recovery.

Some educators may wonder about the potential risks of working with students who experience psychosis. While it seems like our social media feeds are filled with stories of violence and mental illness, most people experiencing psychosis, especially in the early stages, are not violent toward others. The risk of self-harm, however, is much greater. I keep my office stocked with National Suicide Prevention Hotline cards, and I am never afraid to ask a student, "Are you thinking about hurting yourself?" and "Do you have a plan?"

Advocacy

Advocating for your students is critical to their - and your - success.

A few years ago, I worked at a small college where my duties included managing paperwork for students with documented disabilities. I have to confess that as a mother of a child (now in college) who lives with bipolar disorder, I was often frustrated by the reactions of a few instructors who felt that students were getting "special treatment."

Accommodations are not "special treatment." They are designed to level the field so that students with special needs can succeed along with their peers. A SAMHSA toolkit on inclusion for students experiencing psychosis notes the following: "As is true for many other disabilities, psychosis can lead to multiple additional challenges and obstacles for students, but with the right resources and supports these can almost always be addressed" ( Back to School, p. 13).

Over my teaching career, I have seen students successfully complete my courses while managing conditions that range from schizophrenia to bipolar disorder to major depressive disorder. However, it's also important to realize that as with any illness, health should always come first. Sometimes, I have worked with students to connect them with mental healthcare and encouraged them to return to class when they are better able to manage their illness along with the inevitable stressors of an academic environment. In all cases, I advocate for what the student and I think will best serve their educational and health needs.

I also try to design both my on-ground and online courses with universal design principles in mind. This encompasses everything from closed captioning for hearing-impaired students to make-up work policies and classroom management and attendance policies that benefit all students but can be especially helpful for people who have mental illness.

Resources

If you're ready to make a difference in the lives of your students, you may be wondering where to start. Here are a few resources for educators that I have collected over the years:

I always keep a stack of contact cards from the National Suicide Prevention Lifeline in my office; their phone number is 1-800-273-8255. As many as 10 percent of people with psychosis attempt suicide within the first year of treatment. Don't be afraid to ask students if they are having thoughts about harming themselves. It's the first step to connecting them with help.

For more information about Mental Health First Aid and to find trainings in your area, visit https://www.mentalhealthfirstaid.org/.

For an overview of schizophrenia written with educators in mind, see this article from the National Association of Special Education Teachers.

This SAMHSA publication about including students who are showing signs of early psychosis includes a practical toolkit with accommodations examples and inclusive best practices for higher education.

Dr. Xavier Amador has dedicated his professional career to promoting positive and effective communication with people in psychosis. You can watch his TEDx Talk here, and learn more about his LEAP communication model at the LEAP Institute website.

Watch journalist Anderson Cooper as he attempts to work while experiencing a schizophrenia simulation to learn more about how psychosis can affect cognitive function.

Watch a schizophrenia simulation produced by Jannsen Pharmaceuticals (warning: the experience can be intense).

Open Mind of British Columbia, Canada, has collected a variety of resources for educators about mental illness in the classroom.

Schizophrenia and Related Disorders Alliance of America ( https://sardaa.org/ SARDAA) is a wonderful resource for anyone who wants to learn more about these illnesses.

The International Bipolar Foundation offers a variety of supports and resources, including webinars and local education events (full disclosure: I'm a board member).

The Child Mind Institute is involved in cutting-edge research and provides a variety of educational articles like this one about signs of psychosis in teens.

Find more information on Universal Design and inclusive learning in college courses here.

For more information on RAISE (Recovery After an Initial Schizophrenic Episode), see the National Institute of Mental Health's website.

One of my favorite books about managing mental illness in college students is Perfect Chaos: A Daughter's Journey to Survive Bipolar, A Mother's Struggle to Save Her by Cinda and Linea Johnson. Cinda is a special education professor, but her experience with her daughter's illness took her knowledge and empathy to a new level. The book is both personal and practical, and it provides a valuable glimpse at the struggles college students and teachers face.

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How Educators Can Help Students Experiencing Psychosis | Clarity CGC

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In the mental health world, I am best known as a parent advocate for children with mental illness. But in my professional life as an instructor at an open-access community college, I've had multiple opportunities to connect students in mental health crisis with the right resources.

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This severe mental disorder can result in hallucinations, delusions, and extremely disordered thinking and behavior that interfere with daily living.

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National Institute of Mental Health (NIMH)

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RAISE Resources for Patients and Families

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RAISE Resources for Patients and Families

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Schizophrenia support groups: For family, online, and more

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Support groups can help people with schizophrenia manage their symptoms and function well. Learn more about schizophrenia support groups here.

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What Teachers Should Know

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

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

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

take up more than 1 hour each day

cause distress

interfere with daily activities

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

Students with OCD may:

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

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

need to take medicine

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

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

What Teachers Can Do

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

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

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

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

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Language: English | Spanish | French

Abstract

Obsessive-compulsive disorder (OCD) is a clinical syndrome whose hallmarks are excessive, anxiety-evoking thoughts and compulsive behaviors that are generally recognized as unreasonable, but which cause significant distress and impairment. When these are the exclusive symptoms, they constitute uncomplicated OCD. OCD may also occur in the context of other neuropsychiatric disorders, most commonly other anxiety and mood disorders. The question remains as to whether these combinations of disorders should be regarded as independent, cooccurring disorders or as different manifestations of an incompletely understood constellation of OCD spectrum disorders with a common etiology. Additional considerations are given here to two potential etiology-based subgroups: (i) an environmentally based group in which OCD occurs following apparent causal events such as streptococcal infections, brain injury, or atypical neuroleptic treatment; and (ii) a genomically based group in which OCD is related to chromosomal anomalies or specific genes. Considering the status of current research, the concept of OCD and OCD-related spectrum conditions seems fluid in 2010, and in need of ongoing reappraisal.

Keywords: obsession, compulsion, anxiety, comorbid disorder, environmental influence, genetics, genomics, Tourette syndrome, compulsive hoarding, depression

Abstract

El trastorno obsesivo-compulsivo (TOC) es un síndrome clínico cuyo sello distintivo son los pensamientos desmedidos que provocan ansiedad y conductas compulsivas, los cuales habitualmente no son reconocidos como razonables, pero que causan un distrés y un deterioro significativos. Cuando éstos son los síntomas exclusivos, constituyen un TOC no complicado. El TOC también puede presentarse en el contexto de otras patologías neuropsiquiátricas, principalmente en otros trastornos ansiosos y del ánimo. La pregunta que persiste es si acaso estas combinaciones de trastornos deben considerarse como cuadros independientes, trastornos que co-ocurren o como manifestaciones diferentes de una constelación parcialmente comprendida de los trastornos del espectro del TOC con una etiología común. También se entregan consideraciones adicionales para dos subgrupos según sus potenciales bases etiológicas: 1) un grupo de base ambiental en el cual el TOC ocurre a continuatión de acontecimientos aparentemente causales como las infecciones por estreptococo, el daño cerebral o el tratamiento con neurolépticos atípicos y 2) un grupo de base genómica en que el TOC se relaciona con anomalías cromosómicas o de genes específicos. Considerando el estado actual de la investigatión, parece fácil de manejar el concepto de TOC y de las condiciones del espectro relacionado con el TOC en 2010, pero requiere de una r e evaluatión permanente.

Résumé

Le trouble obsessionnel-compulsif (TOC) est un syndrome clinique caractérisé par des comportements compulsifs et des pensées excessives à type d'anxiété, généralement reconnus comme déraisonnables, causant une souffrance et un handicap significatifs. Quand ces symptômes sont les seuls, on parle de TOC non compliqué. Mais le TOC peut également survenir dans le contexte d'autres troubles neuropsychiatriques, plus couramment dans le cadre d'autres troubles anxieux ou de troubles de l'humeur. Il reste à savoir si ces troubles doivent être considérés comme indépendants, simultanés ou comme des manifestations différentes d'une constellation incomplètement comprise de troubles du spectre du TOC avec une étiologie commune. Cet article propose des réflexions supplémentaires sur deux sous-groupes éventuels d'origine étiologique: 1) un groupe d'origine environnementale dans lequel le TOC survient après des événements apparemment causaux comme une infection streptococcique, une lésion cérébrale ou un traitement neuroleptique atypique; et 2) un groupe d'origine génomique dans lequel le TOC est lié à des anomalies chromosomiques ou à des gènes spécifiques. Au stade actuel de la recherche, le concept de TOC et de trouble du spectre obsessionnel compulsif semble flou en 2010 et nécessite une réévaluation.

Obsessive-compulsive disorder (OCD) occurs worldwide, with common features across diverse ethnic groups and cultures. It affects approximately 2% of the population and is associated with substantial social, personal, and work impairment.1,2 In fact, the World Health Organization identified OCD among the top 20 causes of years of life lived with disability for 15- to 44-year-olds.3 Although generally longitudinally stable, OCD is known for its substantial heterogeneity, as symptom presentations and comorbidity patterns can vary markedly in different individuals. Moreover, a number of other psychiatric and neurologic disorders have similar phenomenological features, can be comorbid with OCD, or are sometimes even conceptualized as uncommon presentations of OCD. These include the obsessive preoccupations and repetitive behaviors found in body dysmorphic disorder, hypochondriasis, Tourette syndrome, Parkinson's disease, catatonia, autism, and in some individuals with eating disorders (eg, anorexia nervosa).4-10 These heterogeneous facets of the disorder have led to a search for OCD subtypes that might be associated with different etiologies or treatment responses.

Ruminative, obsessional, preoccupying mental agonies coupled with perseverative, ritualized compulsionresembling behaviors have been depicted in biblical documents as well as Greek and Shakespearian tragedies. In modern nosology, a number of different approaches have been suggested to characterize this syndrome, yet the question of how best to categorize OCD subgroups remains under debate in 2010.

Currently, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) of the American Psychiatric Association, classifies OCD as an anxiety disorder. There have, however, been questions raised about this categorization on the basis of some phenomenological differences between OCD and the other anxiety disorders. As such, suggestions have been made that, in the forthcoming 2012 DSM-5, OCD should be removed from its position as one of the six anxiety disorders - a reformulation still under debate. One solution under discussion is that OCD should constitute an independent entity in DSM-5 (ie, remain outside of any larger grouping), congruent with its designation as such in the current international diagnostic manual, ICD-10 (International Statistical Classification of Diseases and Related Health Problems).11-14 An alternative suggestion would group OCD and related disorders into a new Obsessive-Compulsive Spectrum Disorders (OCSD) category. The concept of an OCSD classification was first postulated over a decade ago.15,16 Later, the original OCSD concept was extended with the proposal that OCD and other compulsive disorders may lie along a larger continuum of corelated compulsive-impulsive disorders.15 Disorders hypothesized at the impulsive end of this spectrum continuum include pathologic gambling, nonparaphilic compulsive sexual activity, and others.17,18 A general feature of these proposed impulsive disorders is that, although they have some repetitive elements, they are generally egosyntonic (in contrast to the egodystonic nature of OCD), often with minimal anxiety and behaviors that are not resisted, and that are usually associated with pleasure (not with relief as in OCD). However, the concept of a compulsive-impulsive continuum has not been widely subscribed to in either a recent survey of OCD experts or in recent reviews.19,20 Some of the original proponents of the OCSD groupings and others in the field have softened the stipulations that implied common underlying etiological components of the OCSD, to a more general notion of "obsessive-compulsive-related disorders (OCRD)".12 This debate continues to wax and wane as additional investigations evaluate the underpinnings of a putative OCD spectrum.21,22 This review focuses on newer contributions to the OCD spectrum concept and efforts to subtype OCD. It does not reiterate already well-evaluated aspects of OCD spectrum concepts recently published in expert reviews (eg, refs 12,23-27). Rather, it discusses new data primarily from recent epidemiologic and clinical research, as well as new quantitative psychological, physiological, and genetic studies with the aim of reappraising and developing additional elements related to the OCSDs and OCRDs. Particular points of emphasis are questions regarding (i) what OCD phenotypes might be of value in present and future genetic studies; and (ii) other types of etiological contributions to OCRDs, with, of course, the ultimate aim of better treatments for OCRDs that might be based on more than our current descriptive nosologies. Our immediate hope in this review is to spur additional thoughts as the field moves towards clarifying how OCD-related disorders might arise and manifest at the phenomenological and mechanistic levels.

What is OCD?

DSM-IV/DSM-IV-TR characterizes OCD by the symptoms outlined in Table I. It is listed within the Anxiety Disorder section. The text highlights that if an individual attempts to resist or delay a compulsion, they can experience marked increases in anxiety and distress that are relieved by the rituals.

OCD symptom heterogeneity in individuals

While the core components of OCD (anxiety-evoking obsessions and repetitive compulsions) are recognizable as the cardinal features of OCD, the specific content of these symptoms varies widely. Thus, there is clear evidence that within OCD, there is symptom heterogeneity. For example, Figure 1 depicts the results of a cluster analysis of OCD symptoms based on two separate symptom checklists for OCD (Yale-Brown Obsessive Compulsive Scale Symptom Checklist (YBOCS) and the Thoughts and Behavior Inventory (TBI) accomplished initially using item clusters and subsequently using individual items from these scales, with essentially identical results.29,30 Notable is that there are distinguishable groupings of symptoms, falling into four major groupings (yellow components) and that both obsessions and compulsions of similar types group together. This clustering is in direct contrast to the current DSM-IV notation of obsessions "and/ or" compulsions. There also exists an inseparable overlapping of symptom groupings (blue components), such that despite separable conceptual entities, there is an overall merging of these groupings on a more hierarchical level.

Adapted from ref 29: Hasler G, LaSalle-Ricci VH, Ronquillo JG, et al. Obsessive-compulsive disorder symptom dimensions show specific relationships to psychiatric comorbidity. Psychiatry Res. 2005;135:121-132. Copyright © Elsevier/North Holland Biomedical Press 2005, and ref 30: Schooler C, Revell AJ, Timpano KR, Wheaton M, Murphy DL. Predicting genetic loading from symptom patterns in obsessive-compulsive disorder: a latent variable analysis. Depress Anxiety. 2008;25:680-688. Copyright © Wiley-Liss 2008

Table I

Obsessions are:

Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress

Thoughts, impulses or images that are not simply excessive worries about real-life problems

The effort by the affected person to ignore and suppress such thoughts, impulses or images, or to neutralize them with some other thought or action

Recognition by the affected person that the obsessional thoughts, impulses or images are a product of his or her own mind rather than imposed from without.

Compulsions are:

Repetitive activities (eg, handwashing, ordering, checking) or mental acts (eg, playing, counting, repeating words silently) that the person feels driven to perform in response to an obsession or according to rigid rules that must be applied rigidly

Behavior or mental acts aimed at preventing or reducing distress or preventing some dreaded event or situation but either clearly excessive or not connecting in a realistic way with what they are designed to neutralize or prevent

Recognition, by the affected person (unless he or she is a child), at some point during the course of the disorder, that the obsessions or compulsions are excessive or unreasonable

Obsessions or compulsion that cause marked distress, are timeconsuming (take more than 1 h/day), or interfere substantially with the person's normal routine, occupational or academic functioning, or usual social activities or relationships

Content of the obsessions and compulsions not restricted to any other Axis I disorder, such as an obsession with food in the context of an eating disorder, that is present

Disturbance not due to the direct physiological effect of a substance or a general medical condition

Many other studies over the last decade have attempted to reduce the variability of OC symptom groupings in different populations of OCD patients through factor, cluster, or latent variable analyses of OCD symptom inventories. The majority of such studies have found support for between three to five symptom dimensions,19 with the most commonly identified solution including four factors: (i) contamination obsessions and cleaning compulsions; (ii) aggressive, sexual, religious, and somatic obsessions with checking-related compulsions; (iii) obsessions regarding symmetry, exactness, and the need for things to be "just right" paired with compulsions relating to ordering, arranging, and counting, and (iv) hoarding obsessions and compulsions. With regard to these four symptom dimensions, it should be noted that current debate exists as to whether hoarding should be considered along with the other core OCD symptoms, or whether it exists as an independent syndrome often comorbid with OCD.31-33 We will revisit this issue in a subsequent section of this review. An additional concern that has been raised is that in studies of pediatric OCD, changes in the most prominent symptom patterns have been found over time.34 In contrast, studies of adult OCD populations revealed stability of the most prominent symptom patterns.35,36 This suggests that perhaps more primary symptom dimensions affecting an individual solidify as an individual matures into adulthood. Family studies, including a sib-pair study, indicate that there is statistically significant within-family preferential sharing of symptom types; however, such correlations are relatively modest.37

Given this literature, there does not seem to be an adequate basis for establishing distinct within-OCD subtypes based on OC symptoms that, however, might be useful for distinguishing individuals with OCD for general treatment-directed investigations. There is one important exception with regard to the hoarding subgroup, which has shown several specific genetic-based and brain imaging-based differences from general OCD groups (eg, refs 38-40). Furthermore, given preliminary research that an individual's dominant symptom dimension may in fact be associated with differential treatment response and functional correlates,41,42 future research into hypothesized multidimensional models is warranted.

It is also worth mentioning that a different, two-dimensional model of OCD phenomenology has been suggested since Janet's 1904 reports on 300 patients43; he highlighted the "anakastic" feature of altered risk assessment (related to the later concepts of harm avoidance or neuroticism) as well as the sense of "indecision" and "incompleteness." Someone suffering from incompleteness was "Continually tormented by an inner sense of imperfection, connected with the perception that actions or intentions have been incompletely achieved."43 This phenomenon has relatively recently been "rediscovered" and seen some empirical study, especially in its narrower sense of the "not just right"44,45 experience frequently seen in OCD.46 Although research tools to characterize patients in this respect remain in development, some promising work has been reported.47,48 Incompleteness symptoms may have more affinity for tic-related phenomena than those strictly encompassed by anxietyrelated mechanisms,49 while Janet's "forced agitations" were also described by him as mental manias.45

Investigators have additionally attempted to subgroup OCD patients using specific phenomenological characteristics, such as overall OCD severity, familiality, gender, age of OCD onset, and comorbidity patterns.24,26,29,50-53 There is considerable indication that OCD which emerges in childhood is meaningfully different from OCD that occurs later in adulthood, including gender and comorbidity differences (eg, a higher prevalence of tic disorders and Tourette syndrome). In addition, some have subgrouped OCD on the basis of the patients' insight into the senselessness of their obsessions and compulsions. Some evidence suggests that OCD patients with poorer insight experience more severe symptoms, are less responsive to treatment, and have more family history of the disorder, though this has not always been observed.57 Interestingly, hoarding symptoms again appear to be distinct from the other OCD symptoms in this regard, in that hoarders typically evidence less insight.

In one latent class analysis of comorbid psychiatric conditions, two OCD subgroups were identified: a dimensional anxiety plus depression class and a panic plus tic disorder class.60 Another latent class analysis using a novel latent variable mixture model following a confirmatory factor analysis of 65 OCD-related items in 398 OCD probands found two statistically significant separate OCD subpopulations.30 One group had a significantly higher proportion of OCD-affected relatives (ie, a familial group) and was associated with an earlier age of OCD onset, more severe OCD symptoms, greater psychiatric comorbidity, and more impairment compared with the second group.30 However, because of considerable overlap among groups of OCD symptoms/dimensions and subgroup composition as identified by different statistical methods, discrete subgroup membership for any specific OCD proband is not yet available.30

OCD and its relationship to the anxiety disorders

At the same time as the field attempts to refine and clarify subtypes within OCD, broader questions about the disorder have also been asked, with some proposing that OCD is miscategorized as an anxiety disorder.61 Some have suggested that OCD bears more in common with other disorders categorized by repetitive thoughts and behaviors, and should be moved to a new category of disorders including OCSDs and OCRDs. This proposal requires elucidation of what constitutes the core of OCD: anxiety, obsessions, or repetitive behaviors. It is of note that, under the key features of OCD described in DSM-IV/DSM-IV-TR anxiety, as a feature is mentioned just once.

Nonetheless, many studies of OCD, and particularly investigations of OCD treatment that used quantitative self- and observer ratings, have documented very high anxiety ratings in individuals with untreated OCD. The levels of these anxiety ratings were as high or even higher than those reported in similar studies of panic disorder, generalized anxiety disorder, social phobia, and specific phobias. Thus, for the present time, OCD's close affinity with other disorders characterized by high anxiety would suggest that it remain under this categorization, unless it becomes recognized as a distinctly separate diagnostic entity in DSM-5, as noted above.

OCD and its relationship to mood disorders

Some proponents of moving OCD from its categorization as an anxiety disorder have suggested that, at its core, OCD is an affective disorder. In fact, depressive features are common in OCD and major depressive disorder is the single most frequently comorbid disorder in OCD probands (Table II). Cumulatively, mood disorders occur in 50% to 90% of OCD probands (not taking into account individuals with overlapping mood diagnoses)(Table II) . However, some have found that depressive symptoms most typically emerge following OCD onset, perhaps, it is speculated, as a consequence of long-term anxiety, stresses, and functional impairment associated with OCD symptoms.64 A special comorbid relationship has been noted between OCD and bipolar I and II disorders, also raising the question of a cyclothymic form of OCD.67 As with the affective disorders, modulating factors that seem to affect the expression and some features of OCD include gender and degree of insight into symptoms.

It is important to note that, although across OCD groups there exist patterns of frequent comorbidity with other anxiety, mood and other disorders, an "uncomplicated" noncomorbid OCD presentation has nonetheless been documented.69,70 This group, comprising ~10% of OCD probands in several studies, represents a relatively understudied entity,71,72 despite some indications that "uncomplicated" OCD may be of high value in refining the question of "What is OCD?"

OCD: its relationship to OCD-comorbid disorders as part of a description-based OCD spectrum

The original conceptualization of the OCD spectrum: considerations of symptomatology

Although there are a number of different approaches and considerations with regard to OCD spectrum disorders, we first present one prevalent view that the spectrum consists of disorders with diverse phenomenological features, but which share commonalities that tie them together. Figure 2 provides a depiction of the original and modified groupings of OCSD and OCRD disorders, including notation of other disorders considered by some as part of a compulsive-impulsive spectrum group of disorders. Some re-evaluations of these relationships have been published recently,12,19,21,27,61,73-75 and reflect the ongoing debate about genetic and environmentallyshaped, neurodevelopmental elements related to OCD onset that also may impact the future status of OCD in DSM-5.

Adapted from ref 12: Hollander E, Kim S, Braun A, Simeon D, Zohar J. Cross-cutting issues and future directions for the OCD spectrum. Psychiatry Res 2009;170:3-6. Copyright © Elsevier/North-Holland Biomedical Press 2009, ref 19: Mataix-Cols D, Rosario-Campos MC, Leckman JF. A multidimensional model of obsessive-compulsive disorder. Am J Psychiatry. 2005;162:228-238. Copyright © American Psychiatric Association 2005, and ref 76: Murphy DL, Timpano KR, Wendland JR. Genetic contributions to obsessive-compulsive disorder (OCD) and OCD-related disorders. In: Nurnberger J, Berrettini W, eds. Principles of Psychiatric Genetics. Cambridge, UK: Cambridge University Press; 2010. Copyright © Cambridge University Press, 2010

Table II indicates the frequency of comorbid disorders found in adult probands with OCD compared with the incidence of these disorders in the general US population. As is evident, two- to sixfold higher prevalence rates of most psychiatric disorders are found in individuals with OCD. Most striking are the high frequencies of all anxiety disorders taken together, and likewise, all affective disorders. Also of interest are the lack of differences in alcohol-related and substance abuse disorders between those with OCD and the general US population. Specific symptomatologic features that potentially may be useful for grouping OCD into more homogeneous and familial phenotypes for etiologic investigations include those of comorbid tic, affective, anxiety and the other disorders listed, as well as obsessive-compulsive personality disorder.

An example of one OCD-comorbid disorder (not listed in Table I Ibut recently identified as a potential OCRD disorder) is attention-deficit hyperactivity disorder (ADHD).80,81 While some of the original OCD comorbid spectrum disorders remain in this grouping simply on the basis of consistent co-occurrence with OCD in descriptive samplings or overlapping features, others such as ADHD have been validated via segregation analysis. In evaluations of the OCD-ADHD relationship, relatives of probands with both disorders have been found to have a significantly higher frequency of OCD plus ADHD compared with the relatives of probands with ADHD only80,81

Table II

Population

OCD (N = 334)71

OCD (N = 206)60

OCD (N = 80)77

OCD (N = 630)79

OCD (N = 418)37

OCD (N = 2073)72

General US Population (N = 8098)78

Apparent environmental etiology-based OCD-related disorders

Three examples of full-blown OCD occurring apparently acutely de novo following putative causal events include: (i) OCD related to an infection such as that associated with streptococcal infections (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections [PANDAS] syndrome); (ii) trauma-related OCD following acute brain injuries; and (iii) OCD occurrence during treatment of schizophrenia with atypical neuroleptic agents. These would seem to constitute an etiologically-based OCD subtype, since most cases of primary, idiopathic OCD have an insidious onset with a gradual development of symptoms and impairment over a longer timeline of months or years.

OCD and infections: the example of PANDAS syndrome

A potential environmental contributor to the development of OCD, particularly in childhood, is a suspected relationship between group A streptococcal infections and onset of OCD and/or tics/Tourette syndrome, akin to the development of Sydenham's chorea reported previously following streptococcal infection.82-84 In fact, an increased prevalence of obsessive-compulsive symptoms85-87 and OCD88 has also been noted in patients with rheumatic fever (RF) with or without Sydenham's chorea. Initially, these findings were reported in children during an active phase of rheumatic fever.88 Subsequent studies revealed the presence of OCSDs in adults with a previous history of rheumatic fever (not active), suggesting that the streptococcal infection may trigger OCD, which may persist throughout life regardless of the activity of the rheumatic fever.85,86 Recent family studies have reported that OCSDs and OCRDs (such as tic disorders, body dysmorphic disorder, trichotillomania, grooming behaviors, and others) aggregate more frequently in first-degree relatives of rheumatic fever probands when compared with controls.89,90 Moreover, two polymorphisms of the promoter region of the tumor necrosis factor-alpha (TNF-α) gene have been associated with both OCD and rheumatic fever, which is an interesting finding since the TNF-α gene is a proinflammatory cytokine involved in rheumatic fever and several other autoimmune diseases,91,92 suggesting that both obsessive-compulsive related disorders and rheumatic fever share a common genetic vulnerability.

Thus, PANDAS OCD could be a mild expression of rheumatic fever whose incidence is higher in developing countries, while the full development of rheumatic feverrelated disorders may be attenuated by the appropriated antibiotic prophylaxis in developed countries. Consistent with this hypothesis, there was a higher family history of rheumatic fever in PANDAS OCD patients. Thus, abnormal immune response to this streptococcal infection, with abnormal antibody production leading to basal ganglia damage has been focused upon as a likely mechanism for both rheumatic fever and PANDAS OCD. This proposed mechanism is supported by behavioral changes and brain lesion development in mice following immunization with streptococcal antigens,95 with resemblances to similar studies investigating immune mechanisms in Sydenham's chorea.83

Abnormal brain autoantibody production may itself be mediated by specific genetic factors, posing a possible gene X environment (G x E) pathogenesis for a PANDAS subgroup. However, a puzzling anomaly potentially reflecting a different possible G x E interaction, or even a confound to the importance of streptococcal infections and autoantibodies in OCD, is that OCD patients with suspected PANDAS had an equal number of OCDaffected relatives as the non-PANDAS comparison OCD population.96 Some recent reviews have concluded that the relationship between strep infections and OCD may be indirect and complex and thus "elusive,"97-99 although other controlled studies continue to support an association.100

Besides streptococcal infections and PANDAS, there are interesting examples of other apparent infection-related OCD development. Both bacterial and viral infections have been noted to be associated with acute OCD onset, including Mycoplasma pneumoniae, varicella, toxoplasmosis, Borna disease virus, Behcet's syndrome, and encephalitis, with some infections accompanied by striatal and other brain region lesions.101-106 In some cases, marked OCD symptoms subsided with antibiotic treatment.

Onset of OCD and/or hoarding after acute traumatic brain injury and in association with other types of neuropathology

A number of reports have described new onset of OCD in previously healthy individuals who suffered documented brain injury, usually after accidents (reviews: refs 45,107-109). Besides OCD, other psychiatric disorders that follow brain injuries have been documented in epidemiologic studies.110 In one of these, which retrospectively evaluated 5034 individuals among whom 361 (8.5% weighted average) reported a history of brain trauma with loss of consciousness or confusion, lifetime prevalence was significantly increased ( P<0.03-0.0001) for many disorders, including OCD, compared with those without head injuries. An odds ratio of 2.1 was reported for OCD, representing a greater than twofold increase of the occurrence of OCD compared with controls without head injuries, after corrections for age, gender, marital status and socioeconomic status.110 Of note, although similar odds ratios have been found for major depression and panic disorder, rates of schizophrenia or bipolar disorder were not increased in this sample of individuals with brain trauma.110

Some case report series noted acute onset of OCD within a day to a few months following traumatic brain injury. One of three studies documented a typical array of OCD symptoms using YBOCS ratings; a subgroup of patients had the generally unusual symptom of "obsessional slowness." 107 Compared with matched controls, the patients with post-brain injury OCD symptoms had poorer performance on an array of cognitive measures, including executive functions. Also, the patients with the most severe traumatic brain injury had more frequent abnormal magnetic resonance imaging (MRI) exams involving the frontotemporal cortex and the caudate nucleus.107 Some of these reports specifically emphasized the lack of prior personal or familial OCD symptoms or diagnoses.

Smaller survey studies of post-brain injury patients with Ns of 100 or less and using various types of diagnostic evaluations, some quite brief, have infrequently noted cases of OCD, although OCD symptoms have been reported as present in other types of brain disorders, including surgery for seizure disorders and carbon dioxide poisoning, as well as brain tumors and stroke lesions affecting portions of the cortico-striato-pallidothalamic circuits.109,113 OCD and OC symptoms have also been associated with other neurological disorders and neuropathology found in Parkinson's disease, postencephalopathic disorders, and other brain disorders.114,115 Influenced in part by the literature that focal injury to the basal ganglia was associated with OCD emergence, we recently observed an MRI abnormality suggesting elevated iron deposition in the globus pallidus in OCD patients whose symptom onset was from around adolescence to early adulthood.116 This initial result adds to the literature suggesting that age of onset is likely to be an important consideration in attempts to separate OCD into etiologically meaningful subgroups. Age of onset may also be an important variable in regard to the repetitive-compulsive OC traits and OCD itself which are well documented in conjunction with autism spectrum disorders, including Asperger's syndrome.117,118

Apparent acute new onset of OCD in patients with schizophrenia during treatment with atypical antipsychotic medications

One recently-recognized OCD-related disorder is atypical neuroleptic-related OCD, as reported in schizophrenic patients successfully treated with clozapine, ritanserin, and other newer neuroleptic agents.119-122 Some have suggested that this syndrome represents OCD -like symptoms induced by the atypical neuroleptics - ie, a drug side effect. Others subscribe to the hypothesis that suppression of overt and more dominant psychotic symptoms by clozapine and other atypical neuroleptics unveils coexisting OCD, permitting diagnosis. The latter would be in accord with some suggestions from earlier studies that reported as many as 5% to 20%, or more of individuals with schizophrenia have comorbid OCD.123-125 It seems more studies are required to evaluate these two somewhat opposing views of this syndrome.

Of note, other detrimental, traumatic life events of a psychological or social nature have been associated with OCD with different possible implications. For instance, one study compared patients with OCD plus post-traumatic stress disorder (PTSD) who developed OCD after clinically significant trauma (designated "post-traumatic OCD") to general OCD patients in terms of sociodemographic and clinical features. Compared with general OCD patients, "Post-traumatic OCD" presented several phenotypic differences such as: later age at onset of obsessions; increased rates of some obsessive-compulsive dimensions (such as aggressive and symmetry features); increased rates of mood, anxiety, impulse-control and tic disorders; greater "suicidality and severity of depressive and anxiety symptoms; and a more frequent family history of PTSD, major depressive disorder and generalized anxiety disorder." 79,126 One study of a treatment-resistant OCD subgroup found that all subjects who met formal criteria for OCD and comorbid PTSD had PTSD onset that preceded OCD onset.127

What is there to make of this diversity of antecedent events suggested to trigger typical OCD? One concept, elaborated below, is that severe acute or more chronic stresses that impact executive (or "ego") functions may elicit a kind of regression to or activation of less goal-oriented but more simplified, ritual-based action patterns that may act to prevent further disorganization of the self.128,129 In this view, OCD "strategies" and symptoms may provide a common pattern of behaviors that are of advantage in the short term, but which may become deleterious if sustained beyond the time of stress.

Putative chromosomal or gene-based, genomic OCD-related disorders

At present, studies of possible genetic contributions to OCD and OCSD remain quite limited. Apart from investigations of specific candidate genes and generelated syndromes, as noted below, the greatest effort in the last decade has been directed towards genome-wide linkage and, more recently, genome-wide association studies that are primarily based upon groups of individuals with DSM-IV-diagnosed OCD without concern for OCD-related subgroups. As reviewed previously and in this same issue, there have been several recent evaluations of genetic contributions to OCD.130-133 In addition, specific investigations of some candidate genes have been subject to meta-analysis with positive results, eg, the SLC6A4 (serotonin transporter gene) polymorphisms,134 plus positive results from investigations of rare variants in SLC6A4 (review in ref 135).

However, in large part these reviews and evaluations of specific genes have not gone beyond generic OCD to address possible associations with OCD spectrum disorders. One notable exception deserves comment. Among five positive studies of variants in SLC1A1 (the neuronal glutamate transporter gene), one study reported separable results for different single-nucleotide polymorphisms associated with overall OCD from associations of a novel 5'-prime region variant (that was not found in the overall OCD sample) with hoarding compulsions.39 This is reminiscent of the report of different patterns of associations with hoarding compulsions compared to associations with overall OCD or with Tourette syndrome for chromosomal regions in genome linkage studies.38,136 In one of these studies, those with OCD plus hoarding exhibited a novel peak on chromosome 14; likewise, in a subgroup of individuals with OCD but from which the individuals with hoarding had been deleted, the peak on chromosome 3q became more distinct.38,137

In keeping with these results, prior studies from different vantage points have suggested that individuals with OCD and hoarding might differ from others with OCD without hoarding, and that hoarding itself might represent a separate syndrome within the OCRDs.31,32 Providing further support for this notion, brain imaging results have indicated that individuals with OCD have distinctly different patterns of cerebral glucose utilization from nonhoarding OCD patients.40 Additionally, hoarding is more frequent in the first-degree relatives of hoarding probands, and hoarding is associated with other biological and gender differences.31,33,37,68,71,138-141

Thus, with only a few interesting exceptions, the chromosomal regions discovered in the genome-wide linkage studies of OCD as possibly harboring OCD-related genes are relevant only to OCD in general, without much attention to OCD diversity and heterogeneity, or with regard to other OCSDs. The same is true for those studies focusing on a single candidate gene. One other exception of possible future interest in regard to likely gene-related subgroupings is age of OCD onset.137

Common gene variants plus rare gene and genetic syndromes associated with OCD and OCD/Tourette syndrome subgroups and/or OCD-related disorders

Uncommon chromosomal anomalies and both rare and common gene variants have come under increasing scrutiny in OCD and OCD-related or OCD-comorbid disorders. Several uncommon chromosomal region abnormalities that are associated with multiple phenotypes have been found to include individuals with OCD. Thus, OCD diagnoses have been made in individuals with the 22q11 microdeletion syndrome (also known as velocardiofacial syndrome).142-145 In one comprehensive study that used the YBOCS scale together with psychiatric interviews in evaluating a VCSF clinic sample, 33% received an OCD diagnosis.142

OCD has also been diagnosed in some individuals with the myoclonus dystonic syndrome related to chromosome 7q.146-149 In one study of three extended myoclonus dystonic syndrome families, OCD meeting direct interview-based DSM-FV criteria was present in 25% (4/16) of symptomatic myoclonus dystonia syndrome carriers with the 7q21 haplotype, but in only 9% (1/11) of nonsymptomatic carriers and 0% (0/28) of the nonhaploytpe carriers.146 This is of special interest because its 7q21-q31 locus is near the chromosomal anomalies described in other individuals with OCD or Tourette syndrome but without the myoclonus dystonic syndrome who have anomalies in chromosome regions 7q31 and 7q35-36.150-152 Additionally, a family-based association study using markers in the 7q31 region demonstrated biased transmission of these marker alleles in individuals with comorbid Tourette syndrome, OCD, and ADHD.153

For the 22q11 and 7q variants, insufficient data exist for OCD, OCD spectrum disorders like other dystonias,154-157 and possibly related disorders like autism spectrum disorder to draw firm conclusions as to how these different disorders might be related. However, these findings from uncommon chromosomal regions and rare genes suggest distinct and different etiologies for an OCD phenotype that may represent a type of OCD spectrum disorder, ie, a genomic group of OCSDs. For example, as noted above, one common candidate gene, SLC1A1, manifested a variant associated with complex hoarding, while different variants were strongly associated with OCD in general.135

Discussion: what might be common elements that could contribute to OCD spectrum disorders?

The relationships among OCD comorbid disorders and additional OCD spectrum disorders: old and new postulated groupings

From an overview perspective, OCD remains as a distinct clinical entity, with classic symptoms and behaviors involving obsessions and compulsions plus high anxiety and, over the lifetime, the occurrence of mood and other anxiety disorders. OCD differs from the other anxiety disorders by its earlier age of onset, more complex comorbidity, and severity of obsessional thoughts and compulsive behaviors. OCD as defined in DSM-IV/IV-TR also occurs concomitantly with other DSM-defined disorders ranging from body dysmorphic disorder, Tourette syndrome, eating disorders, and autism spectrum disorders,118 as well as multiple other disorders. Individuals with these other primary disorders may have separately defined OCD meeting full criteria. There seem to be two views about this overlap: (i) All of these disorders together constitute an OCD spectrum group, with implications that they are all manifestations of a single OC-based entity; or (ii) each may be an independent coexisting disorder. For some individual patients, it may be that a mixture of both may be operative for different components of these disorders. Thus, the relationship among OCD-related disorders remains uncertain.

We have noted that a number of other disorders have sometimes been named in an extended list of OCD spectrum disorders (Figure 2 ) such as the impulsive disorders; however we will not discuss them further, as their association to OCD is tenuous and not acknowledged by most experienced clinicians and researchers or recent reviews.19 On the other hand, we have explicitly added two additional groupings of OCD-related disorders that are not based on descriptive nosology, but rather on etiologic considerations( Figure 3 ). One of these links acute OCD onset to environmental events such as the consequences of infection, traumatic brain injury, and other neurological disease insults. The other newly suggested OCD spectrum encompasses etiologies related to specific gene or narrow chromosome region-related syndromes - a fourth genomic OCD-related group. Some of this latter group also overlaps with disorders such as Tourette syndrome, with its common tripartite combination of tic disorders, OCD, and ADHD. It is of interest that some considerations for DSM-5 and future DSMs are beginning to show additional elements beyond clinical symptoms as bases for designation of an entity. These include biological, psychophysiological, and brain imaging data as well as potential etiological factors including genetic elements and brain neurocircuitry contributions.6,12,14,19,22,25-26

Adapted from ref 12: Hollander E, Kim S, Braun A, Simeon D, Zohar J. Cross-cutting issues and future directions for the OCD spectrum. Psychiatry Res 2009;170:3-6. Copyright © Elsevier/North-Holland Biomedical Press 2009, ref 19: Mataix-Cols D, Rosario-Campos MC, Leckman JF. A multidimensional model of obsessive-compulsive disorder. Am J Psychiatry. 2005;162:228-238. Copyright © American Psychiatric Association 2005, and ref 76: Murphy DL, Timpano KR, Wendland JR. Genetic contributions to obsessive-compulsive disorder (OCD) and OCD-related disorders. In: Nurnberger J, Berrettini W, eds. Principles of Psychiatric Genetics. Cambridge, UK: Cambridge University Press; 2010. Copyright © Cambridge University Press, 2010

Evaluations of treatment responses and familiality of treatment responses as possible bases for OCD-related subgroups

Like OCD, many of the OCD-related spectrum disorders respond to serotonin reuptake inhibitors (SRIs), which some have used as evidence for an association between these conditions. However, given that individuals with these disorders often suffer from comorbid disorders that also respond to SRIs (eg, major depressive disorder and other anxiety disorders), as well as the fact that many other neuropsychiatric and medical disorders with no postulated relationship to OCD also respond to SRI treatment, this treatment responsivity seems patently a weak hypothesis. On the other hand, it is notable that many anxiety disorders, but not OCD, benefit from monotherapy with other types of anxiolytic agents such as benzodiazepines.

Psychological treatments with specificity for OCD provide a more discriminating test for grouping disorders together based on treatment response. Exposure and Ritual Prevention (ERP) is one treatment of choice for OCD, and several studies have demonstrated that body dysmorphic disorder and hypochondriasis also respond to psychological treatments incorporating elements of ERP. Worthy of additional study would be comparative examination of whether nonresponse to other antidepressants compared with anxiolytics such as benzodiazepines might characterize subgroups of these other OCD-related disorders. Data from such approaches are sparse, with very few head-to-head studies like those done in OCD of SRIs versus norepinephrine transporter inhibitors such as desipramine or drugs affecting other neurotransmitter systems that have been reported (eg, ref 158).

Likewise, while there is evidence for some features of OCD to exhibit family-based relationships in treatment responses, as recently reviewed,26 similar data are very meager for OCD-related disorders other than major depression. Thus, these notions have not yet been adequately explored across more than a handful of disorders related to OCD to provide an adequate treatmentbased subcategorization of these disorders or to provide a common understanding of them.

Additional approaches to understanding OCSDs and OCRDs: brain imaging studies, putative endophenotypes (including neuropsychological and neurophysiologic measures) and hints from animal models

Brain imaging investigations of OCD patients have only relatively recently been expanded to include some subgroups such as body dysmorphic disorder and compulsive hoarding. Specific investigations have included positron emission tomography (PET) studies of glucose utilization and MRI-based volumetric studies of components of the cortico-striato-pallido-thalamic circuits most implicated in OCD. Another approach has been PET studies using specific ligands and magnetic resonance spectroscopy-based studies of specific brain chemicals to evaluate receptor and transporter elements of neurotransmitter signaling pathways.159,160

Most studies thus far have endeavored to compare OCD patients with controls, or occasionally other neuropsychiatric patient groups, or pre- and post-treatment comparisons. There has been a decided lack of investigations considering the OCD-related disorders. Expense, difficulty, and time limit the numbers of individuals that can be studied, and thus there are only a very few studies of OCD subgroups, such as one comparing OCD patients with and without hoarding40 and studies comparing the symptom dimensions of OCD.161 A similar situation exists for psychological and physiological measures or endophenotypes and for animal models, all of which are at the stage of mostly searching for relevant measures for OCD phenotypes.162-164

One rodent model, which documented changes in microneuroanatomical structures in pathways that were associated with shifts from normal goal-directed behaviors to more limited, habit -based "compulsive" behaviors following multiple types of chronic stressors would seem of relevance to environmental trauma and stress as discussed above regarding the genesis of an environmental OCD spectrum.128 Conceptually, combinations of stresses (from the environment such as psychological traumatic events and from disease-based etiologies such as neurologic disorders or comorbid anxiety, mood, or other neuropsychiatric disorders), plus genetic vulnerabilities might be envisaged as combining to lead towards temporarily adaptive OCD-related thoughts and behaviors that limit further nonadaptive disorganization. Their continuation, however, past the times of most marked stress, may become nonadaptive - a sustained reduction in abilities to act towards more adaptive, social, and occupational goal-directed functions. Prior clinical data and theoretical formulations have led to some similar suggestions resembling this interpretation and application to OCD of this experimental animal model.128

Conclusions

Thus, we are left with a multifaceted array of obsessivecompulsive features that cut across traditional (DSM-IV/TR) as well as draft plans for the DSM-5. Before elaborating what comprises OCSD and OCRD, it seems important to consider "uncomplicated," OCD, as such individuals may be important to study for many purposes and comparisons.69,70 For example, if our current nosologic distinctions retain some validity, detailed knowledge of uncomplicated OCD may help to clarify which genes are more directly OCD-related when coexisting mood, anxiety, and other groupings of comorbid disorders and their underlying genes are also present. However, even uncomplicated OCD demonstrates symptom heterogeneity, leading to continuing efforts such as using latent class modeling to go beyond factor and cluster analyses in order to parse the condition into more valid groups. Considering underlying features, stressors and the other environmental contribution to symptoms may be additional factors to consider in these investigations.

In view of the present diagnostic scheme, there is some consensus that entities such as body dysmorphic disorder, hypochondriasis, and obsessive-compulsive personality disorder share the highest apparent phenotypic overlap with OCD. At the same time, the most commonly occurring disorders comorbid with an OCD diagnosis are anxiety and mood disorders, especially major depressive disorder and dysthymia, and even bipolar disorder.165 Another interesting connection with additional disorders arises from segregation, and other analyses that have shown that ADHD and bipolar disorder occur in OCD and the families of OCD probands as frequently as these disorders occur in family studies of each of the primary disorders, ADHD, and bipolar disorder.71,80,81 Thus it is apparent that OCD does co-occur with a wide variety of disorders, and certainly some share enough in common to be considered OCD-related.

The search for OCD subtypes and spectrum conditions over the past 15 years has sought to clarify the constellation of features associated with OCD, but has proved to be a monumental task, sometimes beset by false paths and perhaps spurious associations such as the suggestion of an impulsive-compulsive continuum and a range of problems only very distantly resembling OCD ( eg, Figure 2 , lower right). Recently, however, efforts have been made to emphasize shared underlying mechanisms and etiologies. For example we have reviewed two examples of etiologically based OCD presentations that could comprise new OCD-related disorder groupings. Another avenue of approach is the weaving together of model approaches from experimental (eg, brain imaging) and genetic models, combined with more detailed empirical studies of the phenotypical heterogeneity of individuals with OCD and similar disorders.129,164,166,167 With recent advances from ongoing clinical investigations and other research, the state of OCD and OCD-related spectrum disorders is evolving rapidly, with many interesting new developments, as elaborated in a surge of recent publications. It is to be hoped that, together, this work will result in an etiologically based diagnostic scheme that in turn will help advance diagnosis and treatment of these disabling illnesses.

The views expressed in this article are the opinions of the authors and do not necessarily reflect those of the NIMH.

Acknowledgments

This research was supported by the Intramural Research Program of the NIMH, NIH. The authors are grateful to Theresa B. DeGuzman for her editorial and artwork assistance.

Selected abbreviations and acronyms

REFERENCES

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Articles from Dialogues in Clinical Neuroscience are provided here courtesy of Taylor & Francis

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Obsessive-compulsive disorder and its related disorders: a reappraisal of obsessive-compulsive spectrum concepts

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Language: English | Spanish | French Obsessive-compulsive disorder (OCD) is a clinical syndrome whose hallmarks are excessive, anxiety-evoking thoughts and compulsive behaviors that are generally recognized as unreasonable, but which cause significant distress and impairment. When these are the exclusive symptoms, they constitute uncomplicated OCD.

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Children who have obsessive-compulsive disorder (OCD) are plagued with unwanted thoughts, images or impulses that are difficult to suppress, causing them great stress and worry. These are called obsessions. To alleviate the anxiety caused by their obsessive thoughts, they perform repetitive, ritualized actions called compulsions. A child with OCD might need to line things up, touch things in a certain order when leaving the room or wash his hands repeatedly.

Obsessions Common in Kids With OCD

Contamination: Kids with this obsession are sometimes called "germaphobes." In schools, this plays out with kids worrying about other kids sneezing and coughing, touching things that might be dirty or getting sick in many different ways. This is the most common obsession seen in children.

Magical thinking: This is a kind of superstition, like "step on a crack, break your mother's back," taken to extremes. For example, kids might worry that their thoughts can cause someone to get hurt, or get sick. A child might think, "Unless my things are lined up in a certain way, mom will get in a car accident."

Catastrophizing: Some kids easily jump to the conclusion that something terrible has happened. For example, if her parents are five minutes late picking her up, a girl who is catastrophizing might tell herself that they've decided to abandon her.

Scrupulosity: This is when kids have obsessive worries about offending God or being blasphemous in some way.

What ifs: Kids may be plagued by a lot of different kinds of thoughts about bad things they could do. "What if I hurt someone? What if I stab someone? What if I kill someone?"

The "just right feeling": When OCD first develops, from about 6 to 9 years of age, kids may not know why they are doing something, but just that they need to do it until they get what we call the "just right feeling." So: "I'll line these things up until it just kind of feels right, and then I'll stop." And then over time - in the 9- to 12-year-old range - it evolves into magical thinking and becomes more superstitious in nature.

Behaviors You Might See in Students With OCD

Frequent requests to go to the bathroom: This could be to wash hands, if someone near the child was coughing or sneezing, or if she touched something that she perceives as contaminated. She could be washing items-pens, pencils, backpacks, books. It could also be an excuse to get out the classroom and just be away from everyone, and have some respite.

Constant reassurance-seeking: This takes the form of repetitive questions. "Are you sure that's the answer? Could you tell me again? Did you hear what I said?" Checking doors, windows, lockers, desks. Over and over and over again.

Getting stuck on tasks: Sometimes kids with OCD will need to finish something to completion, or understand it to completion, before they're able to move on. So if a child is working out what he did wrong on a math test, and the teacher says, "Now let's open the textbook and start a new chapter," he's not going to be able to shift gears.

Retracing: If a child leaves the classroom and worries that she left a pencil behind, she'll go back into the classroom and go to her desk and check. If she had a bad thought as she went through the doorway, she might have to "fix it" by going back through the doorway again saying a good word. If she had a bad thought when she went down a flight of stairs on the way to class, she might need to go back up that same stairway at the end of the period, even if it means being late to her next class.

Obsessive erasing: A child could be erasing a lot because the letters have to look perfect. Or he could have used a word that disturbs him. For example, if he has a fear of vomiting and he's written the word vomit, he might not be able to stand seeing that word, so he erases it. Kids start having erasers worn down to the metal. Teachers start to see holes in the paper. Words will be drawn over on the back of the page. A lot of different areas of writing become problematic.

Behaviors Often Confused With Another Disorder

Some behaviors associated with OCD are easy to confuse with ADHD, learning problems or being oppositional.

Distraction: If a child is busy thinking that if she doesn't turn the pen cap and count to four the right way then her mom is going to get sick, she's not going to be paying attention in class. And if her teacher calls on her to answer a question, her distraction might look like ADHD, but it isn't.

Slowness on exams, papers and tasks: Sometimes when kids take a long time, they're struggling with the perfectionism of needing to do things the right way. This could look like learning problems, or inattention, but it isn't.

Avoidance: Teachers might see a child who doesn't want to sit on the floor, or pick things up that touched the floor, or get his hands dirty in art class. He may avoid a lot of playground activities - kids with germ fears will view the playground the way some adults view the subway: it's gross. Why touch anything there?

Tapping and touching symmetrically: If a child sits down at her desk and she accidentally kicks the chair of the kid next to her with her right foot, she's going to have to then kick it with her left foot. That might look like somebody who's being oppositional, or somebody who's got too much energy, but actually it's OCD.

Complaints of anxiety and fatigue: There's one interesting theory that kids with OCD are smarter than other kids. And if you consider how much thinking they're doing, they're really using their brain more frequently than a lot of other kids are. But when that's coupled with a lot of anxiety, you can have a lot of fatigue. So it's common for kids with OCD to want to come home and take a nap after school.

How to Help Students With OCD

For children struggling with OCD, functioning in school can be complicated and very difficult. Here are some things you can do to help them, and the class as a whole, focus on learning:

Seating arrangement: If the school has noisy hallways, you might not want to have a child with OCD sit by the door. You might have her sit in the front, where she's less able to hear the noise and can stay more focused on her work. On the other hand, a child who has very observable symptoms, and doesn't want other kids to see her fidgeting with her hands, rocking or getting up a lot, might be better off closer to the door, toward the back of the room.

Extended time for tests and papers: If writing is a problem for a child who needs to find the perfect way to say something, he's going to need more time to finish those essay questions or papers.

Laptops for writing: If writing and rewriting/erasing is really problematic for a child, consider letting her use a laptop for taking notes, and having all assignments be typed instead of handwritten.

Private testing rooms: Research is quite clear that kids with OCD do better, are less overwhelmed and are more in control of their thoughts and their reactions if they're in a quiet place away from the other kids.

Skip reading out loud: Kids who feel they need to read perfectly may have to go back and reread sentences or whole paragraphs over and over to make sure they've got them right. So reading becomes a very laborious task, and reading in front of the class can become a nightmare. So if we know doing this is a problem for children, we can spare them.

Books on tape: If kids get so hung up reading that it takes forever, listening to the books can be a solution.

Break homework into chunks: If looking at a whole page of math makes kids feel overwhelmed and anxious - think of the potential for mistakes! - the problems can be broken up over four pages. It helps kids stay focused on doing the problems instead of worrying.

How to Minimize Behavioral Problems

Plan an escape route: Try working out a communication system so that if the student feels symptoms coming on, she can signal to you and leave the classroom, or go to a protected place in the classroom, without interrupting the class. It can prevent an embarrassing and disruptive blowup of symptoms in the classroom, and the other kids picking on or bullying her about it.

Be aware of triggering events: It's very important for teachers to know what kind of things might trigger the symptoms. Fatigue is a huge piece of OCD, and it can be exacerbated by medication. So it's important to know that if a child is drowsy in class, and maybe he's putting his head down, it's not because he's being oppositional or disrespectful, but because he's overwhelmed with fatigue.

Advance notice: Irritability and frustration are two of the longer-lasting things that kids with OCD are feeling on a daily basis. Changes in schedule can be very disruptive for a child with OCD, so it can be helpful for teachers to give advance notice of things. Kids who know what to expect are less likely to be thrown by the change.

Children with OCD are often teased and bullied because of their symptoms. Kids feel very uncomfortable about their rituals, knowing that they're being watched. It can be helpful to educate the whole class about what's going on, especially if a child is going to be in the same school for a number of years, and it can inspire a surprising amount of support from other children.

Peer understanding program: A peer understanding program includes a presentation in the classroom that explains (with the child participating) what OCD is. The child might say, "Listen, I have OCD. It's an anxiety disorder. It makes me think that my hands are dirty and I have to wash my hands a lot, so if you see me getting up and going to the sink to wash my hands, that's why." Psychologists can role-play with the teacher and child ahead of time, to anticipate questions his classmates might ask, and how to answer them.

A buddy system: A buddy is like a peer coach who sits next to the child and prompts him to keep up with note taking and staying on task. It can be great for the buddy, to foster a sense of confidence and pride and to be able to help someone in need, and great for fostering friendship.

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Lo sentimos, la página que usted busca no se ha podido encontrar. Puede intentar su búsqueda de nuevo o visitar la lista de temas populares. Children who have obsessive-compulsive disorder (OCD) are plagued with unwanted thoughts, images or impulses that are difficult to suppress, causing them great stress and worry.

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If your child has been diagnosed with oppositional defiant disorder (ODD) you may be at a loss as to where to begin. It can be daunting to wade through information to find what is worth reading and what is a waste of your time. Let's begin with some basic information along with resources for learning more, addressing specific behaviors, and getting support so you can best help your child with ODD.

ODD is a mental health disorder in which a child demonstrates aggression and purposeful misbehavior. Thought to affect roughly 10 to 20% of school-age children, this behavior disorder is more common in boys than in girls.﻿﻿ When thinking about these behaviors, it's important to realize that many children without ODD exhibit some of these behaviors from time to time.

So what are normal behavior problems and what are not?

Symptoms of ODD in contrast to normal child behaviors may include:﻿﻿

Being easily annoyed or provoked

Excessive arguing with parents and other authority figures

Frequent angry outbursts

Frustration and lack of concentration for the child, along with a reduced self-esteem and difficulty forming and keeping friendships

Lying and blaming others for mistakes

Purposefully irritating and annoying others and intentionally causing conflict

Questioning authority

Refusal to follow rules

Seeming to lack a conscience

Vindictiveness, being spiteful of others

These symptoms can vary from mild to severe, but usually, arise during the preschool years and almost always before puberty. The behaviors often create significant dysfunction at both homes and in the school setting. Fortunately, while these behaviors can cause havoc for parents and teachers, around two-thirds of children out-grow their disorder in their late teens.﻿﻿

It's not known exactly what causes ODD but is most likely a combination of factors. Genetics can play a role and may increase susceptibility to the disorder. Abnormal levels of neurotransmitters in the brain may play a biochemical role. While ODD can develop in children from loving and stable families, it's not uncommon for these children to have had a dysfunctional home life and/or exposure to violence.﻿﻿

ODD may occur along with other conditions, such as attention deficit disorder (ADD), anxiety disorders, bipolar disorder, and language disorders.﻿﻿ Sometimes it takes some time to distinguish between ODD and other common behavioral disorders in children such as ADD/ADHD and conduct disorder.

What to Do After an ODD Diagnosis

When your child is first diagnosed with ODD, it's helpful to learn as much as you can about the disorder. Not only will this help you learn methods for coping with the behaviors, but it can be reassuring to learn that the majority of children outgrow the disorder. Knowing this alone may give you more strength to cope with difficult behaviors today.

Parenting programs can be extremely helpful in getting you up-to-date on how to parent a child with ODD quickly. Some of these include:

Depending on who diagnosed your child, you may also need to find a therapist who can walk beside you as you learn tools for managing your child's behavior. Therapy has been found to work well for children with ODD and also reduces the chance that ODD will progress to conduct disorder later in childhood or antisocial personality disorder as an adult.﻿﻿

You can ask your doctor or therapist if she knows of anyone who specializes in treating children with ODD or ask in one of the online support communities. Parents who have been living with a child with ODD have often learned by trial and error and may offer you valuable tips in finding the right person. Most commonly, it will be a child or adolescent psychiatrist who cares for a child with ODD.

Don't be afraid to interview different providers. It's important that you find an ally who can support you in helping your child.

How to Prepare Your Child's School

If your child is in school, it's important to meet with your child's teacher or others at the school who will be involved in his education. Combining a school-based program with positive parenting at home is most effective.

Special education services can provide support and accommodations for your child. The Individuals With Disabilities Education Act (IDEA) is a federal law which mandates that children with disabilities be provided with services to allow him to function in the school setting.﻿﻿ This usually requires that the disorder impairs his academic performance. You can request an evaluation for your child at any time.

If your child does not qualify for IDEA (usually under the "other health impaired" category) he may still qualify for an individual accommodation plan under Section 504.﻿﻿ You may also wish to contact your school district, State Department of Education, or your state Parent Training and Information Center.

Disciplining an ODD Child

You may have read everything you can get your hands on, but how do you discipline a child with ODD? Having a child with ODD can grate on your nerves, but despite ample opportunities to give negative attention, finding opportunities to give positive attention can really help. Even though negative consequences will likely be needed at times, positive attention is often more effective.﻿﻿

Thankfully, these "positive" consequences seem to make negative consequences more effective when needed. Avoiding harsh punishment and focusing on behaviors rather than the child is also helpful. The programs listed above provide many examples for working with a child with ODD.

Treatment Options for ODD

As noted above, therapy is often very effective for children with ODD and may prevent the condition from progressing to conduct disorder or antisocial personality disorder.

Of note, there are not any specific medications recommended for ODD, and medications alone should not be used to treat the condition. Medications may be helpful, however, in controlling some of the behaviors or for coexisting mental health conditions.

Living With an ODD Child

Living with a child with ODD can leave you on the edge and frustrated. It can be challenging to back up and view the behaviors as separate from your child and to stay calm. Here are a few tips that have helped other parents cope with the day-to-day challenges of living with a child with ODD.﻿﻿

Avoid power struggles.

Don't sweat the small stuff. It might be best to ignore minor behavioral
problems until you get the major problems controlled. Said in another
way, "pick your battles."

Establish clear household rules.

Give your child plenty of time for imaginative play.

Limit the number of questions you ask your child.

Offer clear consequences, and be aware that consequences are not the same as punishment.

Praise your child often.

Provide positive feedback often, even if your child responds in a positive way on a minor issue. Reinforcing the behavior with positive attention may reduce the amount of negative attention their behavior requires.

Schedule daily doses of one-on-one time.

"Walk the walk:" Model positive behaviors for your children to observe.

Getting Professional Help

Even if you follow all of the tips above for parenting a child with ODD, you may still feel overwhelmed. Take a moment to think about when you should seek help for your child's behavior problems.

If your child's behavior problems aren't changing when you incorporate discipline strategies, if their behavior is interfering with school or their social life, or if their behavior is not age-appropriate, it's likely time to seek help.﻿﻿

Helpful ODD Resources for Parents

There are lots of resources available to help parents manage their child's ODD. Here are some places to start looking.

Websites that offer ideas for parents who have a child with ODD include:

DocSpeak offers further information which directly pertains to parents of children living with ODD.

Lives in the Balance is another site which helps assist children in collaborative problem-solving.

Transforming the Difficult Child is designed to help children manage their intensity in different ways.

ODD is usually diagnosed in the preschool years or shortly thereafter, and for many children resolves by the age of 18.﻿﻿ That said, combining "normal" teen issues with the management of ODD can be a challenge. The following site focuses on difficult behavior in teens, including ODD:

There are a few reference sites which provide good overviews of ODD diagnosis and treatment. The sites mentioned here have information provided by those educated in managing children with ODD and are updated frequently. Reliable references sites include:

As noted earlier, ODD often co-exists with other disorders such as ADD. At times, the management of ODD is similar to that of ADD, but other times it's important to distinguish between the two diagnoses. These sites focused on ADD may offer assistance when your child has ODD as a co-existing condition.

In addition to websites, podcasts, and Youtube videos, there are entire books devoted to helping parents cope with and care for a child with ODD. Books which may be helpful include:

The Defiant Child, by Douglas Riley (published in 1997 but still very up-to-date)

The Explosive Child, by Ross W. Greene

The Kazdin Method for Parenting the Defiant Child, by Alan E. Kazdin

Support for Parents

Having the opportunity to talk with other parents living with a child with ODD can be priceless. No matter how thoughtful and understanding your family and friends, there is something special about talking with others who are facing the same challenges.

In addition to emotional support, online support communities can help you learn about the latest findings and approaches to managing ODD. After all, there is nobody more motivated to understand day-to-day life for a child with ODD more than other parents.

Online support groups allow you to get understanding and advice from other parents around the world. There are a number of other online groups as well as Facebook groups designed to connect parents who are living with a child who has ODD.

A Word From Verywell

Learning that your child has ODD can release a mass of mixed emotions. You may be relieved to finally have a label for your child's behavior but at the same time fear what this means for the future.

As parents, the diagnosis can also make you question your own parenting skills. Yet a sense of guilt and shaming is counterproductive to learning how to meet your child's needs. There are many children raised in warm and loving family environments who nonetheless suffer from ODD.

Once you have a diagnosis you can finally begin to address the behaviors. Talk to your doctor. Find a good child or adolescent psychiatrist. Become involved in support groups. Rest just a bit in the realization that the majority of children "outgrow" these behaviors. That said, therapy can go a long way in reducing the chance your child's behaviors will persist.

Explore the tips above, and use the resources and links provided to educate and empower yourself as a parent of a child with ODD.

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Resources for Parents of Kids With Oppositional Defiant Disorder

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There are many options if you're searching for ODD support groups near you. Try these resources for information to support kids with oppositional defiant disorder.

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What is oppositional defiant disorder (ODD) in children?

Oppositional defiant disorder (ODD) is a type of behavior disorder. It is mostly diagnosed in childhood. Children with ODD are uncooperative, defiant, and hostile toward peers, parents, teachers, and other authority figures. They are more troubling to others than they are to themselves.

What causes ODD in a child?

Researchers don't know what causes ODD. But there are 2 main theories for why it occurs:

Developmental theory. This theory suggests that the problems start when children are toddlers. Children and teens with ODD may have had trouble learning to become independent from a parent or other main person to whom they were emotionally attached. Their behavior may be normal developmental issues that are lasting beyond the toddler years.

Learning theory. This theory suggests that the negative symptoms of ODD are learned attitudes. They mirror the effects of negative reinforcement methods used by parents and others in power. The use of negative reinforcement increases the child's ODD behaviors. That's because these behaviors allow the child to get what he or she wants: attention and reaction from parents or others.

Which children are at risk for ODD?

ODD is more common in boys than in girls. Children with the following mental health problems are also more likely to have ODD:

Mood or anxiety disorders

Conduct disorder

Attention-deficit/hyperactivity disorder (ADHD)

What are the symptoms of ODD in a child?

Most symptoms seen in children and teens with ODD also happen at times in other children without it. This is especially true for children around ages 2 or 3, or during the teen years. Many children tend to disobey, argue with parents, or defy authority. They may often behave this way when they are tired, hungry, or upset. But in children and teens with ODD, these symptoms happen more often. They also interfere with learning and school adjustment. And in some cases, they disrupt the child's relationships with others.

Symptoms of ODD may include:

Having frequent temper tantrums

Arguing a lot with adults

Refusing to do what an adult asks

Always questioning rules and refusing to follow rules

Doing things to annoy or upset others, including adults

Blaming others for the child's own misbehaviors or mistakes

Being easily annoyed by others

Often having an angry attitude

Speaking harshly or unkindly

Seeking revenge or being vindictive

These symptoms may look like other mental health problems. Make sure your child sees his or her healthcare provider for a diagnosis.

How is ODD diagnosed in a child?

If you notice symptoms of ODD in your child or teen, you can help by seeking a diagnosis right away. Early treatment can often prevent future problems.

A child psychiatrist or qualified mental health expert can diagnose ODD. He or she will talk with the parents and teachers about the child's behavior and may observe the child. In some cases, your child may need mental health testing.

How is ODD treated in a child?

Early treatment can often prevent future problems. Treatment will depend on your child's symptoms, age, and health. It will also depend on how bad the ODD is.

Children with ODD may need to try different therapists and types of therapies before they find what works for them. Treatment may include:

Cognitive-behavioral therapy. A child learns to better solve problems and communicate. He or she also learns how to control impulses and anger.

Family therapy. This therapy helps make changes in the family. It improves communication skills and family interactions. Having a child with ODD can be very hard for parents. It can also cause problems for siblings. Parents and siblings need support and understanding.

Peer group therapy. A child develops better social and interpersonal skills.

Medicines. These are not often used to treat ODD. But a child may need them for other symptoms or disorders, such as ADHD.

How can I help prevent ODD in my child?

Researchers don't know what causes ODD. But certain approaches can help prevent the disorder. Young children be helped by early intervention programs that teach them social skills and how to deal with anger. For teens, talk therapy (psychotherapy), learning social skills, and getting help with schoolwork can all help reduce problem behaviors. School-based programs can also help to stop bullying and improve relationships among teens.

Parent-management training programs are also important. These programs teach parents how to manage their child's behavior. Parents learn positive reinforcement methods, and also how to discipline their child.

How can I help my child live with ODD?

Early treatment for your child can often prevent future problems. Here are things you can do to help:

Keep all appointments with your child's healthcare provider.

Take part in family therapy as needed.

Talk with your child's healthcare provider about other providers who will be involved in your child's care. Your child may get care from a team that may include counselors, therapists, social workers, psychologists, and psychiatrists. Your child's care team will depend on his or her needs and how serious the disorder is.

Tell others about your child's conduct disorder. Work with your child's healthcare provider and school to develop a treatment plan.

Reach out for support. Being in touch with other parents who have a child with ODD may be helpful. If you feel overwhelmed or stressed out, talk with your child's healthcare provider. He or she may direct you to a support group for caregivers of children with ODD.

When should I call my child's healthcare provider?

Call your child's healthcare provider right away if your child:

Feels extreme depression, fear, anxiety, or anger toward him or herself or others

Feels out of control

Hears voices that others don't hear

Sees things that others don't see

Can't sleep or eat for 3 days in a row

Shows behavior that concerns friends, family, or teachers, and others express concern about this behavior and ask you to seek help

Call 911 if your child has suicidal thoughts, a suicide plan, and the means to carry out the plan.

Key points about ODD in children

Oppositional defiant disorder (ODD) is a type of behavior disorder. Children with ODD are uncooperative, defiant, and hostile toward peers, parents, teachers, and other authority figures.

Developmental problems may cause ODD. Or the behaviors may be learned.

A child with ODD may argue a lot with adults or refuse to do what they ask. He or she may also be unkind to others.

A mental health expert often diagnoses ODD.

Therapy that helps the child interact better with others is the main treatment. Medicines may be needed for other problems, such as ADHD.

Next steps

Tips to help you get the most from a visit to your child's healthcare provider:

Know the reason for the visit and what you want to happen.

Before your visit, write down questions you want answered.

At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.

Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.

Ask if your child's condition can be treated in other ways.

Know why a test or procedure is recommended and what the results could mean.

Know what to expect if your child does not take the medicine or have the test or procedure.

If your child has a follow-up appointment, write down the date, time, and purpose for that visit.

Know how you can contact your child's provider after office hours. This is important if your child becomes ill and you have questions or need advice.

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Oppositional Defiant Disorder (ODD) in Children

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Oppositional defiant disorder (ODD) is a type of behavior disorder. It is mostly diagnosed in childhood. Children with ODD are uncooperative, defiant, and hostile toward peers, parents, teachers, and other authority figures.

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Difference between Conduct Disorders and Oppositional Defiant Disorder (ODD)

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Difference between Conduct Disorders and Oppositional Defiant Disorder (ODD)

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Oppositional defiant disorder (ODD) and Conduct Disorder (CD) are among the prevalent disruptive behaviors in both children and adolescents. These disorders are under the "Disruptive, Impulse-Control, and Conduct Disorders" in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5). Hence, such behaviors are characterized by self-control issues, aggression, and conflict with social norms.

Moreover, these disorders have been linked with disinhibition and negative emotionalism as well as inversely correlated with constraint personality dimensions. This makes them co-morbid with each other as well as with attention deficit hyperactivity disorder (ADHD). Regarding their distinctiveness, the main diagnostic criteria for ODD are angry or irritable mood, argumentative or defiant behavior, and vindictiveness while those for CD are aggression to people and animals, destruction of property, deceitfulness or theft, and serious violations of rules. The following discussions further delve into such differences.

What is Conduct Disorder?

According to the DSM 5, CD is a "repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated". The manual furthered that the following criteria should be met in the past 12 months.

The individual often does the following:
Aggression to People and Animals

Bullying, intimidating, or threatening

Initiating physical fights

Using weapons which can cause serious harm

Physically cruel to people and animals

Stealing with confrontation like extortion and mugging

Sexual harassment

Destruction of Property

Setting fire with the intention of harm

Destroying others' property aside from setting fire

Deceitfulness or Theft

Breaking into a property

Lying for selfish reasons

Stealing without confrontation like shoplifting

Serious Violations of Rules

Staying out late at night (despite curfews), beginning before 13 years old

Running away from home

Truancy in school before age 13

What is Oppositional Defiant Disorder?

The DSM 5 states that ODD has at least four of the following diagnostic criteria which lasts for at least six months and is manifested during non-sibling interaction.

The individual often manifests the following:

Losing one's temper

Getting easily annoyed

Feels resentful or angry

Angry/Irritable Mood

Arguing with others

Defying rules or requests

Annoying others deliberately

Blaming others for one's mistakes

Argumentative/Defiant Behavior
Difference between Conduct Disorder and Oppositional Defiant Disorder
Vindictiveness
The diagnostic criteria for CD are aggression, destruction, deceitfulness or theft, and serious violations. On the other hand, those for ODD are angry or irritable mood, argumentative or defiant, and vindictiveness.

It can be observed from the respective criteria of the disorders that CD is more characterized by physical violence as compared to ODD. The former includes physical fights, mugging, rape, and arson while the latter generally deals with upset moods, nonconformity, and spitefulness.

The symptoms of ODD must last for at least 6 months while that of CD must last for at least 12 months with at least one criterion being met in the past 6 months. Generally, it will take a longer observation time for the diagnosis of CD to be finalized.

The diagnosis for ODD is specified to be mild if the symptoms are merely confined to a certain setting, moderate if manifested in 2 settings, and severe if present in at least three settings. As for CD, the severity is marked according to the frequency and extent of conduct problems. It is mild if there are few conduct issues which cause only minor harm, moderate if the occurrence of conduct problems is intermediate between mild and severe, and severe if there are many conduct problems and considerable harm is done.

There are three subtypes for conduct disorder: childhood-onset type, adolescent-onset type, and unspecified-onset type. On the other hand, oppositional defiant disorder has no specified subtypes.

The temperamental risk factors for ODD are high emotional reactivity levels, low frustration tolerance levels, and other emotional regulation dimensions. In the case of CD, the pertinent elements are difficult and uncontrolled infant temperament as well as a below average IQ (particularly verbal intelligence). Thus, those of ODD are more affective-oriented while those of CD are a combination of affective and cognitive.

The DSM 5 states that it must be specified if the CD is characterized by limited prosocial emotions such as lack of remorse or guilt, being callous or lack of empathy, unconcerned regarding performance, and shallow affect. However, the specifiers for OD did not include similar qualifiers.

Conduct Disorder vs Oppositional Defiant Disorder

Summary of Conduct Disorder Vs. Oppositional Defiant Disorder

Oppositional defiant disorder (ODD) and Conduct Disorder (CD) are among the prevalent disruptive behaviors among both children and adolescents.

Regarding their distinctiveness, the main diagnostic criteria for ODD are angry or irritable mood, argumentative or defiant behavior, and vindictiveness while those for CD are aggression to people and animals, destruction of property, deceitfulness or theft, and serious violations of rules.

CD is more characterized by physical violence as compared to ODD.

The symptoms of ODD must last for at least 6 months while that of CD must last for at least 12 months with at least one criterion being met in the past 6 months.

Severity of CD is based on the frequency and extent of misconduct while that of ODD is according to the number of settings where the behavior is manifested.

CD has three subtypes while ODD has none.

CD has affective-oriented risk factors while ODD has both affective and cognitive-oriented risk factors.

Unlike CD, ODD has specifiers on limited prosocial emotions

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Difference Between Conduct Disorder and Oppositional Defiant Disorder

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Difference Between Conduct Disorder and Oppositional Defiant Disorder Oppositional defiant disorder (ODD) and Conduct Disorder (CD) are among the prevalent disruptive behaviors in both children and adolescents. These disorders are under the "Disruptive, Impulse-Control, and Conduct Disorders" in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5).

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What Symptoms Should Parents Look for?

There are four basic types of behavior that characterize conduct disorder:

Physical aggression (such as cruelty toward animals, assault or rape).

Violating others' rights (such as theft or vandalism).

Lying or manipulation.

Delinquent behaviors (such as truancy or running away from home).

Conduct disorder is characterized by aggression toward others and a callous disregard for their rights and needs. Adolescents and teens with conduct disorder can find acts of aggression, deceit and coercion to be gratifying. Your child may meet the criteria for conduct disorder if you find them engaging in several of the below behaviors:

Many young people with conduct disorder will have trouble:

Feeling and expressing empathy or remorse.

Showing emotion toward others.

Performing well in the school or community and blaming others for poor performance.

They often misinterpret the actions of others as being hostile or aggressive. They respond by escalating the situation into verbal or physical conflict.

In adolescents and teens, conduct disorder may be associated with other difficulties, including:

In younger children, it can be more of a challenge to distinguish signs of conduct disorder from more typical "acting out".

At times, these same symptoms can be seen in children without the disorder. The difference is frequency, intensity, and duration, as well as to what extent it impacts their functioning. In children with conduct disorder, these behaviors happen much more frequently.

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There are four basic types of behavior that characterize conduct disorder: Physical aggression (such as cruelty toward animals, assault or rape). Violating others' rights (such as theft or vandalism). Lying or manipulation. Delinquent behaviors (such as truancy or running away from home).

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Attention deficit disorder (ADD) is a term that is sometimes used for one of the presentations of attention-deficit/hyperactivity disorder (ADHD). ADHD is a neurological disorder that causes a range of behavior problems such as difficulties with attending to instruction, focusing on schoolwork, keeping up with assignments, following instructions, completing tasks, and social interaction.

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), this condition is officially known as "attentional deficit/hyperactivity disorder, predominantly inattentive presentation."

Symptoms of ADD (Inattentive Type ADHD)

People with the inattentive type of ADHD struggle to pay attention or stay focused for long periods of time. Some of the symptoms of this type of ADHD include:

Being easily distracted

Difficulty following directions

Difficulty staying on task

Forgetfulness

Losing personal items such as keys or books

Not paying attention to details

Problems staying organized

Short attention span

Children with ADHD without the hyperactivity component may appear to be bored or disinterested in classroom activities. They may be prone to daydreaming or forgetfulness, work at a slow pace, and turn in incomplete work.

Their assignments, desks, and lockers may look disorganized. They may lose materials at school and at home or misplace schoolwork and fail to turn in assignments. This can frustrate teachers and parents and result in the child earning poor marks in class.

Symptoms in Kids vs. Teens vs. Adults

While symptoms of the condition are similar in kids, teens, and adults, they may also change over time. Children may be more likely to be affected by symptoms of hyperactivity. These symptoms may become more noticeable and disruptive when children are in classroom settings.

While symptoms change as people grow older, teens and adults are likely to continue to experience symptoms such as poor attention, difficultly remembering information, and troubles with organization.

Press Play for Advice On Improving Focus

ADD vs. ADHD: What's the Difference?

While many people continue to use the terms ADD and ADHD interchangeably, it's important to recognize that they are not the same. Here are some key points to be aware of:

ADD is an older term for what is now known as the inattentive type of ADHD.

The term ADHD has been used to describe both inattentive and hyperactive types since the mid-1990s.

However, some people continue to use the term ADD as a way to indicate that the condition does not include hyperactivity as a symptom.

The DSM-5 currently recognizes three subtypes of ADHD: inattentive type (sometimes casually called ADD), hyperactive-impulsive type, and combined type.

ADD (inattentive type ADHD) doesn't manifest itself in the same way that predominantly hyperactive-impulsive or combined types do. Children with these presentations have different symptoms.

Children with the other two presentations of ADHD, for example, tend to act out or exhibit behavior problems in class. Children with inattentive type ADHD are generally not disruptive in school. They may even sit in class quietly, but that doesn't mean their disorder isn't a problem and that they're not struggling to focus. In addition, not all children with inattentive type ADHD are alike.

Children with combined type ADHD display several symptoms of both hyperactive-impulsive type and inattentive type.

If you suspect your child has ADHD, talk to your child's school counselor, teacher, or physician about appropriate treatment. If you have any concerns, begin these discussions today. Earlier intervention can ensure that your child experiences fewer disruptions due to their condition.

Your child's pediatrician may recommend seeing a child psychologist who can do formal testing to see if your child fits the criteria for ADHD and, if so, where they fall on the spectrum. Not only can this testing help differentiate ADHD from other issues that may be causing difficulty with schoolwork, but it can be used to follow a child's response to interventions over time.

Primarily Inattentive ADHD (Previously ADD)

When people use the term ADD, they are likely referring to this type of ADHD. Some of the behaviors that someone with this type might experience include forgetfulness, problems with organization, difficulty listening, and lack of focus.

To be diagnosed with this type, a person must display six of the following nine symptoms:

Difficulty sustaining attention

Often seeming to not be listening

Failing to pay attention to details

Difficulty organizing tasks and activities

Frequently losing things

Getting easily distracted

Forgetfulness

Avoiding tasks that required sustained mental effort

Trouble following instructions

Hyperactive-Impulsive ADHD

This presentation of ADHD is characterized by hyperactive and impulsive behavior. To be diagnosed, a person must display six of the following symptoms:

Fidgeting hands and feet or squirming while seated

Running or climbing inappropriately or feelings of restlessness

Difficulty engaging in activities quietly

Seeming to always be on the go

Excessive talking

Blurting out responses

Problems taking turns

An inability to stay seated

Frequently interrupting others

Combined Type ADHD

This presentation of ADHD involves exhibiting symptoms of both the inattentive and hyperactive-impulsive types. To be diagnosed with this type of ADHD, a person must display six or more inattention symptoms and six or more hyperactive-impulsive ADHD symptoms.

Inattentive Type ADHD in Girls

There is no cure for ADHD, but treatment can help children manage their symptoms and improve daily functioning. Treatment for ADHD often involves medications, behavioral interventions, or a combination of the two. The type of treatment chosen depends on the child's symptoms and needs.

Medications

ADHD is often treated with one of three types of medication: psychostimulants, antidepressants, or non-stimulant drugs. These medications can help children with inattentive type ADHD (ADD) stay on task and focused.

Psychostimulants: Psychostimulants affect neurotransmitters in the brain, and may help to boost energy and increase alertness. The extended-release form is often recommended (instead of the immediate-release form). Psychostimulants include amphetamines such as Adderall and methylphenidates such as Ritalin and Concerta.

Antidepressants: Antidepressants also affect neurotransmitters in the brain, and may help to improve mood and attention. Common antidepressants prescribed for the inattentive presentation of ADHD include Wellbutrin (bupropion) and Effexor (venlafaxine).

Non-stimulant drugs: Non-stimulant medications can be helpful for those who experience unwanted side effects from stimulants and include Strattera (atomoxetine), Qelbree (viloxazine), and Intuniv (guanfacine). Non-stimulants affect a specific neurotransmitter, norepinephrine, and may help to regulate emotions and improve focus on specific tasks.

As with any medication, there are common side effects. Psychostimulants, antidepressants, and non-stimulants can cause dizziness, loss of appetite, upset stomach, and more. Be sure to talk to your doctor if you notice that your child is experiencing any unusual symptoms.

Behavior Management

Whether or not parents choose medication as a treatment option, most physicians and child psychologists suggest that a behavior intervention plan should be developed to help teach kids adaptive behavior skills and reduce off-task and inattentive behaviors.

Often, a combination of various methods is used, including:

Behavior therapy: With young children, a therapist will usually meet with you and your child. A session often includes the therapist facilitating a conversation with your child or even providing them with an activity to help them express their feelings. Your doctor or therapist might recommend family therapy so that all members of the family can learn healthy ways of managing your child's condition.

Parent training in behavior management: Recommended for parents of children under 12 years old, a therapist will train the parent to facilitate their child's behavior changes. You will learn strategies such as play therapy and talk therapy to allow your child to freely express their feelings and help them adopt healthy coping mechanisms to deal with tough emotions.

Behavioral interventions at school: Your child may meet the criteria for extra assistance under the Individuals With Disabilities Education Act (IDEA), or Section 504 of the Rehabilitation Act of 1973. Accommodations may include extra time on tests, additional break time, changes to their environment, positive reinforcement, and assignments made specifically for your child.

Behavioral peer interventions: With this approach, a therapist or trained professional will lead a group of children in activities that teach them how to interact constructively with their peers. Skills are taught such as having conversations, coping with teasing, and making friends. Parents and teachers may be trained to reinforce the lessons at home and at school.

Many people find that holistic methods are effective at managing the behavioral symptoms of ADHD in children. Engaging in regular physical exercise has been shown to boost mood, improve attention and executive functioning in adults and children with ADHD.

Studies have shown improved focus and emotional regulation in people with ADHD after they practiced yoga.

Diet may also play a role in managing behaviors of ADHD. There is some research that indicates fried food, added sugars, salt, and artificial ingredients may worsen behavioral problems and attention.

However, more studies are needed to understand how diet affects ADHD. Talk to your child's doctor to make sure they are getting adequate nutrition, regular meals, and a high intake of vegetables-all of which are linked with improved mood in children with ADHD.

A Word From Verywell

If you think that your child may have "ADD," it is important to talk to your child's doctor about inattentive type ADHD. Effective treatments are available that can help kids who struggle with inattention, and early intervention can prevent the disorder from taking a detrimental toll on their life.

Some parents fear the stigma associated with getting their child evaluated for ADHD. It's important to talk to your child so that they know that everyone has different skills and abilities. By getting treatment, you can help your child develop new skills and ways of coping with their symptoms.

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Symptoms of Attention Deficit Disorder Without Hyperactivity

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Attention deficit disorder (ADD) is a term that is sometimes used for one of the presentations of attention-deficit/hyperactivity disorder (ADHD). ADHD is a neurological disorder that causes a range of behavior problems such as difficulties with attending to instruction, focusing on schoolwork, keeping up with assignments, following instructions, completing tasks, and social interaction.

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Though children with bipolar disorder are often gifted, they require patience and new approaches to help them learn and grow. Here are eight teaching strategies to help these students excel in the classroom.

#1 Flexibility works best

It is best to adapt a more flexible lesson plan for children with bipolar disorder. Additional time for assignments and tests may be required and understanding given for missed classes due to appointments with health care professionals.

#2 Consistent schedules

Children who live with bipolar require flexibility with their schedules such as incorporating many breaks throughout the day to aid with focus and staying positive. It's important; however, that this routine stay consistent.

#3 Few distractions

Distractions can cause more disruptive behaviors and can negatively affect the student's ability to focus. Some students will need to be seated near the front of the room to help reduce the distractions.

#4 Practice patience

Understand that the child's grades may drop or he could participate less in class activities. Practice tolerance in dealing with minor problems and, instead of focusing on negative conduct, recognize and praise the positive behavior.

#5 Maintain good communication

There should be open lines between educators, the school and the child's parents/guardians, psychologist or other health care professionals. It is important to practice good communication and be ready to adapt and try different approaches for the child if something is not working.

#6 Have a plan

It's essential that teachers watch for extreme behavioral changes or any signs of suicidal thoughts. These signs should be taken seriously and a plan should be in place about how school staff should respond to such situations. The plan can be decided ahead between the child's parents, psychologist and teachers.

#7 Accommodate special needs

May children with bipolar disorder need to visit the school nurse regularly for medication or talk to a school psychologist. And, especially for children taking lithium, they may need to carry a water bottle and have unlimited access to restrooms.

#8 Agree on a safe place/person

Children suffering from bipolar can feel overwhelmed or anxious or they may be unsure of how to deal with their strong emotions and feel out of control. It's important to establish both a safe place and a safe person they can go to in times of distress. Allow them access to leave the classroom on their own.
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8 Things Every Teacher Should Know About Bipolar Disorder | bpHope.com

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It is best to adapt a more flexible lesson plan for children with bipolar disorder. Additional time for assignments and tests may be required and understanding given for missed classes due to appointments with health care professionals. Children who live with bipolar require flexibility with their schedules such as incorporating many breaks throughout the day to aid with focus and staying positive.

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Anita Everett, M.D. DFAPA, Director of the Center for Mental Health Services (CMHS)

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Living with Bipolar Disorder: How Family and Friends Can Help

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Bipolar Disorder is a condition that includes episodes of disabling depression and periods of uncontrollable energy. It is common for all of us to have some changes in mood; Bipolar Disorder however is a brain disorder that includes extreme depression and periods of mania. Symptoms of the disease ca…

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What Teachers Should Know

It's normal for students to feel sad, angry, or moody at times. But when a sad or bad mood lasts for weeks, months, or even longer - and when it affects a student's ability to do well in school and with peers - it might be depression.

Depression is not uncommon among students. But it can go unrecognized or undiagnosed. Many students with depression don't receive the care they need.

Depression can get better with the right treatment and support. Mental health professionals treat depression with therapy, medication, or both. Effective early treatment can reduce the risk of future episodes of depression.

Teachers can help by knowing the signs of depression, taking steps to guide students toward the help they need, and by being a source of support and encouragement.

Teachers should know the signs that could mean a student is depressed. Students with depression may:

seem sad or irritable more often than not

seem tired, lack energy, give up easily

put little effort into schoolwork

have trouble concentrating in class

fail to turn in work, get lower grades

seem not to enjoy things

withdraw from friends or activities

miss school days, or be frequently late

Some students with depression may:

have experienced trauma or adverse life events

have other mental health issues, such as anxiety

engage in risky or self-harming behaviors (for example, be reckless or turn to alcohol, drugs, or self-injury)

talk about death or suicide

Teachers should know student behaviors that can be warning signs for suicide, including:

talking about suicide or death

hinting that they might not be around anymore

writing songs, poems, or letters about death

giving away treasured possessions

losing interest in school, classmates, sports, or other activities

engaging in risky behaviors

Teachers should be aware of suicide prevention methods, and follow their school's protocol for how to:

notify parents if a student appears suicidal

get help for a student at risk of suicide

supervise an at-risk student

work with the school's crisis team to set up a support system at school and at home

Students with depression may need:

treatment from mental health professionals

emotional support from a school counselor or school psychologist

a 504 plan for accommodations at school

short breaks throughout the day to avoid feeling overwhelmed

extra time or extra help to complete assignments

to take medication

treatment for other mental health issues or healing for trauma they've faced

What Teachers Can Do

Offer support and encouragement. Help students with depression feel welcome and included. Let them know you're available to help. Encourage their strengths and their interests. Look for opportunities for them to succeed in the classroom. Let them know you see their efforts - even the small steps.

Give extra time to complete assignments. Offer extra help. Consider having students work with a supportive peer to work on assignments or to study for tests.

Make physical activities a part of your daily classroom routine. This can help ease mild depression symptoms. It can energize all of your other students, too.

Make brief mindfulness practices a part of everyday instruction. At random or scheduled times, invite your class, "Let's all pause and take a few slow, calm breaths." This helps students learn and practice this simple but effective self-calming skill.

Use trauma-informed education approaches. Create and maintain an environment where every student can feel a sense of safety and inclusion. This helps every student thrive.

Date reviewed: April 2022

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What teachers should know about depression and how to help a student who is depressed.

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Overview

What is depression? A Mayo Clinic expert explains.

Learn more about depression from Craig Sawchuk, Ph.D., L.P., clinical psychologist at Mayo Clinic.

Hi, I'm Dr. Craig Sawchuk, a clinical psychologist at Mayo Clinic. And I'm here to talk with you about depression. Whether you're looking for answers for yourself, a friend, or loved one, understanding the basics of depression can help you take the next step.

What is depression?

Depression is a mood disorder that causes feelings of sadness that won't go away. Unfortunately, there's a lot of stigma around depression. Depression isn't a weakness or a character flaw. It's not about being in a bad mood, and people who experience depression can't just snap out of it. Depression is a common, serious, and treatable condition. If you're experiencing depression, you're not alone. It honestly affects people of all ages and races and biological sexes, income levels and educational backgrounds. Approximately one in six people will experience a major depressive episode at some point in their lifetime, while up to 16 million adults each year suffer from clinical depression. There are many types of symptoms that make up depression. Emotionally, you may feel sad or down or irritable or even apathetic. Physically, the body really slows down. You feel tired. Your sleep is often disrupted. It's really hard to get yourself motivated. Your thinking also changes. It can just be hard to concentrate. Your thoughts tend to be much more negative. You can be really hard on yourself, feel hopeless and helpless about things. And even in some cases, have thoughts of not wanting to live. Behaviorally, you just want to pull back and withdraw from others, activities, and day-to-day responsibilities. These symptoms all work together to keep you trapped in a cycle of depression. Symptoms of depression are different for everyone. Some symptoms may be a sign of another disorder or medical condition. That's why it's important to get an accurate diagnosis.

What causes depression?

While there's no single cause of depression, most experts believe there's a combination of biological, social, and psychological factors that contribute to depression risk. Biologically, we think about genetics or a family history of depression, health conditions such as diabetes, heart disease or thyroid disorders, and even hormonal changes that happen over the lifespan, such as pregnancy and menopause. Changes in brain chemistry, especially disruptions in neurotransmitters like serotonin, that play an important role in regulating many bodily functions, including mood, sleep, and appetite, are thought to play a particularly important role in depression. Socially stressful and traumatic life events, limited access to resources such as food, housing, and health care, and a lack of social support all contribute to depression risk. Psychologically, we think of how negative thoughts and problematic coping behaviors, such as avoidance and substance use, increase our vulnerability to depression.

The good news is that treatment helps. Effective treatments for depression exist and you do have options to see what works best for you. Lifestyle changes that improve sleep habits, exercise, and address underlying health conditions can be an important first step. Medications such as antidepressants can be helpful in alleviating depressive symptoms. Therapy, especially cognitive behavioral therapy, teaches skills to better manage negative thoughts and improve coping behaviors to help break you out of cycles of depression. Whatever the cause, remember that depression is not your fault and it can be treated.

To help diagnose depression, your health care provider may use a physical exam, lab tests, or a mental health evaluation. These results will help identify various treatment options that best fit your situation.

Help is available. You don't have to deal with depression by yourself. Take the next step and reach out. If you're hesitant to talk to a health care provider, talk to a friend or loved one about how to get help. Living with depression isn't easy and you're not alone in your struggles. Always remember that effective treatments and supports are available to help you start feeling better. Want to learn more about depression? Visit mayoclinic.org. Do take care.

Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Also called major depressive disorder or clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems. You may have trouble doing normal day-to-day activities, and sometimes you may feel as if life isn't worth living.

More than just a bout of the blues, depression isn't a weakness and you can't simply "snap out" of it. Depression may require long-term treatment. But don't get discouraged. Most people with depression feel better with medication, psychotherapy or both.
Depression care at Mayo Clinic
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Symptoms

Although depression may occur only once during your life, people typically have multiple episodes. During these episodes, symptoms occur most of the day, nearly every day and may include:

Feelings of sadness, tearfulness, emptiness or hopelessness

Angry outbursts, irritability or frustration, even over small matters

Loss of interest or pleasure in most or all normal activities, such as sex, hobbies or sports

Sleep disturbances, including insomnia or sleeping too much

Tiredness and lack of energy, so even small tasks take extra effort

Reduced appetite and weight loss or increased cravings for food and weight gain

Anxiety, agitation or restlessness

Slowed thinking, speaking or body movements

Feelings of worthlessness or guilt, fixating on past failures or self-blame

Trouble thinking, concentrating, making decisions and remembering things

Frequent or recurrent thoughts of death, suicidal thoughts, suicide attempts or suicide

Unexplained physical problems, such as back pain or headaches

For many people with depression, symptoms usually are severe enough to cause noticeable problems in day-to-day activities, such as work, school, social activities or relationships with others. Some people may feel generally miserable or unhappy without really knowing why.

Depression symptoms in children and teens

Common signs and symptoms of depression in children and teenagers are similar to those of adults, but there can be some differences.

In younger children, symptoms of depression may include sadness, irritability, clinginess, worry, aches and pains, refusing to go to school, or being underweight.

In teens, symptoms may include sadness, irritability, feeling negative and worthless, anger, poor performance or poor attendance at school, feeling misunderstood and extremely sensitive, using recreational drugs or alcohol, eating or sleeping too much, self-harm, loss of interest in normal activities, and avoidance of social interaction.

Depression symptoms in older adults

Depression is not a normal part of growing older, and it should never be taken lightly. Unfortunately, depression often goes undiagnosed and untreated in older adults, and they may feel reluctant to seek help. Symptoms of depression may be different or less obvious in older adults, such as:

Memory difficulties or personality changes

Physical aches or pain

Fatigue, loss of appetite, sleep problems or loss of interest in sex - not caused by a medical condition or medication

Often wanting to stay at home, rather than going out to socialize or doing new things

Suicidal thinking or feelings, especially in older men

When to see a doctor

If you feel depressed, make an appointment to see your doctor or mental health professional as soon as you can. If you're reluctant to seek treatment, talk to a friend or loved one, any health care professional, a faith leader, or someone else you trust.

When to get emergency help

If you think you may hurt yourself or attempt suicide, call 911 in the U.S. or your local emergency number immediately.

Also consider these options if you're having suicidal thoughts:

Call your doctor or mental health professional.

Contact a suicide hotline.

In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline, available 24 hours a day, seven days a week. Or use the Lifeline Chat. Services are free and confidential.

U.S. veterans or service members who are in crisis can call 988 and then press "1" for the Veterans Crisis Line. Or text 838255. Or chat online.

The Suicide & Crisis Lifeline in the U.S. has a Spanish language phone line at 1-888-628-9454 (toll-free).

Reach out to a close friend or loved one.

Contact a minister, spiritual leader or someone else in your faith community.

If you have a loved one who is in danger of suicide or has made a suicide attempt, make sure someone stays with that person. Call 911 or your local emergency number immediately. Or, if you think you can do so safely, take the person to the nearest hospital emergency room.

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Causes

It's not known exactly what causes depression. As with many mental disorders, a variety of factors may be involved, such as:

Biological differences. People with depression appear to have physical changes in their brains. The significance of these changes is still uncertain, but may eventually help pinpoint causes.

Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that likely play a role in depression. Recent research indicates that changes in the function and effect of these neurotransmitters and how they interact with neurocircuits involved in maintaining mood stability may play a significant role in depression and its treatment.

Hormones. Changes in the body's balance of hormones may be involved in causing or triggering depression. Hormone changes can result with pregnancy and during the weeks or months after delivery (postpartum) and from thyroid problems, menopause or a number of other conditions.

Inherited traits. Depression is more common in people whose blood relatives also have this condition. Researchers are trying to find genes that may be involved in causing depression.

Risk factors

Depression often begins in the teens, 20s or 30s, but it can happen at any age. More women than men are diagnosed with depression, but this may be due in part because women are more likely to seek treatment.

Factors that seem to increase the risk of developing or triggering depression include:

Certain personality traits, such as low self-esteem and being too dependent, self-critical or pessimistic

Traumatic or stressful events, such as physical or sexual abuse, the death or loss of a loved one, a difficult relationship, or financial problems

Blood relatives with a history of depression, bipolar disorder, alcoholism or suicide

Being lesbian, gay, bisexual or transgender, or having variations in the development of genital organs that aren't clearly male or female (intersex) in an unsupportive situation

History of other mental health disorders, such as anxiety disorder, eating disorders or post-traumatic stress disorder

Abuse of alcohol or recreational drugs

Serious or chronic illness, including cancer, stroke, chronic pain or heart disease

Certain medications, such as some high blood pressure medications or sleeping pills (talk to your doctor before stopping any medication)

Complications

Depression is a serious disorder that can take a terrible toll on you and your family. Depression often gets worse if it isn't treated, resulting in emotional, behavioral and health problems that affect every area of your life.

Examples of complications associated with depression include:

Excess weight or obesity, which can lead to heart disease and diabetes

Pain or physical illness

Alcohol or drug misuse

Anxiety, panic disorder or social phobia

Family conflicts, relationship difficulties, and work or school problems

Social isolation

Suicidal feelings, suicide attempts or suicide

Self-mutilation, such as cutting

Premature death from medical conditions

Prevention

There's no sure way to prevent depression. However, these strategies may help.

Take steps to control stress, to increase your resilience and boost your self-esteem.

Reach out to family and friends, especially in times of crisis, to help you weather rough spells.

Get treatment at the earliest sign of a problem to help prevent depression from worsening.

Consider getting long-term maintenance treatment to help prevent a relapse of symptoms.

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Depression (major depressive disorder) - Symptoms and causes

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Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning.

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National Institute of Mental Health (NIMH)

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Overview

Bipolar disorder (formerly called manic-depressive illness or manic depression) is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration. These shifts can make it difficult 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 is defined by manic episodes that last for at least 7 days (nearly every day for most of the day) or by manic symptoms that are so severe that the person needs immediate medical 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. Experiencing four or more episodes of mania or depression within 1 year is called "rapid cycling."

Bipolar II disorder is defined by a pattern of depressive episodes and hypomanic episodes. The hypomanic episodes are less severe than the manic episodes in bipolar I disorder.

Cyclothymic disorder (also called cyclothymia) is defined by recurring hypomanic and depressive symptoms that are not intense enough or do not last long enough to qualify as hypomanic or depressive episodes.

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

Bipolar disorder is often diagnosed during late adolescence (teen years) or early adulthood. Sometimes, bipolar symptoms can appear in children. 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

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Learn about bipolar disorder, including signs and symptoms, types, risk factors, how it is diagnosed, and potential treatments and therapies.

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Overview

Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression).

When you become depressed, you may feel sad or hopeless and lose interest or pleasure in most activities. When your mood shifts to mania or hypomania (less extreme than mania), you may feel euphoric, full of energy or unusually irritable. These mood swings can affect sleep, energy, activity, judgment, behavior and the ability to think clearly.

Episodes of mood swings may occur rarely or multiple times a year. While most people will experience some emotional symptoms between episodes, some may not experience any.

Although bipolar disorder is a lifelong condition, you can manage your mood swings and other symptoms by following a treatment plan. In most cases, bipolar disorder is treated with medications and psychological counseling (psychotherapy).
Bipolar disorder care at Mayo Clinic
Symptoms

There are several types of bipolar and related disorders. They may include mania or hypomania and depression. Symptoms can cause unpredictable changes in mood and behavior, resulting in significant distress and difficulty in life.

Bipolar I disorder. You've had at least one manic episode that may be preceded or followed by hypomanic or major depressive episodes. In some cases, mania may trigger a break from reality (psychosis).

Bipolar II disorder. You've had at least one major depressive episode and at least one hypomanic episode, but you've never had a manic episode.

Cyclothymic disorder. You've had at least two years - or one year in children and teenagers - of many periods of hypomania symptoms and periods of depressive symptoms (though less severe than major depression).

Other types. These include, for example, bipolar and related disorders induced by certain drugs or alcohol or due to a medical condition, such as Cushing's disease, multiple sclerosis or stroke.

Bipolar II disorder is not a milder form of bipolar I disorder, but a separate diagnosis. While the manic episodes of bipolar I disorder can be severe and dangerous, individuals with bipolar II disorder can be depressed for longer periods, which can cause significant impairment.

Although bipolar disorder can occur at any age, typically it's diagnosed in the teenage years or early 20s. Symptoms can vary from person to person, and symptoms may vary over time.

Mania and hypomania

Mania and hypomania are two distinct types of episodes, but they have the same symptoms. Mania is more severe than hypomania and causes more noticeable problems at work, school and social activities, as well as relationship difficulties. Mania may also trigger a break from reality (psychosis) and require hospitalization.

Both a manic and a hypomanic episode include three or more of these symptoms:

Abnormally upbeat, jumpy or wired

Increased activity, energy or agitation

Exaggerated sense of well-being and self-confidence (euphoria)

Decreased need for sleep

Unusual talkativeness

Racing thoughts

Distractibility

Poor decision-making - for example, going on buying sprees, taking sexual risks or making foolish investments

Major depressive episode

A major depressive episode includes symptoms that are severe enough to cause noticeable difficulty in day-to-day activities, such as work, school, social activities or relationships. An episode includes five or more of these symptoms:

Depressed mood, such as feeling sad, empty, hopeless or tearful (in children and teens, depressed mood can appear as irritability)

Marked loss of interest or feeling no pleasure in all - or almost all - activities

Significant weight loss when not dieting, weight gain, or decrease or increase in appetite (in children, failure to gain weight as expected can be a sign of depression)

Either insomnia or sleeping too much

Either restlessness or slowed behavior

Fatigue or loss of energy

Feelings of worthlessness or excessive or inappropriate guilt

Decreased ability to think or concentrate, or indecisiveness

Thinking about, planning or attempting suicide

Other features of bipolar disorder

Signs and symptoms of bipolar I and bipolar II disorders may include other features, such as anxious distress, melancholy, psychosis or others. The timing of symptoms may include diagnostic labels such as mixed or rapid cycling. In addition, bipolar symptoms may occur during pregnancy or change with the seasons.

Symptoms in children and teens

Symptoms of bipolar disorder can be difficult to identify in children and teens. It's often hard to tell whether these are normal ups and downs, the results of stress or trauma, or signs of a mental health problem other than bipolar disorder.

Children and teens may have distinct major depressive or manic or hypomanic episodes, but the pattern can vary from that of adults with bipolar disorder. And moods can rapidly shift during episodes. Some children may have periods without mood symptoms between episodes.

The most prominent signs of bipolar disorder in children and teenagers may include severe mood swings that are different from their usual mood swings.

When to see a doctor

Despite the mood extremes, people with bipolar disorder often don't recognize how much their emotional instability disrupts their lives and the lives of their loved ones and don't get the treatment they need.

And if you're like some people with bipolar disorder, you may enjoy the feelings of euphoria and cycles of being more productive. However, this euphoria is always followed by an emotional crash that can leave you depressed, worn out - and perhaps in financial, legal or relationship trouble.

If you have any symptoms of depression or mania, see your doctor or mental health professional. Bipolar disorder doesn't get better on its own. Getting treatment from a mental health professional with experience in bipolar disorder can help you get your symptoms under control.

When to get emergency help

Suicidal thoughts and behavior are common among people with bipolar disorder. If you have thoughts of hurting yourself, call 911 or your local emergency number immediately, go to an emergency room, or confide in a trusted relative or friend. Or contact a suicide hotline. In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline, available 24 hours a day, seven days a week. Or use the Lifeline Chat. Services are free and confidential.

If you have a loved one who is in danger of suicide or has made a suicide attempt, make sure someone stays with that person. Call 911 or your local emergency number immediately. Or, if you think you can do so safely, take the person to the nearest hospital emergency room.

Causes

The exact cause of bipolar disorder is unknown, but several factors may be involved, such as:

Biological differences. People with bipolar disorder appear to have physical changes in their brains. The significance of these changes is still uncertain but may eventually help pinpoint causes.

Genetics. Bipolar disorder is more common in people who have a first-degree relative, such as a sibling or parent, with the condition. Researchers are trying to find genes that may be involved in causing bipolar disorder.

Risk factors

Factors that may increase the risk of developing bipolar disorder or act as a trigger for the first episode include:

Having a first-degree relative, such as a parent or sibling, with bipolar disorder

Periods of high stress, such as the death of a loved one or other traumatic event

Drug or alcohol abuse

Complications

Left untreated, bipolar disorder can result in serious problems that affect every area of your life, such as:

Problems related to drug and alcohol use

Suicide or suicide attempts

Legal or financial problems

Damaged relationships

Poor work or school performance

Co-occurring conditions

If you have bipolar disorder, you may also have another health condition that needs to be treated along with bipolar disorder. Some conditions can worsen bipolar disorder symptoms or make treatment less successful. Examples include:

Anxiety disorders

Eating disorders

Attention-deficit/hyperactivity disorder (ADHD)

Alcohol or drug problems

Physical health problems, such as heart disease, thyroid problems, headaches or obesity

Prevention

There's no sure way to prevent bipolar disorder. However, getting treatment at the earliest sign of a mental health disorder can help prevent bipolar disorder or other mental health conditions from worsening.

If you've been diagnosed with bipolar disorder, some strategies can help prevent minor symptoms from becoming full-blown episodes of mania or depression:

Pay attention to warning signs. Addressing symptoms early on can prevent episodes from getting worse. You may have identified a pattern to your bipolar episodes and what triggers them. Call your doctor if you feel you're falling into an episode of depression or mania. Involve family members or friends in watching for warning signs.

Avoid drugs and alcohol. Using alcohol or recreational drugs can worsen your symptoms and make them more likely to come back.

Take your medications exactly as directed. You may be tempted to stop treatment - but don't. Stopping your medication or reducing your dose on your own may cause withdrawal effects or your symptoms may worsen or return.

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Bipolar disorder causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression).

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Although the term "eating" is in the name, eating disorders are about more than food. They're complex mental health conditions that often require the intervention of medical and psychological experts to alter their course.

These disorders are described in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) ( 1).

In the United States alone, an estimated 28 million Americans have or have had an eating disorder at some point in their life ( 2).

This article describes six of the most common types of eating disorders and their symptoms.

Eating disorders are a range of psychological conditions that cause unhealthy eating habits to develop. They might start with an obsession with food, body weight, or body shape ( 3).

In severe cases, eating disorders can cause serious health consequences and may even result in death if left untreated. In fact, eating disorders are among the deadliest mental illnesses, second to opioid overdose ( 4).

People with eating disorders can have a variety of symptoms. Common symptoms include severe restriction of food, food binges, and purging behaviors like vomiting or overexercising.

Although eating disorders can affect people of any gender at any life stage, they're increasingly common in men and gender nonconforming people. These populations often seek treatment at lower rates or may not report their eating disorder symptoms at all ( 5, 6).

Different types of eating disorders have different symptoms, but each condition involves an extreme focus on issues related to food and eating, and some involve an extreme focus on weight.

This preoccupation with food and weight may make it hard to focus on other aspects of life ( 3).

Mental and behavioral signs may include ( 7):

dramatic weight loss

concern about eating in public

preoccupation with weight, food, calories, fat grams, or dieting

complaints of constipation, cold intolerance, abdominal pain, lethargy, or excess energy

excuses to avoid mealtime

intense fear of weight gain or being "fat"

dressing in layers to hide weight loss or stay warm

severely limiting and restricting the amount and types of food consumed

refusing to eat certain foods

denying feeling hungry

expressing a need to "burn off" calories

repeatedly weighing oneself

patterns of binge eating and purging

developing rituals around food

excessively exercising

cooking meals for others without eating

missing menstrual periods (in people who would typically menstruate)

Physical signs may include ( 7):

Experts believe that a variety of factors may contribute to eating disorders.

One of these is genetics. People who have a sibling or parent with an eating disorder seem to be at an increased risk of developing one ( 3).

Personality traits are another factor. In particular, neuroticism, perfectionism, and impulsivity are three personality traits often linked to a higher risk of developing an eating disorder, according to a 2015 research review ().

Other potential causes include perceived pressures to be thin, cultural preferences for thinness, and exposure to media promoting these ideals ().

More recently, experts have proposed that differences in brain structure and biology may also play a role in the development of eating disorders. In particular, levels of the brain messaging chemicals serotonin and dopamine may be factors ( 9).

However, more studies are needed before strong conclusions can be made.

Eating disorders are a group of related conditions involving extreme food and weight issues, but each disorder has unique symptoms and diagnosis criteria. Here are six of the most common eating disorders and their symptoms.

Anorexia nervosa is likely the most well-known eating disorder.

It generally develops during adolescence or young adulthood and tends to affect more women than men ().

People with anorexia generally view themselves as overweight, even if they're dangerously underweight. They tend to constantly monitor their weight, avoid eating certain types of foods, and severely restrict their calorie intake.

Common symptoms of anorexia nervosa include ( 1):

very restricted eating patterns

intense fear of gaining weight or persistent behaviors to avoid gaining weight, despite being underweight

a relentless pursuit of thinness and unwillingness to maintain a healthy weight

a heavy influence of body weight or perceived body shape on self-esteem

a distorted body image, including denial of being seriously underweight

However, it's important to note that weight should not be the major focus of diagnosing someone with anorexia.

Using body mass index as a factor in diagnosis is outdated because people who are categorized as "normal" or "overweight" can have the same risks.

In atypical anorexia, for example, a person may meet the criteria for anorexia but not be underweight despite significant weight loss ( 7).

Obsessive-compulsive symptoms are also often present. For instance, many people with anorexia are preoccupied with constant thoughts about food, and some may obsessively collect recipes or hoard food.

They may also have difficulty eating in public and exhibit a strong desire to control their environment, limiting their ability to be spontaneous ( 3).

Anorexia is officially categorized into two subtypes - the restricting type and the binge eating and purging type ( 1).

Individuals with the restricting type lose weight solely through dieting, fasting, or excessive exercise.

Individuals with the binge eating and purging type may binge on large amounts of food or eat very little. In both cases, after they eat, they purge using activities such as vomiting, taking laxatives or diuretics, or exercising excessively.

Anorexia can be very damaging to the body. Over time, individuals living with it may experience thinning of their bones, infertility, and brittle hair and nails.

In severe cases, anorexia can result in heart, brain, or multi-organ failure and death.

Bulimia nervosa is another well-known eating disorder.

Like anorexia, bulimia tends to develop during adolescence and early adulthood and appears to be less common among men than women ().

People with bulimia frequently eat unusually large amounts of food in a specific period of time.

Each binge eating episode usually continues until the person becomes painfully full. During a binge, the person usually feels that they cannot stop eating or control how much they are eating.

Binges can happen with any type of food but most commonly occur with foods the individual would usually avoid.

Individuals with bulimia then attempt to purge to compensate for the calories consumed and to relieve gut discomfort.

Common purging behaviors include forced vomiting, fasting, laxatives, diuretics, enemas, and excessive exercise.

Symptoms may appear very similar to those of the binge eating or purging subtypes of anorexia nervosa. However, individuals with bulimia usually maintain a relatively typical weight rather than losing a large amount of weight.

Common symptoms of bulimia nervosa include ( 1):

recurrent episodes of binge eating with a feeling of lack of control

recurrent episodes of inappropriate purging behaviors to prevent weight gain

self-esteem overly influenced by body shape and weight

a fear of gaining weight, despite having a typical weight

Side effects of bulimia may include an inflamed and sore throat, swollen salivary glands, worn tooth enamel, tooth decay, acid reflux, irritation of the gut, severe dehydration, and hormonal disturbances ().

In severe cases, bulimia can also create an imbalance in levels of electrolytes, such as sodium, potassium, and calcium. This can cause a stroke or heart attack.

Binge eating disorder is the most prevalent form of eating disorder and one of the most common chronic illnesses among adolescents ().

It typically begins during adolescence and early adulthood, although it can develop later on.

Individuals with this disorder have symptoms similar to those of bulimia or the binge eating subtype of anorexia.

For instance, they typically eat unusually large amounts of food in relatively short periods of time and feel a lack of control during binges.

People with binge eating disorder do not restrict calories or use purging behaviors, such as vomiting or excessive exercise, to compensate for their binges ().

Common symptoms of binge eating disorder include ():

eating large amounts of food rapidly, in secret, and until uncomfortably full, despite not feeling hungry

feeling a lack of control during episodes of binge eating

feelings of distress, such as shame, disgust, or guilt, when thinking about the binge eating behavior

no use of purging behaviors, such as calorie restriction, vomiting, excessive exercise, or laxative or diuretic use, to compensate for the binge eating

People with binge eating disorder often consume an excessive amount of food and may not make nutritious food choices. This may increase their risk of medical complications such as heart disease, stroke, and type 2 diabetes ().

Pica is an eating disorder that involves eating things that are not considered food and that do not provide nutritional value ( 14).

Individuals with pica crave non-food substances such as ice, dirt, soil, chalk, soap, paper, hair, cloth, wool, pebbles, laundry detergent, or cornstarch ().

Pica can occur in adults, children, and adolescents.

It is most frequently seen in individuals with conditions that affect daily functioning, including intellectual disabilities, developmental conditions such as autism spectrum disorder, and mental health conditions such as schizophrenia ( 14).

Individuals with pica may be at an increased risk of poisoning, infections, gut injuries, and nutritional deficiencies. Depending on the substances ingested, pica may be fatal.

However, for the condition to be considered pica, the eating of non-food substances must not be a typical part of someone's culture or religion. In addition, it must not be considered a socially acceptable practice by a person's peers.

Rumination disorder is another newly recognized eating disorder.

It describes a condition in which a person regurgitates food they have previously chewed and swallowed, re-chews it, and then either re-swallows it or spits it out ( 15).

This rumination typically occurs within the first 30 minutes after a meal ( 16).

This disorder can develop during infancy, childhood, or adulthood. In infants, it tends to develop between 3 and 12 months of age and often disappears on its own. Children and adults with the condition usually require therapy to resolve it.

If not resolved in infants, rumination disorder can result in weight loss and severe malnutrition that can be fatal.

Adults with this disorder may restrict the amount of food they eat, especially in public. This may lead them to lose weight and become underweight ( 16).

Avoidant/restrictive food intake disorder (ARFID) is a new name for an old disorder.

The term has replaced the term "feeding disorder of infancy and early childhood," a diagnosis previously reserved for children under age 7 ( 17).

Individuals with this disorder experience disturbed eating due to either a lack of interest in eating or a distaste for certain smells, tastes, colors, textures, or temperatures.

Common symptoms of ARFID include ():

avoidance or restriction of food intake that prevents the person from eating enough calories or nutrients

eating habits that interfere with typical social functions, such as eating with others

weight loss or poor development for age and height

nutrient deficiencies or dependence on supplements or tube feeding

It's important to note that ARFID goes beyond common behaviors such as picky eating in toddlers or lower food intake in older adults.

Moreover, it does not include the avoidance or restriction of foods due to lack of availability or religious or cultural practices.

In addition to the six eating disorders above, other less known or less common eating disorders also exist.

These include ( 18):

Purging disorder. Individuals with purging disorder often use purging behaviors, such as vomiting, laxatives, diuretics, or excessive exercising, to control their weight or shape. However, they do not binge.

Night eating syndrome. Individuals with this syndrome frequently eat excessively at night, often after awakening from sleep.

Other specified feeding or eating disorder (OSFED). While it is not found in the DSM-5, this category includes any other conditions that have symptoms similar to those of an eating disorder but don't fit any of the disorders above.

One disorder that may currently fall under OSFED is orthorexia. Although orthorexia is increasingly mentioned in the media and in scientific studies, the DSM does not yet recognize it as a separate eating disorder ( 19).

Individuals with orthorexia tend to have an obsessive focus on healthy eating to an extent that disrupts their daily lives. They may compulsively check ingredient lists and nutritional labels and obsessively follow "healthy lifestyle" accounts on social media.

Someone with this condition may eliminate entire food groups, fearing that they're unhealthy. This can lead to malnutrition, severe weight loss, difficulty eating outside the home, and emotional distress.

Individuals with orthorexia are rarely focused on losing weight. Instead, their self-worth, identity, or satisfaction is dependent on how well they comply with their self-imposed diet rules ( 19).

If you have an eating disorder, identifying the condition and seeking treatment sooner will improve your chances of recovering. Being aware of the warning signs and symptoms can help you decide whether you need to seek help.

Not everyone will have every sign or symptom at once, but certain behaviors may signal a problem, such as ( 20):

behaviors and attitudes that indicate that weight loss, dieting, and control over food are becoming primary concerns

preoccupation with weight, food, calories, fats, grams, and dieting

refusal to eat certain foods

discomfort with eating around others

food rituals (not allowing foods to touch, eating only particular food groups)

skipping meals or eating only small portions

frequent dieting or fad diets

extreme concern with body size, shape, and appearance

frequently checking in the mirror for perceived flaws in appearance

extreme mood swings

If these symptoms resonate with you and you think you may have an eating disorder, it's important to reach out to a medical professional for help.

Making the decision to start eating disorder recovery might feel scary or overwhelming, but seeking help from medical professionals, eating disorder recovery support groups, and your community can make recovery easier.

If you're not sure where to start, you can contact the National Eating Disorders Association helpline for support, resources, and treatment options for yourself or someone you know.

To contact, call: (800) 931-2237

Monday-Thursday 11 a.m.-9 p.m. ET

Friday 11 a.m.-5 p.m. ET

Text: (800) 931-2237

Monday-Thursday 3 p.m.-6 p.m. ET

Friday 1 p.m.-5 p.m. ET

Eating disorder treatment plans are specifically tailored to each person and may include a combination of multiple therapies.

Treatment will usually involve talk therapy, as well as regular health checks with a physician ( 21).

It's important to seek treatment early for eating disorders, as the risk of medical complications and suicide is high ().

Treatment options include:

Individual, group, or family psychotherapy. A type of psychotherapy called cognitive behavioral therapy (CBT) may be recommended to help reduce or eliminate disordered behavior such as binge eating, purging, and restricting. CBT involves learning how to recognize and change distorted or unhelpful thought patterns ().

Medications. A doctor may recommend treatment with medications such as antidepressants, antipsychotics, or mood stabilizers to help treat an eating disorder or other conditions that may occur at the same time, such as depression or anxiety ().

Nutritional counseling. This involves working with a dietitian to learn proper nutrition and eating habits and may also involve restoring or managing a person's weight if they have experienced significant weight changes. Studies suggest that combining nutritional therapy with cognitive therapy may significantly improve treatment outcomes (22).

If you think someone in your life has an eating disorder, your best bet is to support and encourage them to seek help from a healthcare professional.

This can be extremely difficult for someone living with an eating disorder, but supporting them in other ways will help them feel cared for and encouraged in their recovery.

Recovering from an eating disorder can take a long time, and this person may have periods of relapsing into old behaviors, especially during times of stress. If you're close to this person, it's important to be there for them, and be patient, throughout their recovery ( 21).

Ways to support someone with an eating disorder include ( 21):

Listening to them. Taking time to listen to their thoughts can help them feel heard, respected, and supported. Even if you don't agree with what they say, it's important that they know you're there for them and that they have someone to confide in.

Including them in activities. You can reach out and invite them to activities and social events or ask if they want to hang out one-on-one. Even if they do not want to be social, it's important to check in and invite them to help them feel valued and less alone.

Trying to build their self-esteem. Make sure they know that they are valued and appreciated, especially for nonphysical reasons. Remind them why you are their friend and why they are valued.

The categories above are meant to provide a better understanding of the most common eating disorders and dispel myths about them.

Eating disorders are mental health conditions that usually require treatment. They can also be damaging to the body if left untreated.

If you have an eating disorder or know someone who might have one, you can seek help from a healthcare professional who specializes in eating disorders.

You can book an appointment with an eating disorder specialist in your area using our Healthline FindCare tool.
Read this article in Spanish.

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Learn about 6 common types of eating disorders and their symptoms

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Eating disorders are characterized by unusual or disturbed eating habits. Learn more here.

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If your child has been diagnosed with an eating disorder, here's what you can do to help.

Talk to them about it

If your child becomes withdrawn, touchy or moody, it might make it difficult to talk to them. It may be even more difficult if they cannot accept they have a problem.

But talking about their condition is needed for their recovery, so keep trying.

They might come across as angry, even if they're really feeling scared or insecure.

It might be difficult for them to talk about their feelings, so be patient and listen to what they're trying to say.

It can help if you:

stay calm and prepare what you're going to say to them - do not blame or judge them, just focus on how they're feeling

avoid talking about their appearance, even if you're trying to say something nice

try to use sentences starting with "I", like, "I'm worried because you do not seem happy", rather than sentences beginning with "you"

avoid discussing people's diets or weight problems

try not to feel hurt if they do not open up straight away

do not be upset if they are being secretive, because this is part of their illness, not their relationship with you

Get advice on how to talk to your teenager

Try these mealtime tips

Mealtimes can be particularly difficult. You may find the following advice helpful:

if your child is in treatment, ask their treatment team for advice on how to cope with mealtimes

try to make meal plans with your child that you both agree to

agree with the family that none of you will talk about portion sizes, calories or anything else about the meal

avoid eating low-calorie or diet foods in front of them or having them in the house

try to keep things lighthearted and positive throughout the meal, even if you do not feel that way on the inside

if your child tries to get too involved in cooking the meal as a way of controlling it, gently ask them to set the table or wash up instead

try not to focus too much on them during mealtimes - enjoy your own meal and try to make conversation

a family activity after the meal, such as a game or watching TV, can help distract them from wanting to purge or overexercise

do not worry if a meal goes badly, and just move on

Support for your child

If your child is being treated for an eating disorder, their treatment team will play a big part in their recovery.

But do not underestimate the importance of your love and support.

It may help to:

learn as much as possible about eating disorders, so you understand what you're dealing with

keep telling them that you love them and will always be there for them

make them aware of the professional help available

suggest activities they could do that do not involve food, such as hobbies and spending time with friends

ask them what you can do to help

try to be honest about your own feelings, as this will encourage them to do the same

be a good role model by eating a balanced diet and doing a healthy amount of exercise

try to build their confidence, for example, praise them for being thoughtful or congratulate them on something they've done

Get support for yourself

Ask a GP or a health professional in your child's treatment team for advice on how to help at home.

It's important the whole family understands the situation and has support.

The following organisations offer advice online:

You can also ask your GP about support groups for parents caring for someone with an eating disorder.
Find services for people with eating disorders

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Find out what you can do to help if your child has been diagnosed with an eating disorder.

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Eating Recovery Center is accredited through the Joint Commission. This organization seeks to enhance the lives of the persons served in healthcare settings through a consultative accreditation process emphasizing quality, value and optimal outcomes of services.

Organizations that earn the Gold Seal of Approval™ have met or exceeded The Joint Commission's rigorous performance standards to obtain this distinctive and internationally recognized accreditation. Learn more about this accreditation here.

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Eating Disorder Treatment Centers | Anorexia, Bulimia & Binge Eating

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Eating Recovery Center is accredited through the Joint Commission. This organization seeks to enhance the lives of the persons served in healthcare settings through a consultative accreditation process emphasizing quality, value and optimal outcomes of services. Organizations that earn the Gold Seal of Approval™ have met or exceeded The Joint Commission's rigorous performance standards to obtain this distinctive and internationally recognized accreditation.

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National Institute of Mental Health (NIMH)

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Overview

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

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

Signs and Symptoms

Risk Factors

Treatments and Therapies

Join a Study

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

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What Teachers Should Know

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

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

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

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

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

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

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

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

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

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

Students with an anxiety disorder may:

have trouble concentrating in class or completing classwork

feel self-conscious and avoid certain situations

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

take medication to help reduce anxiety

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

What Teachers Can Do

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

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

allowing students extra time to do work

checking that their assignments are written down correctly

giving them daily schedules

modifying assignments and reducing workloads when necessary

promoting relaxation techniques and allowing for breaks throughout day

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

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

easing anxiety in the classroom by pairing with a peer

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Anxiety Disorders Factsheet (for Schools)

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

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If you deal with anxiety, there are strategies you can use to help manage immediate symptoms, as well as long-term methods to combat recurring issues.

Anxiety is the body's response to real or perceived danger. It's a natural process that every person deals with at one time or another.

People often use anxiety as a blanket term for a general feeling of worry, nervousness, or unease. However, there's a difference between feeling anxious and having an anxiety disorder, the latter of which includes many different conditions.

If your anxiety is sporadic and getting in the way of your focus or tasks, some quick natural remedies could help you take control of the situation.

Suppose your anxiety is focused on a situation, such as worrying about an upcoming event. In that case, you may notice the symptoms are short-lived and usually subside after the anticipated event takes place.

1. Question your thought pattern

Unhelpful thoughts can take root in your mind and distort the severity of the situation. One way is to challenge your fears, ask if they're true, and see where you can regain control.

2. Practice focused, deep breathing

Measured breathing practices may help you manage immediate feelings of anxiety. Try breathing in for 4 counts and breathing out for 4 counts for 5 minutes total. By evening out your breath, you'll slow your heart rate, which should help calm you down.

The 4-7-8 technique is another popular breathing pattern for anxiety management.

Discover eight breathing techniques for anxiety management here.

3. Use aromatherapy

Limited research suggests that aromatherapy can help reduce feelings of anxiety in some settings. Aromatherapy practitioners and supporters often report many anecdotal benefits of the practice.

Whether they're in essential oil form, incense, or a candle, natural scents like lavender, chamomile, and sandalwood can be very soothing.

Learn more about aromatherapy here.

4. Exercise

Sometimes, the best way to stop anxious thoughts is to leave a situation and get moving. Focusing on your body and not your mind may help relieve your anxiety. Low impact exercises like walking, yoga, and tai-chi can often help people to reduce stress and manage anxiety symptoms.

Getting some quick exercise can help boost your mood and calm your mind.

Learn more about the benefits of exercise for your mental health here.

5. Grounding techniques

Grounding techniques such as journaling and the 333 rule can often help to calm immediate feelings of anxiety.

The 333 rule involves naming three things you can see, three sounds you can hear, and interacting with three things you can touch.

Writing down what's making you anxious gets it out of your head and can make it less daunting. Reading your thoughts and feelings can help you take stock of your emotions in the immediate moment.

This can also help you better understand the situations and events that cause anxiety.

If anxiety is a regular part of your life, it's important to find treatment strategies to help you keep it in check.

If you're unsure where to start, discussing options with a mental health professional who might suggest something you hadn't thought of before is always helpful.

1. Identify and learn to manage your triggers

You can identify triggers on your own or with a therapist. Sometimes they can be obvious, and other times, less so.

Common anxiety triggers include:

work, relationship, and other life stresses

withdrawal from drugs or certain medications

side effects of certain medications

exacerbation of past trauma

chronic pain

Everyone has different triggers, and identifying them is one of the most important steps to coping with and managing anxiety attacks.

Learn more about the different triggers for anxiety here.

2. Try therapy

Different psychotherapies can help you better understand your anxious feelings and develop coping strategies.

For example, cognitive behavioral therapy (CBT) helps people learn different ways of thinking about and reacting to anxiety-causing situations. Research shows that CBT can be an effective method of treating anxiety disorders.

Learn more about CBT for anxiety here.

3. Ask your doctor about medications

If your anxiety is severe enough that your mental health professional believes you'd benefit from medication, there are several directions, depending on your symptoms. Discuss your concerns with your doctor.

The most common anxiety medications are:

Learn more about anxiety medications here.

4. Do a daily or routine meditation

While this takes some practice to do successfully, mindful meditation, when done regularly, may eventually help train your brain to manage anxious thoughts when they arise.

If sitting still and concentrating is difficult, try starting with yoga or walking meditation. Many free guided meditation apps can help you get started.

Learn more about the different types of meditation here.

5. Keep a journal

It can be helpful to create a habit of writing down your thoughts and emotions in a journal daily. The process of writing down thoughts itself can be calming for some.

Journalling can also have long-term benefits. show that regular emotion-led journalling can help reduce anxiety, depression, and feelings of distress.

Discover six benefits of journaling.

6. Socialize

Although everyone is different, and some people experience social anxiety, spending time with friends and family regularly may help you manage your anxiety.

Socialization can help relieve stress, encourage feelings of laughter and togetherness, and decrease loneliness. has shown that social connectedness can help you become more resilient to stress in the long run.

Discover our 12 tips for socializing here.

7. Staying active

Exercising regularly, getting enough sleep, and staying connected to people who care about you are great ways to stave off anxiety symptoms.

Studies show that exercise, in particular, can have a positive impact on managing anxiety.

Discover 10 natural lifestyle remedies for anxiety.

8. Diet and supplements

Changing your diet or taking supplements is a long-term strategy. Research shows certain supplements and foods can play a positive role as part of broader anxiety treatment.

These include:

If you're taking other medications, make sure to discuss herbal remedies with your doctor, as there can be adverse reactions.

Discover more about foods that may help reduce anxiety here.

When anxious, people feel a general unease or worry over an actual or perceived danger. The extent of these feelings can range from mild to severe. This unease can cause additional physical symptoms. However, these will vary between people and events.

Common physical symptoms of anxious feelings include:

Anxiety attacks

There are times anxiety can get severe and become an anxiety attack. An attack may initially feel manageable and gradually build up over a few hours.

Anxiety attacks may cause:

Anxiety attacks share some symptoms with panic attacks, but they are distinct occurrences.

Learn about the differences between anxiety and panic attacks here.

Anxiety may always be a part of your life, but it shouldn't overtake your day-to-day. There are many things you can do to manage immediate and long-term anxious feelings.

While home remedies may help, a mental health professional can help streamline the process of identifying your triggers and maintaining long-term strategies through behavioral therapy, medications, and more.

Read this article in Spanish.

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How to Cope with Anxiety: 13 Simple Tips

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Identifying your triggers can take some time and self-reflection. In the meantime, here are 13 strategies you can try to help calm or quiet your anxiety from taking over.

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Program for students

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At Mind Above Matter, we offer a range of comprehensive mental health services to proactively address the challenges our communities face.

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

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

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

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

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

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

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

* The child's parent or caregiver

* General and special education teachers

* The school principal

* The child's parent or caregiver

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

* At least one special education teacher

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

* A district representative with authority over special education services

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

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

* Specific accommodations, supports, or services for the child

* Names of who will provide each service

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

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

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

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

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

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

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

* How the child will participate in standardized tests

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

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

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

How to resolve disputes

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

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

* Mediation

* Alternative dispute resolution

* Impartial hearing

* Complaint to the Office for Civil Rights (OCR)

* Lawsuit

* Mediation

* Due process complaint

* Resolution session

* Civil lawsuit

* State complaint

* Lawsuit

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

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

About the author

About the author

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

Reviewed by

Reviewed by

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

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The difference between IEPs and 504 plans

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

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EDUCATION CODE



TITLE 2. PUBLIC EDUCATION



SUBTITLE F. CURRICULUM, PROGRAMS, AND SERVICES



CHAPTER 33. SERVICE PROGRAMS AND EXTRACURRICULAR ACTIVITIES



SUBCHAPTER A. SCHOOL COUNSELORS AND COUNSELING PROGRAMS



Sec. 33.002. CERTIFIED SCHOOL COUNSELOR. (a) From funds appropriated for the purpose or other funds that may be used for the purpose, the commissioner shall distribute funds for programs under this subchapter. In distributing those funds, the commissioner shall give preference to a school district that received funds under this subsection for the preceding school year and then to the districts that have the highest concentration of students at risk of dropping out of school, as described by Section 29.081. To receive funds for the program, a school district must apply to the commissioner. For each school year that a school district receives funds under this subsection, the district shall allocate an amount of local funds for school guidance and counseling programs that is equal to or greater than the amount of local funds that the school district allocated for that purpose during the preceding school year. This section applies only to a school district that receives funds as provided by this subsection.


(b) A school district with 500 or more students enrolled in elementary school grades shall employ a school counselor certified under the rules of the State Board for Educator Certification for each elementary school in the district. A school district shall employ at least one school counselor for every 500 elementary school students in the district.


(c) A school district with fewer than 500 students enrolled in elementary school grades shall provide guidance and counseling services to elementary school students by:


(1) employing a part-time school counselor certified under the rules of the State Board for Educator Certification;


(2) employing a part-time teacher certified as a school counselor under the rules of the State Board for Educator Certification; or


(3) entering into a shared services arrangement agreement with one or more school districts to share a school counselor certified under the rules of the State Board for Educator Certification.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995. Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 6.005(a), eff. Sept. 1, 2003.


Amended by:


Acts 2009, 81st Leg., R.S., Ch. 1328 (H.B. 3646), Sec. 39, eff. September 1, 2009.


Acts 2013, 83rd Leg., R.S., Ch. 443 (S.B. 715), Sec. 27, eff. June 14, 2013.


Acts 2013, 83rd Leg., R.S., Ch. 443 (S.B. 715), Sec. 28, eff. June 14, 2013.


Sec. 33.003. PARENTAL CONSENT. The board of trustees of each school district shall adopt guidelines to ensure that written consent is obtained from the parent, legal guardian, or person entitled to enroll the student under Section 25.001(j) for the student to participate in those activities for which the district requires parental consent.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995.


Sec. 33.004. PARENTAL INVOLVEMENT. (a) Each school shall obtain, and keep as part of the student's permanent record, written consent of the parent or legal guardian as required under Section 33.003. The consent form shall include specific information on the content of the program and the types of activities in which the student will be involved.


(b) Each school, before implementing a comprehensive school counseling program under Section 33.005, shall annually conduct a preview of the program for parents and guardians. All materials, including curriculum to be used during the year, must be available for a parent or guardian to preview during school hours. Materials or curriculum not included in the materials available on the campus for preview may not be used.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995.


Amended by:


Acts 2019, 86th Leg., R.S., Ch. 352 (H.B. 18), Sec. 1.10, eff. December 1, 2019.


Sec. 33.005. COMPREHENSIVE SCHOOL COUNSELING PROGRAMS. (a) A school counselor shall work with the school faculty and staff, students, parents, and the community to plan, implement, and evaluate a comprehensive school counseling program that conforms to the most recent edition of the Texas Model for Comprehensive School Counseling Programs developed by the Texas Counseling Association.


(b) The school counselor shall design the program to include:


(1) a guidance curriculum to help students develop their full educational potential, including the student's interests and career objectives;


(2) a responsive services component to intervene on behalf of any student whose immediate personal concerns or problems put the student's continued educational, career, personal, or social development at risk;


(3) an individual planning system to guide a student as the student plans, monitors, and manages the student's own educational, career, personal, and social development; and


(4) system support to support the efforts of teachers, staff, parents, and other members of the community in promoting the educational, career, personal, and social development of students.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995. Amended by Acts 2001, 77th Leg., ch. 1487, Sec. 2, eff. June 17, 2001.


Amended by:


Acts 2013, 83rd Leg., R.S., Ch. 443 (S.B. 715), Sec. 29, eff. June 14, 2013.


Acts 2019, 86th Leg., R.S., Ch. 352 (H.B. 18), Sec. 1.11, eff. December 1, 2019.


Sec. 33.006. SCHOOL COUNSELORS; GENERAL DUTIES. (a) The primary responsibility of a school counselor is to counsel students to fully develop each student's academic, career, personal, and social abilities.


(b) In addition to a school counselor's responsibility under Subsection (a), the school counselor shall:


(1) participate in planning, implementing, and evaluating a comprehensive developmental guidance program to serve all students and to address the special needs of students:


(A) who are at risk of dropping out of school, becoming substance abusers, participating in gang activity, or committing suicide;


(B) who are in need of modified instructional strategies; or


(C) who are gifted and talented, with emphasis on identifying and serving gifted and talented students who are educationally disadvantaged;


(2) consult with a student's parent or guardian and make referrals as appropriate in consultation with the student's parent or guardian;


(3) consult with school staff, parents, and other community members to help them increase the effectiveness of student education and promote student success;


(4) coordinate people and resources in the school, home, and community;


(5) with the assistance of school staff, interpret standardized test results and other assessment data that help a student make educational and career plans;


(6) deliver classroom guidance activities or serve as a consultant to teachers conducting lessons based on the school's guidance curriculum; and


(7) serve as an impartial, nonreporting resource for interpersonal conflicts and discord involving two or more students, including accusations of bullying under Section 37.0832.


(c) Nothing in Subsection (b)(7) exempts a school counselor from any mandatory reporting requirements imposed by other provisions of law.


(d) Except as provided by Subsection (e), the board of trustees of each school district shall adopt a policy that requires a school counselor to spend at least 80 percent of the school counselor's total work time on duties that are components of a counseling program developed under Section 33.005. For purposes of this subsection, time spent in administering assessment instruments or providing other assistance in connection with assessment instruments, except time spent in interpreting data from assessment instruments, is not considered time spent on counseling. Each school in the district shall implement the policy. A copy of the policy shall be maintained in the office of each school in the district and made available on request during regular school hours to district employees, parents of district students, and the public.


(e) If the board of trustees of a school district determines that, because of staffing needs in the district or at a school in the district, a school counselor must spend less than 80 percent of the school counselor's total work time on duties that are components of a counseling program developed under Section 33.005, the policy adopted under Subsection (d) shall:


(1) include the reasons why the counselor needs to spend less than 80 percent of the counselor's work time on duties that are components of the counseling program;


(2) list the duties the counselor is expected to perform that are not components of the counseling program; and


(3) set the percentage of work time that the counselor is required to spend on components of the counseling program.


(f) A school district may not include a provision in an employment contract with a school counselor under Chapter 21 that conflicts with the policy required by Subsection (d) or, except as provided by Subsection (g), has the effect of authorizing a school principal or school district superintendent to require a school counselor to generally perform duties that are not primarily related to a counseling function.


(g) A school district to which Subsection (e) applies may not include a provision in an employment contract under Chapter 21 with an affected school counselor that has the effect of requiring the counselor to generally perform a duty that is not primarily related to a counseling function unless the duty is specified in the district's policy under Subsection (e)(2).


(h) Each school district shall annually assess the district's compliance with the policy adopted under Subsection (d) and, on request by the commissioner, provide a written copy of the assessment to the agency on or before the date specified by the commissioner. The commissioner shall adopt rules to implement this subsection.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995. Amended by Acts 2001, 77th Leg., ch. 1487, Sec. 3, eff. June 17, 2001.


Amended by:


Acts 2013, 83rd Leg., R.S., Ch. 443 (S.B. 715), Sec. 30, eff. June 14, 2013.


Acts 2013, 83rd Leg., R.S., Ch. 443 (S.B. 715), Sec. 31, eff. June 14, 2013.


Acts 2017, 85th Leg., R.S., Ch. 522 (S.B. 179), Sec. 10, eff. September 1, 2017.


Acts 2021, 87th Leg., R.S., Ch. 938 (S.B. 179), Sec. 1, eff. September 1, 2021.


Sec. 33.007. COUNSELING REGARDING POSTSECONDARY EDUCATION. (a) Each school counselor at an elementary, middle, or junior high school, including an open-enrollment charter school offering those grades, shall advise students and their parents or guardians regarding the importance of postsecondary education, coursework designed to prepare students for postsecondary education, and financial aid availability and requirements.


(b) During the first school year a student is enrolled in a high school or at the high school level in an open-enrollment charter school, and again during each year of a student's enrollment in high school or at the high school level, a school counselor shall provide information about postsecondary education to the student and the student's parent or guardian. The information must include information regarding:


(1) the importance of postsecondary education;


(2) the advantages of earning an endorsement and a performance acknowledgment and completing the distinguished level of achievement under the foundation high school program under Section 28.025;


(3) the disadvantages of taking courses to prepare for a high school equivalency examination relative to the benefits of taking courses leading to a high school diploma;


(4) financial aid eligibility;


(5) instruction on how to apply for federal financial aid;


(6) the center for financial aid information established under Section 61.0776;


(7) the automatic admission of certain students to general academic teaching institutions as provided by Section 51.803;


(8) the eligibility and academic performance requirements for the TEXAS Grant as provided by Subchapter M, Chapter 56;


(9) the availability of programs in the district under which a student may earn college credit, including advanced placement programs, dual credit programs, joint high school and college credit programs, and international baccalaureate programs;


(10) the availability of education and training vouchers and tuition and fee waivers to attend an institution of higher education as provided by Section 54.366 for a student who is or was previously in the conservatorship of the Department of Family and Protective Services; and


(11) the availability of college credit awarded by institutions of higher education to veterans and military servicemembers for military experience, education, and training obtained during military service as described by the informational materials developed under Section 302.0031(h), Labor Code.


(b-1) When providing information under Subsection (b)(10), the school counselor must report to the student and the student's parent or guardian the number of times the counselor has provided the information to the student.


(b-2) Information provided under Subsection (b)(11) must explain to any student who is enlisted or intends to enlist in the armed forces of the United States the informational materials developed under Section 302.0031(h), Labor Code.


(c) At the beginning of grades 10 and 11, a school counselor certified under the rules of the State Board for Educator Certification shall explain the requirements of automatic admission to a general academic teaching institution under Section 51.803 to each student enrolled in a high school or at the high school level in an open-enrollment charter school who has a grade point average in the top 25 percent of the student's high school class.


Amended by:


Acts 2007, 80th Leg., R.S., Ch. 973 (S.B. 282), Sec. 2, eff. June 15, 2007.


Acts 2009, 81st Leg., R.S., Ch. 1342 (S.B. 175), Sec. 4, eff. June 19, 2009.


Acts 2013, 83rd Leg., R.S., Ch. 211 (H.B. 5), Sec. 29(a), effective beginning with the 2014-2015 school year.


Acts 2013, 83rd Leg., R.S., Ch. 211 (H.B. 5), Sec. 30(a), eff. June 10, 2013.


Acts 2017, 85th Leg., R.S., Ch. 481 (H.B. 2537), Sec. 1, eff. June 9, 2017.


Acts 2017, 85th Leg., R.S., Ch. 550 (S.B. 490), Sec. 1, eff. June 9, 2017.


Acts 2019, 86th Leg., R.S., Ch. 37 (H.B. 114), Sec. 1, eff. May 16, 2019.


Sec. 33.009. POSTSECONDARY EDUCATION AND CAREER COUNSELING ACADEMIES. (a) In this section, "coordinating board" means the Texas Higher Education Coordinating Board.


(b) The coordinating board shall develop and make available postsecondary education and career counseling academies for school counselors and other postsecondary advisors employed by a school district at a middle school, junior high school, or high school.


(c) In developing academies under this section, the coordinating board shall solicit input from the agency, school counselors, the Texas Workforce Commission, institutions of higher education, and business, community, and school leaders.


(d) An academy developed under this section must provide counselors and other postsecondary advisors with knowledge and skills to provide counseling to students regarding postsecondary success and productive career planning and must include information relating to:


(1) each endorsement described by Section 28.025(c-1), including:


(A) the course requirements for each endorsement; and


(B) the postsecondary educational and career opportunities associated with each endorsement;


(2) available methods for a student to earn credit for a course not offered at the school in which the student is enrolled, including enrollment in an electronic course provided through the state virtual school network under Chapter 30A;


(3) general academic performance requirements for admission to an institution of higher education, including the requirements for automatic admission to a general academic teaching institution under Section 51.803;


(4) regional workforce needs, including information about the required education and the average wage or salary for careers that meet those workforce needs; and


(5) effective strategies for engaging students and parents in planning for postsecondary education and potential careers, including participation in mentorships and business partnerships.


(d-1) An academy developed under this section may include information regarding social-emotional learning and indicators of behavioral issues.


(e) The coordinating board shall develop an online instructional program that school districts may use in providing the instruction in high school, college, and career preparation required by Section 28.016. The program must be structured for use as part of an existing course.


(f) Repealed by Acts 2021, 87th Leg., R.S., Ch. 1001 (H.B. 2827), Sec. 2, eff. June 18, 2021.


(g) A teacher of a course described by Section 28.016(c)(2) or (3) may attend an academy developed under this section.


(h) From funds appropriated for that purpose, a school counselor who attends the academy under this section is entitled to receive a stipend in the amount determined by the coordinating board. If funds are available after all eligible school counselors have received a stipend under this subsection, the coordinating board shall pay a stipend in the amount determined by the coordinating board to a teacher who attends the academy under this section. A stipend received under this subsection is not considered in determining whether a district is paying the school counselor or teacher the minimum monthly salary under Section 21.402.


(i) From available funds appropriated for purposes of this section, the coordinating board may provide to school counselors and other educators curricula, instructional materials, and technological tools relating to postsecondary education and career counseling.


(j) Repealed by Acts 2021, 87th Leg., R.S., Ch. 1001 (H.B. 2827), Sec. 2, eff. June 18, 2021.


Added by Acts 2015, 84th Leg., R.S., Ch. 988 (H.B. 18), Sec. 5, eff. June 19, 2015.


Amended by:


Acts 2019, 86th Leg., R.S., Ch. 961 (S.B. 504), Sec. 1, eff. June 14, 2019.


Acts 2021, 87th Leg., R.S., Ch. 1001 (H.B. 2827), Sec. 1, eff. June 18, 2021.


Acts 2021, 87th Leg., R.S., Ch. 1001 (H.B. 2827), Sec. 2, eff. June 18, 2021.


SUBCHAPTER B. LIBRARIES



Sec. 33.021. LIBRARY STANDARDS. The Texas State Library and Archives Commission, in consultation with the State Board of Education, shall adopt standards for school library services. A school district shall consider the standards in developing, implementing, or expanding library services.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995.


Sec. 33.022. CONTRACT WITH COUNTY OR MUNICIPALITY. (a) A school district may enter into contracts with a county or municipality in which the district is located to provide joint library facilities.


(b) The board of trustees of the school district and the commissioners court of the county or governing body of the municipality must conduct public hearings before entering into a contract under this section. The hearings may be held jointly.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995.


SUBCHAPTER C. MISSING CHILD PREVENTION AND IDENTIFICATION PROGRAMS



Sec. 33.051. DEFINITIONS. In this subchapter:


(1) "Child" and "minor" have the meanings assigned by Section 101.003, Family Code.


(2) "Missing child" means a child whose whereabouts are unknown to the legal custodian of the child and:


(A) the circumstances of whose absence indicate that the child did not voluntarily leave the care and control of the custodian and that the taking of the child was not authorized by law; or


(B) the child has engaged in conduct indicating a need for supervision under Section 51.03(b)(2), Family Code.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995.


Amended by:


Acts 2015, 84th Leg., R.S., Ch. 935 (H.B. 2398), Sec. 16, eff. September 1, 2015.


Sec. 33.052. MISSING CHILD PREVENTION AND IDENTIFICATION PROGRAMS. (a) The board of trustees of a school district or of a private school may participate in missing child prevention and identification programs, including fingerprinting and photographing as provided by this subchapter.


(b) The board of trustees of a school district may delegate responsibility for implementation of the program to the district's school administration or to the district's community education services administration.


(c) The chief administrative officer of each private primary or secondary school may participate in the programs and may contract with the regional education service center in which the school is located for operation of all or any part of the program through a shared services arrangement.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995.


Sec. 33.053. FINGERPRINTS OF CHILDREN. (a) A missing child prevention and identification program may include a procedure for taking the fingerprints of each student registered in the school whose parent or legal custodian has consented in writing to the fingerprinting. Fingerprints obtained under this section may be used only for the identification and location of a missing child.


(b) The board of trustees of a school district or the chief administrative officer of a private school may establish a reasonable fee to cover the costs of fingerprinting not provided by volunteer assistance. The fee may not exceed $3 for each child fingerprinted. If the school charges a fee, the school may waive all or a portion of the costs of fingerprinting for educationally disadvantaged children.


(c) A representative of a law enforcement agency of the county or the municipality in which the school district is located or of the Department of Public Safety, or a person trained in fingerprinting technique by a law enforcement agency or the Department of Public Safety, shall make one complete set of fingerprints on a fingerprint card for each child participating in the program. If the school requests, the Department of Public Safety may provide fingerprint training to persons designated by the school.


(d) A fingerprint card shall include a description of the child, including the name, address, date and place of birth, color of eyes and hair, weight, and sex of the child.


(e) Except as provided by Section 33.054(b), the fingerprint card and other materials developed under this subchapter shall be made part of the school's permanent student records.


(f) A state agency, law enforcement agency, or other person may not retain a copy of a child's fingerprints taken under this program.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995.


Sec. 33.0531. CHILD IDENTIFICATION PROGRAM. (a) The agency shall provide to all school districts and open-enrollment charter schools inkless, in-home fingerprint and DNA identification kits to be distributed through the district or school on request to the parent or legal custodian of any kindergarten, elementary, or middle school student.


(b) A parent or legal custodian who receives a fingerprint and DNA identification kit may submit the kit to federal, state, tribal, or local law enforcement to help locate and return a missing or trafficked child.


Added by Acts 2021, 87th Leg., R.S., Ch. 891 (S.B. 2158), Sec. 1, eff. September 1, 2021.


Sec. 33.054. PHOTOGRAPHS OF CHILDREN. (a) A participating school shall retain a current photograph of each child registered in the school whose parent or legal custodian has consented in writing. Photographs retained under this section may be used only for the identification and location of a missing child.


(b) The photograph shall be retained by the participating school until the photograph is replaced by a subsequently made photograph under this section or until the expiration of three years, whichever is earlier.


(c) On the request of a parent or legal custodian of a missing child, or of a peace officer who is engaged in the investigation of a missing child, a participating school may give to the parent, legal custodian, or peace officer a copy of that child's photograph held by the school under this section. Except as provided by this subsection, a photograph held under this section may not be given to any person.


(d) A participating school may charge a fee for making and keeping records of photographs under this section. If the school charges a fee, the school may waive this fee for educationally disadvantaged children.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995.


Sec. 33.055. FINGERPRINTS AND PHOTOGRAPHS NOT USED AS EVIDENCE. (a) A child's fingerprint card made under Section 33.053 or a photograph of a child made or kept under Section 33.054 may not be used as evidence in any criminal proceeding in which the child is a defendant or in any case under Title 3, Family Code, in which the child is alleged to have engaged in delinquent conduct or in conduct indicating a need for supervision.


(b) This subchapter does not apply to the use by a law enforcement agency for an official purpose of a photograph published in a school annual.


(c) This subchapter does not prevent the use of a videotape or photograph taken to monitor the activity of students for disciplinary reasons or in connection with a criminal prosecution or an action under Title 3, Family Code.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995.


Sec. 33.056. LIABILITY FOR NONPERFORMANCE. A person is not liable in any suit for damages for negligent performance or nonperformance of any requirement of this subchapter.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995.


Sec. 33.057. DESTRUCTION OF FINGERPRINTS AND PHOTOGRAPHS. The agency shall adopt rules relating to the destruction of fingerprints and photographs made or kept under Section 33.053 or 33.054.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995.


Amended by:


Acts 2021, 87th Leg., R.S., Ch. 891 (S.B. 2158), Sec. 2, eff. September 1, 2021.


SUBCHAPTER D. EXTRACURRICULAR ACTIVITIES



Sec. 33.081. EXTRACURRICULAR ACTIVITIES. (a) The State Board of Education by rule shall limit participation in and practice for extracurricular activities during the school day and the school week. The rules must, to the extent possible, preserve the school day for academic activities without interruption for extracurricular activities. In scheduling those activities and practices, a school district must comply with the rules of the board.


(b) A student enrolled in a school district in this state or who participates in an extracurricular activity or a University Interscholastic League competition is subject to school district policy and University Interscholastic League rules regarding participation only when the student is under the direct supervision of an employee of the school or district in which the student is enrolled or at any other time specified by resolution of the board of trustees of the district.


(c) A student who is enrolled in a school district in this state or who participates in a University Interscholastic League competition shall be suspended from participation in any extracurricular activity sponsored or sanctioned by the school district or the University Interscholastic League after a grade evaluation period in which the student received a grade lower than the equivalent of 70 on a scale of 100 in any academic class other than a course described by Subsection (d-1). A suspension continues for at least three school weeks and is not removed during the school year until the conditions of Subsection (d) are met. A suspension does not last beyond the end of a school year. For purposes of this subsection, "grade evaluation period" means:


(1) the six-week grade reporting period; or


(2) the first six weeks of a semester and each grade reporting period thereafter, in the case of a district with a grade reporting period longer than six weeks.


(d) Until the suspension is removed under this subsection or the school year ends, a school district shall review the grades of a student suspended under Subsection (c) at the end of each three-week period following the date on which the suspension began. At the time of a review, the suspension is removed if the student's grade in each class, other than a course described by Subsection (d-1), is equal to or greater than the equivalent of 70 on a scale of 100. The principal and each of the student's teachers shall make the determination concerning the student's grades.


(d-1) Subsections (c) and (d) do not apply to an advanced placement or international baccalaureate course, or to an honors or dual credit course in the subject areas of English language arts, mathematics, science, social studies, economics, or a language other than English. The agency shall review on a biennial basis courses described by this subsection to determine if other courses should be excluded from the requirement that a student be suspended from participation in an extracurricular activity under Subsection (c). Not later than January 1 of each odd-numbered year, the agency shall report the findings under this subsection to the legislature.


(e) Suspension of a student with a disability that significantly interferes with the student's ability to meet regular academic standards must be based on the student's failure to meet the requirements of the student's individualized education program. The determination of whether a disability significantly interferes with a student's ability to meet regular academic standards must be made by the student's admission, review, and dismissal committee. For purposes of this subsection, "student with a disability" means a student who is eligible for a district's special education program under Section 29.003(b).


(e-1) A student who is enrolled in a school district in this state or who participates in a University Interscholastic League competition shall be prohibited from participation in any future extracurricular activity sponsored or sanctioned by the school district or the University Interscholastic League if the state executive committee of the league determines that the student intentionally, knowingly, or recklessly causes bodily injury to a person serving as referee, judge, or other official of an extracurricular activity in retaliation for or as a result of the person's actions taken in performing the duties of a referee, judge, or other official of the extracurricular activity.


(e-2) A student prohibited from participation in an extracurricular activity under Subsection (e-1) may submit to the University Interscholastic League a request that the student be permitted to participate in future extracurricular activities sponsored or sanctioned by the University Interscholastic League if:


(1) the request is submitted at least:


(A) one year after the date the student engaged in the conduct that resulted in the prohibition under Subsection (e-1) if the student was enrolled in eighth grade or below at the time of the conduct; or


(B) two years after the date the student engaged in the conduct that resulted in the prohibition under Subsection (e-1) if the student was enrolled in ninth grade or above at the time of the conduct;


(2) the student:


(A) completed a course in anger management since engaging in the conduct that resulted in the prohibition under Subsection (e-1);


(B) completed any other course, activity, or action required by the school district in which the student is enrolled as a result of the conduct that resulted in the prohibition under Subsection (e-1); and


(C) demonstrates, to the satisfaction of the school district and the University Interscholastic League, that the student has been rehabilitated and is unlikely to again engage in the conduct described by Subsection (e-1); and


(3) a previous request submitted by the student under this section has not been denied during the school year in which the request is submitted.


(e-3) When determining whether to grant a request under Subsection (e-2), the University Interscholastic League:


(1) shall take into account the severity of the conduct that resulted in the prohibition under Subsection (e-1); and


(2) may set conditions for the student's future participation in extracurricular activities.


(e-4) The University Interscholastic League may prohibit a student from participating in any future extracurricular activity sponsored or sanctioned by the University Interscholastic League if the student violates a condition set by the University Interscholastic League under Subsection (e-3)(2).


(f) Except for a student prohibited from participation under Subsection (e-1), a student suspended under this section may practice or rehearse with other students for an extracurricular activity but may not participate in a competition or other public performance.


(g) An appeal to the commissioner is not a contested case under Chapter 2001, Government Code, if the issues presented relate to a student's eligibility to participate in extracurricular activities, including issues related to the student's grades, the school district's grading policy as applied to the student's eligibility, or the student's eligibility based on conduct described by Subsection (e-1). The commissioner may delegate the matter for decision to a person the commissioner designates. The decision of the commissioner or the commissioner's designee in a matter governed by this subsection may not be appealed except on the grounds that the decision is arbitrary or capricious. Evidence may not be introduced on appeal other than the record of the evidence before the commissioner.


(h) A request made under Subsection (e-2) is not a contested case subject to Chapter 2001, Government Code.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995. Amended by Acts 1999, 76th Leg., ch. 1482, Sec. 2, eff. June 19, 1999.


Amended by:


Acts 2007, 80th Leg., R.S., Ch. 1327 (S.B. 1517), Sec. 1, eff. June 15, 2007.


Acts 2021, 87th Leg., R.S., Ch. 824 (H.B. 2721), Sec. 1, eff. June 16, 2021.


Sec. 33.0811. SCHOOL DISTRICT POLICY ON ABSENCES TO PARTICIPATE IN EXTRACURRICULAR ACTIVITIES. (a) Notwithstanding Section 33.081(a), the board of trustees of a school district may adopt a policy establishing the number of times a student who is otherwise eligible to participate in an extracurricular activity under Section 33.081 may be absent from class to participate in an extracurricular activity sponsored or sanctioned by the district or the University Interscholastic League or by an organization sanctioned by resolution of the board of trustees of the district.


(b) A policy adopted by the board of trustees of a district under this section:


(1) prevails over a conflicting policy adopted under Section 33.081(a); and


(2) must permit a student to be absent from class at least 10 times during the school year.


Added by Acts 1999, 76th Leg., ch. 1482, Sec. 3, eff. June 19, 1999.


Sec. 33.0812. SCHEDULING EXTRACURRICULAR ACTIVITIES PROHIBITED IN CERTAIN CIRCUMSTANCES. (a) The State Board of Education by rule shall prohibit participation in a University Interscholastic League area, regional, or state competition:


(1) on Monday through Thursday of the school week in which the primary administration of assessment instruments under Section 39.023(a), (c), or (l) occurs; or


(2) if the primary administration of the assessment instruments is completed before Thursday of the school week, beginning on Monday and ending on the last school day on which the assessment instruments are administered.


(b) The commissioner shall determine the school week during the school year in which the primary administration of assessment instruments occurs for purposes of Subsection (a).


(c) The commissioner shall adopt rules to provide the University Interscholastic League with a periodic calendar of dates reserved for testing for planning purposes under this section. The periodic calendar must be provided at least every three years on or before May 1 of the year preceding the three-year cycle of reserved testing dates.


(d) In adopting rules under this section, the commissioner shall:


(1) include a procedure for changing, in exceptional circumstances, testing dates reserved under the periodic calendar;


(2) define circumstances that constitute exceptional circumstances under Subdivision (1) as unforeseen events, including a natural disaster, severe weather, fire, explosion, or similar circumstances beyond the control of school districts or the agency; and


(3) establish criteria for determining whether a University Interscholastic League area, regional, or state competition must be canceled if that event conflicts with a changed testing date.


(e) This section does not apply to testing dates on which assessment instruments are administered only to students retaking assessment instruments.


Added by Acts 2005, 79th Leg., Ch. 812 (S.B. 658), Sec. 1, eff. June 17, 2005.


Sec. 33.082. EXTRACURRICULAR ACTIVITIES; USE OF DISCRIMINATORY ATHLETIC CLUB. (a) An extracurricular activity sponsored or sanctioned by a school district, including an athletic event or an athletic team practice, may not take place at an athletic club located in the United States that denies any person full and equal enjoyment of equipment or facilities provided by the athletic club because of the race, color, religion, creed, national origin, or sex of the person.


(b) In this section, "athletic club" means an entity that provides sports or exercise equipment or facilities to its customers or members or to the guests of its customers or members.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995.


Sec. 33.083. INTERSCHOLASTIC LEAGUES. (a) The rules and procedures of an organization sanctioning or conducting interscholastic competition, including rules providing penalties for rules violations by school district personnel, must be consistent with State Board of Education rules.


(b) The University Interscholastic League is a part of The University of Texas at Austin and must submit its rules and procedures to the commissioner for approval or disapproval. The funds belonging to the University Interscholastic League shall be deposited with The University of Texas at Austin for the benefit of the league and shall be subject to audits by The University of Texas at Austin, The University of Texas System, and the state auditor. Copies of annual audits shall be furnished, on request, to members of the legislature.


(c) The State Board of Education may seek an injunction to enforce this section.


(d) The University Interscholastic League shall file annually with the governor and the presiding officer of each house of the legislature a complete and detailed written report accounting for all funds received and disbursed by the University Interscholastic League during the preceding fiscal year. The form of the annual report and the reporting time are as provided by the General Appropriations Act.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995. Amended by Acts 1999, 76th Leg., ch. 1482, Sec. 4, eff. June 19, 1999.


Amended by:


Acts 2013, 83rd Leg., R.S., Ch. 1279 (H.B. 1675), Sec. 1.04, eff. June 14, 2013.


Sec. 33.0831. UNIVERSITY INTERSCHOLASTIC LEAGUE RULES: FISCAL IMPACT STATEMENT. (a) The legislative council of the University Interscholastic League may not take final action on a new or amended rule that would result in additional costs for a member school unless a fiscal impact statement regarding the rule has been completed in accordance with this section.


(b) For purposes of Subsection (a), final action by the legislative council means:


(1) submitting a rule to school superintendents, if the submission is required under the legislative council's procedures; or


(2) submitting a rule approved by the council to the commissioner for the commissioner's approval under Section 33.083(b), if the rule does not require submission to school superintendents under the legislative council's procedures.


(c) A fiscal impact statement regarding a rule must include:


(1) a projection of the costs to member schools of complying with the rule during the five-year period following the effective date of the rule; and


(2) an explanation of the methodology used to analyze the fiscal impact of the rule and determine the costs projection required by Subdivision (1).


(d) If a fiscal impact statement is prepared for a rule, a copy of the statement must be attached to the rule when it is submitted for approval to school superintendents, if applicable, and when it is submitted to the commissioner for approval.


Added by Acts 2011, 82nd Leg., R.S., Ch. 966 (H.B. 1286), Sec. 1, eff. September 1, 2011.


Text of section as added by Acts 2021, 87th Leg., R.S., Ch. 235 (H.B. 1080), Sec. 1



For text of section as added by Acts 2021, 87th Leg., R.S., Ch. 996 (H.B. 547), Sec. 1, see other Sec. 33.0832.



Sec. 33.0832. PARTICIPATION IN UNIVERSITY INTERSCHOLASTIC LEAGUE ACTIVITIES BY STUDENTS RECEIVING OUTPATIENT MENTAL HEALTH SERVICES. (a) This section applies to a student who:


(1) receives outpatient mental health services from a mental health facility, as defined by Section 571.003, Health and Safety Code; and


(2) is enrolled in a school district or open-enrollment charter school or otherwise receives public education services from a district or school.


(b) The University Interscholastic League shall ensure that league rules do not exclude from eligibility for participation in a league activity a student to whom this section applies based solely on the criteria described in Subsection (a)(1).


(c) A school district or open-enrollment charter school may not adopt or enforce policies that restrict participation in University Interscholastic League activities by a student to whom this section applies based solely on:


(1) the criteria described in Subsection (a)(1); or


(2) the student's absence during instructional time while receiving outpatient mental health services as described by Subsection (a)(1).


(d) This section does not exempt a student to whom this section applies from any eligibility requirement for participation in University Interscholastic League activities other than an eligibility requirement based solely on the criteria described in Subsection (a)(1).


Added by Acts 2021, 87th Leg., R.S., Ch. 235 (H.B. 1080), Sec. 1, eff. June 4, 2021.


Text of section as added by Acts 2021, 87th Leg., R.S., Ch. 996 (H.B. 547), Sec. 1



For text of section as added by Acts 2021, 87th Leg., R.S., Ch. 235 (H.B. 1080), Sec. 1, see other Sec. 33.0832.



Sec. 33.0832. EQUAL OPPORTUNITY FOR CERTAIN STUDENTS TO PARTICIPATE IN UNIVERSITY INTERSCHOLASTIC LEAGUE ACTIVITIES. (a) In this section:


(1) "League" means the University Interscholastic League.


(2) "Non-enrolled student" means a student who receives instruction as described by Section 29.916(a)(1) from a nonpublic school.


(b) Nothing in this section may be construed to affect the holding in Texas Educ. Agency v. Leeper, 893 S.W.2d 432 (Tex. 1994), classifying home schools as private schools. The legislature finds that a home school is a private school for purposes of this section.


(c) Except as provided by Subsection (i), a public school that participates in an activity sponsored by the league may provide a non-enrolled student, who otherwise meets league eligibility standards to represent that school in a league activity, with the opportunity to participate in the activity on behalf of the school in the same manner that the school provides the opportunity to participate to students enrolled in the school.


(d) A non-enrolled student who seeks to participate or participates in a league activity on behalf of a school is subject to the following relevant policies that apply to students enrolled in the school:


(1) registration for league activities;


(2) age eligibility;


(3) fees;


(4) insurance;


(5) transportation;


(6) physical condition;


(7) qualifications;


(8) responsibilities;


(9) event schedules;


(10) standards of behavior; and


(11) performance.


(e) A non-enrolled student may only participate in a league activity for the school in the school district that the student would be eligible to attend based on the student's residential address. A non-enrolled student who seeks to participate in a league activity on behalf of a school shall be required to establish minimum proof of residency acceptable to the district in the same manner as an applicant to attend a school in the district under Section 25.001.


(f) The parent or person standing in parental relation to a non-enrolled student is responsible for oversight of academic standards relating to the student's participation in a league activity. As a condition of eligibility to participate in a league activity during the first six weeks of a school year, a non-enrolled student must demonstrate grade-level academic proficiency on any nationally recognized, norm-referenced assessment instrument, such as the Iowa Test of Basic Skills, Stanford Achievement Test, California Achievement Test, or Comprehensive Test of Basic Skills. A non-enrolled student demonstrates the required academic proficiency by achieving a composite, core, or survey score that is within the average or higher than average range of scores, as established by the applicable testing service. For purposes of this subsection, a school district shall accept assessment results administered or reported by a third party.


(g) A non-enrolled student's demonstration of academic proficiency under Subsection (f) is sufficient for purposes of that subsection for the school year in which the student achieves the required score and the subsequent school year.


(h) After the first six weeks of a school year, the parent or person standing in parental relation to a non-enrolled student participating in a league activity on behalf of a public school must periodically, in accordance with the school's grading calendar, provide written verification to the school indicating that the student is receiving a passing grade in each course or subject being taught.


(i) A non-enrolled student is not authorized by this section to participate in a league activity during the remainder of any school year during which the student was previously enrolled in a public school.


(j) The league may not prohibit a non-enrolled student from participating in league activities in the manner authorized by this section.


(k) With respect to a non-enrolled student's education program, nothing in this section shall be construed to permit an agency of this state, a public school district, or any other governmental body to exercise control, regulatory authority, or supervision over a non-enrolled student or a parent or person standing in parental relation to a non-enrolled student beyond the control, regulatory authority, or supervision required to participate in a league activity.


(l) Subject only to eligibility requirements under this section for a non-enrolled student to participate in a league activity:


(1) the curriculum or assessment requirements, performance standards, practices, or creed of the education program provided to a non-enrolled student may not be required to be changed in order for the non-enrolled student to participate in a league activity; and


(2) for a non-enrolled student participating in an education program on January 1, 2021, the education program provided to that student may not be required to comply with any state law or agency rule relating to that education program unless the law or rule was in effect on January 1, 2021.


(m) Notwithstanding any other law, a non-enrolled student who participates in a league activity under this section is subject to the immunization requirements and exceptions of Section 38.001 in the same manner as a public school student.


Added by Acts 2021, 87th Leg., R.S., Ch. 996 (H.B. 547), Sec. 1, eff. September 1, 2021.


Sec. 33.0834. INTERSCHOLASTIC ATHLETIC COMPETITION BASED ON BIOLOGICAL SEX. (a) Except as provided by Subsection (b), an interscholastic athletic team sponsored or authorized by a school district or open-enrollment charter school may not allow a student to compete in an interscholastic athletic competition sponsored or authorized by the district or school that is designated for the biological sex opposite to the student's biological sex as correctly stated on:


(1) the student's official birth certificate, as described by Subsection (c); or


(2) if the student's official birth certificate described by Subdivision (1) is unobtainable, another government record.


(b) An interscholastic athletic team described by Subsection (a) may allow a female student to compete in an interscholastic athletic competition that is designated for male students if a corresponding interscholastic athletic competition designated for female students is not offered or available.


(c) For purposes of this section, a statement of a student's biological sex on the student's official birth certificate is considered to have correctly stated the student's biological sex only if the statement was:


(1) entered at or near the time of the student's birth; or


(2) modified to correct any type of scrivener or clerical error in the student's biological sex.


(d) The University Interscholastic League shall adopt rules to implement this section, provided that the rules must be approved by the commissioner in accordance with Section 33.083(b). The rules must ensure compliance with state and federal law regarding the confidentiality of student medical information, including Chapter 181, Health and Safety Code, and the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. Section 1320d et seq.).


Added by Acts 2021, 87th Leg., 3rd C.S., Ch. 2 (H.B. 25), Sec. 3, eff. January 18, 2022.


Sec. 33.084. INTERSCHOLASTIC LEAGUE ADVISORY COUNCIL. (a) The interscholastic league advisory council is composed of:


(1) two members of the State Board of Education appointed by the chair of the board;


(2) a member of the house of representatives appointed by the speaker of the house;


(3) a member of the senate appointed by the lieutenant governor;


(4) two members of the legislative council of the University Interscholastic League appointed by the chairman of the council;


(5) two public school board members appointed by the commissioner; and


(6) three members of the public appointed by the commissioner.


(b) A member of the advisory council serves at the will of the member's appointing authority.


(c) In appointing public members to the advisory council, the commissioner shall give special consideration to students, parents of students, and teachers.


(d) The advisory council shall select a chair from among its members and shall meet at the call of the chair.


(e) The advisory council shall review the rules of the University Interscholastic League and shall make recommendations relating to the rules to the governor, the legislature, the legislative council of the University Interscholastic League, and the State Board of Education.


(f) A member of the advisory council may not receive compensation but is entitled to reimbursement from the University Interscholastic League for transportation expenses and the per diem allowance for state employees in accordance with the General Appropriations Act.


(g) The advisory council shall study:


(1) University Interscholastic League policy with respect to the eligibility of students to participate in programs;


(2) geographic distribution of University Interscholastic League resources and programs; and


(3) gender equity.


(h) An action of the University Interscholastic League relating to the provision of additional programs of school districts may not be taken pending submission of a final report by the advisory council.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995.


Sec. 33.085. AUTHORITY OF UNIVERSITY INTERSCHOLASTIC LEAGUE REGARDING ACTIVITIES INVOLVING SPORTS OFFICIALS. (a) In this section:


(1) "League" means the University Interscholastic League.


(2) "Sports official" means a person who officiates, judges, or in any manner enforces contest rules in any official capacity with respect to and during the course of an interscholastic athletic team competition and who is a member of a league-recognized local chapter or association of sports officials. The term includes a referee, umpire, linesman, judge, or any other person similarly involved in supervising competitive play. The term does not include a league board member or a league official who is acting in an official capacity to supervise, administer, or enforce the league constitution or league contest rules.


(b) The league may require a sports official, as a condition of eligibility to officiate a contest sponsored by the league, to:


(1) be registered with the league and comply with the registration requirements of Subsections (c) and (c-1);


(2) have completed initial and continuing education programs regarding league rules;


(3) be a member in good standing of a local chapter or association of sports officials recognized by the league for that purpose; and


(4) agree to abide by league rules, including fee schedules and travel reimbursement guidelines for payment by school districts or open-enrollment charter schools to a sports official.


(c) In registering with the league, a sports official must be required to provide directory information required by the league and undergo an initial criminal background check.


(c-1) To maintain registration with the league, a sports official must:


(1) maintain compliance with conditions of eligibility required by the league under Subsection (b); and


(2) undergo a subsequent criminal background check once every three years following the date of the initial criminal background check under Subsection (c).


(d) The league may not charge a sports official who completes a program under Subsection (b)(2) a fee for more than one program described by Subsection (b)(2).


(e) The league may charge and collect a registration fee only to defray the cost of registering sports officials and shall post the amount of the fee on the league's Internet website and make the information available at other places the league determines appropriate. The amount of the fee may not exceed the amount reasonably determined by the league to be necessary to cover the cost of administering registration.


(f) The league may revoke or suspend the league registration of a sports official determined by the league to have violated the provisions of the league constitution or contest rules governing sports officials or other league policy applicable to sports officials. Before the league may take action to revoke or suspend a sports official's registration, the league shall notify and consult with the local chapter or association of sports officials of which the sports official is a member. The local chapter or association may, on or before the 15th day after the date notice is received from the league, take action to adjudicate the alleged violation. If after the 15th day after the date notice is received from the league the local chapter or association has failed to take action against the sports official or takes action that the league finds to be insufficient, the league may take action against the sports official. The league shall adopt rules to provide a sports official with the opportunity for an appeals process before the league revokes or suspends the sports official's registration. In adopting rules under this subsection, the league shall make a determination of the actions and subsequent sanctions that would be considered sufficient under this subsection.


(g) The league may not sponsor or organize or attempt to sponsor or organize any association of sports officials in which the majority of the membership is composed of sports officials who officiate team sports.


(h) The league may set rates or fee schedules payable by a school district or open-enrollment charter school to a sports official.


(i) Before the league may take any action that amends rules related to the activities of sports officials, other than an action against an individual sports official under Subsection (f), the league must submit the proposed action for public review and comment, including:


(1) notifying registered sports officials of the proposed action by e-mail not later than the 30th day before the date set for action on the proposal; and


(2) posting the proposal on the league's Internet website for at least 30 consecutive days before the date set for action on the proposal.


Added by Acts 2013, 83rd Leg., R.S., Ch. 952 (H.B. 1775), Sec. 1, eff. June 14, 2013.


Amended by:


Acts 2017, 85th Leg., R.S., Ch. 335 (H.B. 1075), Sec. 1, eff. September 1, 2017.


Sec. 33.086. CERTIFICATION IN CARDIOPULMONARY RESUSCITATION AND FIRST AID. (a) A school district employee who serves as the head director of a school marching band or as the head coach or chief sponsor for an extracurricular athletic activity, including cheerleading, sponsored or sanctioned by a school district or the University Interscholastic League must maintain and submit to the district proof of current certification in first aid and cardiopulmonary resuscitation issued by the American Red Cross, the American Heart Association, or another organization that provides equivalent training and certification.


(b) Each school district shall adopt, in accordance with the policy adopted under Section 21.4515, procedures necessary for administering this section, including procedures for the time and manner in which proof of current certification must be submitted.


Added by Acts 1999, 76th Leg., ch. 396, Sec. 2.14(a), eff. Sept. 1, 1999. Amended by Acts 2003, 78th Leg., ch. 881, Sec. 1, eff. June 20, 2003.


Amended by:


Acts 2021, 87th Leg., R.S., Ch. 1045 (S.B. 1267), Sec. 14, eff. June 18, 2021.


Sec. 33.087. ELIGIBILITY OF STUDENTS PARTICIPATING IN JOINT CREDIT OR CONCURRENT ENROLLMENT PROGRAMS. A student otherwise eligible to participate in an extracurricular activity or a University Interscholastic League competition is not ineligible because the student is enrolled in a course offered for joint high school and college credit, or in a course offered under a concurrent enrollment program, regardless of the location at which the course is provided.


Added by Acts 2007, 80th Leg., R.S., Ch. 199 (H.B. 208), Sec. 1, eff. May 24, 2007.


Sec. 33.091. PREVENTION OF ILLEGAL STEROID USE; RANDOM TESTING. (a) In this section:


(1) "League" means the University Interscholastic League.


(2) "Parent" includes a guardian or other person standing in parental relation.


(3) "Steroid" means an anabolic steroid as described by Section 481.104, Health and Safety Code.


(b) The league shall adopt rules prohibiting a student from participating in an athletic competition sponsored or sanctioned by the league unless:


(1) the student agrees not to use steroids and, if the student is enrolled in high school, the student submits to random testing for the presence of illegal steroids in the student's body, in accordance with the program established under Subsection (d); and


(2) the league obtains from the student's parent a statement signed by the parent and acknowledging that:


(A) the parent's child, if enrolled in high school, may be subject to random steroid testing;


(B) state law prohibits possessing, dispensing, delivering, or administering a steroid in a manner not allowed by state law;


(C) state law provides that bodybuilding, muscle enhancement, or the increase of muscle bulk or strength through the use of a steroid by a person who is in good health is not a valid medical purpose;


(D) only a licensed practitioner with prescriptive authority may prescribe a steroid for a person; and


(E) a violation of state law concerning steroids is a criminal offense punishable by confinement in jail or imprisonment in the Texas Department of Criminal Justice.


(c) The league shall:


(1) develop an educational program for students engaged in extracurricular athletic activities sponsored or sanctioned by the league, parents of those students, and coaches of those activities regarding the health effects of steroid use; and


(2) make the program available to school districts.


(c-1) A school district shall require that each district employee who serves as an athletic coach at or above the seventh grade level for an extracurricular athletic activity sponsored or sanctioned by the league complete:


(1) the educational program developed by the league under Subsection (c); or


(2) a comparable program developed by the district or a private entity with relevant expertise.


(d) The league shall adopt rules for the annual administration of a steroid testing program under which high school students participating in an athletic competition sponsored or sanctioned by the league are tested at multiple times throughout the year for the presence of steroids in the students' bodies. The testing program must:


(1) require the random testing of a statistically significant number of high school students in this state who participate in athletic competitions sponsored or sanctioned by the league;


(2) provide for the selection of specific students described by Subdivision (1) for testing through a process that randomly selects students from a single pool consisting of all students who participate in any activity for which the league sponsors or sanctions athletic competitions;


(3) be administered at approximately 30 percent of the high schools in this state that participate in athletic competitions sponsored or sanctioned by the league;


(4) provide for a process for confirming any initial positive test result through a subsequent test conducted as soon as practicable after the initial test, using a sample that was obtained at the same time as the sample used for the initial test;


(5) require the testing to be performed only by an anabolic steroid testing laboratory with a current certification from the Substance Abuse and Mental Health Services Administration of the United States Department of Health and Human Services, the World Anti-Doping Agency, or another appropriate national or international certifying organization; and


(6) provide for a period of ineligibility from participation in an athletic competition sponsored or sanctioned by the league for any student with a confirmed positive test result or any student who refuses to submit to random testing.


(e) Results of a steroid test conducted under Subsection (d) are confidential and, unless required by court order, may be disclosed only to the student and the student's parent and the activity directors, principal, and assistant principals of the school attended by the student.


(f) From funds already appropriated, the agency shall pay the costs of the steroid testing program established under Subsection (d).


(g) The league may increase the membership fees required of school districts that participate in athletic competitions sponsored or sanctioned by the league in an amount necessary to offset the cost of league activities under this section.


(h) Subsection (b)(1) does not apply to the use by a student of a steroid that is dispensed, prescribed, delivered, and administered by a medical practitioner for a valid medical purpose and in the course of professional practice, and a student is not subject to a period of ineligibility under Subsection (d)(6) on the basis of that steroid use.


Added by Acts 2005, 79th Leg., Ch. 1177 (H.B. 3563), Sec. 1, eff. June 18, 2005.


Amended by:


Acts 2007, 80th Leg., R.S., Ch. 1292 (S.B. 8), Sec. 1, eff. June 15, 2007.


Acts 2007, 80th Leg., R.S., Ch. 1292 (S.B. 8), Sec. 2, eff. June 15, 2007.


Sec. 33.092. STUDENT ELECTION CLERKS AND EARLY VOTING CLERKS. A student who is appointed as a student election clerk under Section 32.0511, Election Code, or as a student early voting clerk under Section 83.012, Election Code, may apply the time served as a student election clerk or student early voting clerk toward:


(1) a requirement for a school project at the discretion of the teacher who assigned the project; or


(2) a service requirement for participation in an advanced academic course program at the discretion of the program sponsor or a school-sponsored extracurricular activity at the discretion of the school sponsor.


Added by Acts 2009, 81st Leg., R.S., Ch. 517 (S.B. 1134), Sec. 4, eff. September 1, 2009.


Amended by:


Acts 2013, 83rd Leg., R.S., Ch. 542 (S.B. 553), Sec. 2, eff. June 14, 2013.


Sec. 33.093. RECOGNITION OF PARTICIPATION IN SPECIAL OLYMPICS. If a school district allows high school students to earn a letter for academic, athletic, or extracurricular achievements, the district must allow high school students in the district to earn a letter on the basis of a student's participation in a Special Olympics event.


Added by Acts 2017, 85th Leg., R.S., Ch. 261 (H.B. 1645), Sec. 1, eff. May 29, 2017.


Sec. 33.094. FOOTBALL HELMET SAFETY REQUIREMENTS. (a) A school district may not use a football helmet that is 16 years old or older in the district's football program.


(b) A school district shall ensure that each football helmet used in the district's football program that is 10 years old or older is reconditioned at least once every two years.


(c) A school district shall maintain and make available to parents of students enrolled in the district documentation indicating the age of each football helmet used in the district's football program and the dates on which each helmet is reconditioned.


(d) The University Interscholastic League may adopt rules necessary to implement this section, provided that the rules must be approved by the commissioner in accordance with Section 33.083(b).


Added by Acts 2011, 82nd Leg., R.S., Ch. 239 (H.B. 675), Sec. 1, eff. September 1, 2011.


Sec. 33.096. CARDIAC ASSESSMENTS OF HIGH SCHOOL PARTICIPANTS IN EXTRACURRICULAR ATHLETIC ACTIVITIES. (a) A school district must provide a district student, who is required under University Interscholastic League rule or policy to receive a physical examination before being allowed to participate in an athletic activity sponsored or sanctioned by the University Interscholastic League, the following:


(1) information about sudden cardiac arrest and electrocardiogram testing; and


(2) notification of the option of the student to request the administration of an electrocardiogram, in addition to the physical examination.


(b) A student may request an electrocardiogram from any health care professional, including a health care professional provided through the student's patient-centered medical home, as defined by Section 533.0029, Government Code, a health care professional provided through a school district program, or another health care professional chosen by the parent or person standing in parental relation to the student, provided that the health care professional is:


(1) appropriately licensed in this state; and


(2) authorized to administer and interpret electrocardiograms under the health care professional's scope of practice, as established by the health care professional's Texas licensing act.


(c) The University Interscholastic League shall adopt rules as necessary to administer this section.


(d) The rules adopted under Subsection (c) must include:


(1) criteria under which a school district may request an exemption from the requirements of Subsection (a);


(2) variances that allow for a delay of the implementation of the requirement to notify students of the option to request an electrocardiogram under this section;


(3) procedures to ensure students receiving the required annual physical examination are notified of the option to request an electrocardiogram; and


(4) provisions to ensure that the requirements under this section are minimum standards that provide a school district with the option to implement a program that exceeds the standards required by this section.


(e) This section does not create a cause of action or liability or a standard of care, obligation, or duty that provides a basis for a cause of action or liability against a health care professional described by Subsection (b), the University Interscholastic League, a school district, or a district officer or employee for:


(1) the injury or death of a student participating in or practicing for an athletic activity sponsored or sanctioned by the University Interscholastic League based on or in connection with the administration or interpretation of or reliance on an electrocardiogram; or


(2) the content or distribution of the information required under Subsection (a) or the failure to distribute the required information under this section.


Added by Acts 2019, 86th Leg., R.S., Ch. 1023 (H.B. 76), Sec. 1, eff. September 1, 2019.


Sec. 33.097. INCLUSIVE SPORTS PROGRAM FOR STUDENTS WITH INTELLECTUAL DISABILITIES. (a) The University Interscholastic League shall ensure students with intellectual disabilities have an opportunity to participate in team athletic activities by establishing and maintaining an inclusive sports program.


(b) The University Interscholastic League shall adopt rules as necessary to establish, maintain, and expand the inclusive sports program. The rules must:


(1) accommodate inclusive team sports offered through the program at participating public middle schools, junior high schools, and high schools in the state;


(2) establish eligibility requirements for participation in each inclusive team sport offered through the program;


(3) identify best practices for school districts to incorporate inclusive sports; and


(4) require the program to incorporate activities that promote:


(A) bullying prevention;


(B) moral intelligence;


(C) character development;


(D) leadership development;


(E) physical fitness; and


(F) positive school culture.


(c) In adopting the rules under Subsection (b), the University Interscholastic League shall consider and incorporate as appropriate:


(1) federal guidance regarding providing access to extracurricular athletics for students with intellectual disabilities;


(2) guidance available from nationally recognized organizations that promote inclusion and acceptance among students with and without intellectual disabilities;


(3) information regarding inclusive sports programs that have been successfully implemented in this state, in other states, and by nonprofit organizations;


(4) input from school districts and the agency; and


(5) guidance provided by impacted stakeholders, including by parents of or persons standing in parental relation to students with intellectual disabilities.


(d) The University Interscholastic League may appoint a person to provide guidance on behalf of impacted stakeholders for purposes of Subsection (c)(5).


(e) In maintaining the inclusive sports program, the University Interscholastic League shall, to the greatest extent possible, require:


(1) students who participate in the inclusive sports program to be subject to the same rules and requirements as students who participate in other athletic programs offered by the league, including:


(A) grade and disciplinary requirements under Section 33.081(c); and


(B) requirements related to student safety in athletic activities under this chapter and Chapter 38; and


(2) team sports provided through the inclusive sports program to be organized similarly to other athletic programs offered by the league, including with respect to team practices, seasonal play, and local and statewide competitions.


(f) In addition to using funds available or appropriated for the purpose, the University Interscholastic League or a partner affiliated with the league may seek and accept gifts, grants, or donations of money from public and private sources for the purpose of establishing or expanding the inclusive sports program.


Added by Acts 2021, 87th Leg., R.S., Ch. 522 (S.B. 776), Sec. 2, eff. September 1, 2021.


SUBCHAPTER E. COMMUNITIES IN SCHOOLS PROGRAM



Sec. 33.151. DEFINITIONS. In this subchapter:


(1) Repealed by Acts 2007, 80th Leg., R.S., Ch. 1204, Sec. 4, eff. September 1, 2007.


(2) "Communities In Schools program" means an exemplary youth dropout prevention program.


(3) "Delinquent conduct" has the meaning assigned by Section 51.03, Family Code.


(4) "Student at risk of dropping out of school" means:


(A) a student at risk of dropping out of school as defined by Section 29.081;


(B) a student who is eligible for a free or reduced lunch; or


(C) a student who is in family conflict or crisis.


Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993. Renumbered from Labor Code Sec. 216.001 by Acts 1995, 74th Leg., ch. 655, Sec. 11.05, eff. Sept. 1, 1995. Amended by Acts 1997, 75th Leg., ch. 165, Sec. 6.69, eff. Sept. 1, 1997. Redesignated from Labor Code, Sec. 305.001 and amended by Acts 1999, 76th Leg., ch. 489, Sec. 3, eff. Sept. 1, 1999. Redesignated from Family Code, Sec. 264.751 and amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.118(a), eff. Sept. 1, 2003; Acts 2003, 78th Leg., ch. 1205, Sec. 1, eff. Sept. 1, 2003.


Amended by:


Acts 2007, 80th Leg., R.S., Ch. 1204 (H.B. 1609), Sec. 4, eff. September 1, 2007.


Sec. 33.152. STATEWIDE OPERATION OF PROGRAM. It is the intent of the legislature that the Communities In Schools program operate throughout this state. It is also the intent of the legislature that programs established under Chapter 305, Labor Code, as that chapter existed on August 31, 1999, and its predecessor statute, the Texas Unemployment Compensation Act (Article 5221b-9d, Vernon's Texas Civil Statutes), and programs established under this subchapter shall remain eligible to participate in the Communities In Schools program if funds are available and if their performance meets the criteria established by the agency for renewal of their contracts.


Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993. Renumbered from Labor Code Sec. 216.002 by Acts 1995, 74th Leg., ch. 655, Sec. 11.05, eff. Sept. 1, 1995. Redesignated from Labor Code Sec. 305.002 and amended by Acts 1999, 76th Leg., ch. 489, Sec. 3, eff. Sept. 1, 1999. Redesignated from Family Code Sec. 264.752 and amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.118(a), eff. Sept. 1, 2003; Acts 2003, 78th Leg., ch. 1205, Sec. 1, eff. Sept. 1, 2003.


Sec. 33.154. DUTIES OF COMMISSIONER. (a) The commissioner shall:


(1) coordinate the efforts of the Communities In Schools program with other social service organizations and agencies and with public school personnel to provide services to students who are at risk of dropping out of school or engaging in delinquent conduct, including students who are in family conflict or emotional crisis;


(2) set standards for the Communities In Schools program and establish state performance goals, objectives, and measures for the program, including performance goals, objectives, and measures that consider improvement in student:


(A) behavior;


(B) academic achievement; and


(C) promotion, graduation, retention, and dropout rates;


(3) obtain information to determine accomplishment of state performance goals, objectives, and measures;


(4) promote and market the program in communities in which the program is not established;


(5) help communities that want to participate in the program establish a local funding base;


(6) provide training and technical assistance for participating communities and programs; and


(7) adopt policies concerning:


(A) the responsibility of the agency in encouraging local businesses to participate in local Communities In Schools programs;


(B) the responsibility of the agency in obtaining information from participating school districts;


(C) the use of federal or state funds available to the agency for programs of this nature; and


(D) any other areas concerning the program identified by the commissioner.


(b) The commissioner shall adopt rules to implement the policies described by Subsection (a)(7) and shall annually update the rules.


(c) Notwithstanding any provision of this subchapter, if the commissioner determines that a program consistently fails to achieve the performance goals, objectives, and measures established by the commissioner under Subsection (a)(2), the commissioner may withhold funding from that program and require the program to compete through a competitive bidding process to receive funding to participate in the program.


Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993. Renumbered from Labor Code Sec. 216.012 by Acts 1995, 74th Leg., ch. 655, Sec. 11.05, eff. Sept. 1, 1995. Redesignated from Labor Code Sec. 305.012 and amended by Acts 1999, 76th Leg., ch. 489, Sec. 3, eff. Sept. 1, 1999. Redesignated from Family Code Sec. 264.754 by Acts 2003, 78th Leg., ch. 198, Sec. 2.118(a), eff. Sept. 1, 2003; Acts 2003, 78th Leg., ch. 1205, Sec. 1, eff. Sept. 1, 2003.


Amended by:


Acts 2007, 80th Leg., R.S., Ch. 1204 (H.B. 1609), Sec. 1, eff. September 1, 2007.


Sec. 33.155. COOPERATION WITH COMMUNITIES IN SCHOOLS, INC. The agency and Communities In Schools, Inc. shall work together to maximize the effectiveness of the Communities In Schools program.


Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993. Renumbered from Labor Code Sec. 216.013 by Acts 1995, 74th Leg., ch. 655, Sec. 11.05, eff. Sept. 1, 1995. Redesignated from Labor Code Sec. 305.013 and amended by Acts 1999, 76th Leg., ch. 489, Sec. 3, eff. Sept. 1, 1999. Redesignated from Family Code Sec. 264.755 and amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.118(a), eff. Sept. 1, 2003; Acts 2003, 78th Leg., ch. 1205, Sec. 1, eff. Sept. 1, 2003.


Amended by:


Acts 2007, 80th Leg., R.S., Ch. 1204 (H.B. 1609), Sec. 1, eff. September 1, 2007.


Sec. 33.156. FUNDING; EXPANSION OF PARTICIPATION. (a) The agency shall develop and implement an equitable formula for the funding of local Communities In Schools programs. The formula may provide for the reduction of funds annually contributed by the state to a local program by an amount not more than 50 percent of the amount contributed by the state for the first year of the program. The formula must consider the financial resources of individual communities and school districts. Savings accomplished through the implementation of the formula may be used to extend services to counties and municipalities currently not served by a local program or to extend services to counties and municipalities currently served by an existing local program.


(b) Each local Communities In Schools program shall develop a funding plan which ensures that the level of services is maintained if state funding is reduced.


(c) A local Communities In Schools program may accept federal funds, state funds, private contributions, grants, and public and school district funds to support a campus participating in the program.


Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993. Amended by Acts 1995, 74th Leg., ch. 76, Sec. 9.40(a), eff. Sept. 1, 1995. Renumbered from Labor Code Sec. 216.021 and amended by Acts 1995, 74th Leg., ch. 655, Sec. 11.05, eff. Sept. 1, 1995. Redesignated from Labor Code Sec. 305.021 and amended by Acts 1999, 76th Leg., ch. 489, Sec. 3, eff. Sept. 1, 1999. Redesignated from Family Code Sec. 264.756 and amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.118(a), eff. Sept. 1, 2003; Acts 2003, 78th Leg., ch. 1205, Sec. 1, eff. Sept. 1, 2003.


Sec. 33.157. PARTICIPATION IN PROGRAM. An elementary or secondary school receiving funding under Section 33.156 shall participate in a local Communities In Schools program if the number of students enrolled in the school who are at risk of dropping out of school is equal to at least 10 percent of the number of students in average daily attendance at the school, as determined by the agency.


Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993. Renumbered from Labor Code Sec. 216.022 and amended by Acts 1995, 74th Leg., ch. 655, Sec. 11.05, eff. Sept. 1, 1995. Redesignated from Labor Code Sec. 305.022 and amended Acts 1999, 76th Leg., ch. 489, Sec. 3, eff. Sept. 1, 1999. Redesignated from Family Code Sec. 264.757 and amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.118(a), eff. Sept. 1, 2003; Acts 2003, 78th Leg., ch. 1205, Sec. 1, eff. Sept. 1, 2003.


Sec. 33.158. DONATIONS TO PROGRAM. (a) The agency may accept a donation of services or money or other property that the agency determines furthers the lawful objectives of the agency in connection with the Communities In Schools program.


(b) Each donation, with the name of the donor and the purpose of the donation, must be reported in the public records of the agency.


Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993. Renumbered from Labor Code Sec. 216.031 by Acts 1995, 74th Leg., ch. 655, Sec. 11.05, eff. Sept. 1, 1995. Redesignated from Labor Code Sec. 305.031 and amended by Acts 1999, 76th Leg., ch. 489, Sec. 3, eff. Sept. 1, 1999. Redesignated from Family Code Sec. 264.758 and amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.118(a), eff. Sept. 1, 2003; Acts 2003, 78th Leg., ch. 1205, Sec. 1, eff. Sept. 1, 2003.


Sec. 33.159. AGENCY PERFORMANCE OF COMMUNITIES IN SCHOOLS FUNCTIONS REQUIRED. The agency, through the Communities In Schools State Office:


(1) must perform each function concerning the Communities In Schools program for which the agency is responsible; and


(2) may not contract with a private entity to perform a function described by Subdivision (1).


Added by Acts 2007, 80th Leg., R.S., Ch. 1204 (H.B. 1609), Sec. 2, eff. September 1, 2007.


SUBCHAPTER F. SAFETY REGULATIONS FOR CERTAIN



EXTRACURRICULAR ACTIVITIES



Sec. 33.201. APPLICABILITY. This subchapter applies to each public school in this state and to any other school in this state subject to University Interscholastic League rules.


Added by Acts 2007, 80th Leg., R.S., Ch. 1296 (S.B. 82), Sec. 1, eff. June 15, 2007.


Sec. 33.202. SAFETY TRAINING REQUIRED. (a) The University Interscholastic League shall develop and adopt an extracurricular activity safety training program as provided by this section. In developing the program, the league may use materials available from the American Red Cross, Emergency Medical Systems (EMS), or another appropriate entity.


(b) The following persons must satisfactorily complete the safety training program in accordance with the policy adopted under Section 21.4515:


(1) a coach, trainer, or sponsor for an extracurricular athletic activity; and


(2) a director responsible for a school marching band.


(c) The safety training program must include:


(1) certification of participants by the American Red Cross, the American Heart Association, or a similar organization or by the University Interscholastic League;


(2) current training in:


(A) emergency action planning;


(B) communicating effectively with 9-1-1 emergency service operators and other emergency personnel; and


(C) recognizing symptoms of potentially catastrophic injuries, including head and neck injuries, concussions, injuries related to second impact syndrome, asthma attacks, heatstroke, cardiac arrest, and injuries requiring use of a defibrillator; and


(3) a safety drill that incorporates the training described by Subdivision (2) and simulates various injuries described by Subdivision (2)(C).


Added by Acts 2007, 80th Leg., R.S., Ch. 1296 (S.B. 82), Sec. 1, eff. June 15, 2007.


Amended by:


Acts 2019, 86th Leg., R.S., Ch. 439 (S.B. 1376), Sec. 2.01, eff. June 4, 2019.


Acts 2021, 87th Leg., R.S., Ch. 1045 (S.B. 1267), Sec. 15, eff. June 18, 2021.


Acts 2021, 87th Leg., R.S., Ch. 1045 (S.B. 1267), Sec. 24(9), eff. June 18, 2021.


Sec. 33.203. COMPLETION OF UNIVERSITY INTERSCHOLASTIC LEAGUE FORMS. (a) Each student participating in an extracurricular athletic activity must complete the University Interscholastic League forms entitled "Preparticipation Physical Evaluation--Medical History" and "Acknowledgment of Rules." Each form must be signed by both the student and the student's parent or guardian.


(b) Each form specified by Subsection (a) must clearly state that failure to accurately and truthfully answer all questions on a form required by statute or by the University Interscholastic League as a condition for participation in an extracurricular athletic activity subjects a signer of the form to penalties determined by the University Interscholastic League.


Added by Acts 2007, 80th Leg., R.S., Ch. 1296 (S.B. 82), Sec. 1, eff. June 15, 2007.


Sec. 33.204. CERTAIN UNSAFE ATHLETIC ACTIVITIES PROHIBITED. A coach, trainer, or sponsor for an extracurricular athletic activity may not encourage or permit a student participating in the activity to engage in any unreasonably dangerous athletic technique that unnecessarily endangers the health of a student, including using a helmet or any other sports equipment as a weapon.


Added by Acts 2007, 80th Leg., R.S., Ch. 1296 (S.B. 82), Sec. 1, eff. June 15, 2007.


Sec. 33.205. CERTAIN SAFETY PRECAUTIONS REQUIRED. (a) A coach, trainer, or sponsor for an extracurricular athletic activity shall at each athletic practice or competition ensure that:


(1) each student participating in the activity is adequately hydrated;


(2) any prescribed asthma medication for a student participating in the activity is readily available to the student;


(3) emergency lanes providing access to the practice or competition area are open and clear; and


(4) heatstroke prevention materials are readily available.


(b) If a student participating in an extracurricular athletic activity, including a practice or competition, becomes unconscious during the activity, the student may not:


(1) return to the practice or competition during which the student became unconscious; or


(2) participate in any extracurricular athletic activity until the student receives written authorization for such participation from a physician.


Added by Acts 2007, 80th Leg., R.S., Ch. 1296 (S.B. 82), Sec. 1, eff. June 15, 2007.


Sec. 33.206. COMPLIANCE; ENFORCEMENT. (a) In accordance with Chapter 552, Government Code, a school shall make available to the public proof of compliance for each person enrolled in, employed by, or volunteering for the school who is required to receive safety training described by Section 33.202.


(b) The superintendent of a school district or the director of a school subject to this subchapter shall maintain complete and accurate records of the district's or school's compliance with Section 33.202.


(c) A school campus that is determined by the school's superintendent or director to be out of compliance with Section 33.202, 33.204, or 33.205 with regard to University Interscholastic League activities shall be subject to the range of penalties determined by the University Interscholastic League.


Added by Acts 2007, 80th Leg., R.S., Ch. 1296 (S.B. 82), Sec. 1, eff. June 15, 2007.


Sec. 33.207. CONTACT INFORMATION. (a) The commissioner shall maintain an existing telephone number and an electronic mail address to allow a person to report a violation of this subchapter.


(b) Each school that offers an extracurricular athletic activity shall prominently display at the administrative offices of the school the telephone number and electronic mail address maintained under Subsection (a).


Added by Acts 2007, 80th Leg., R.S., Ch. 1296 (S.B. 82), Sec. 1, eff. June 15, 2007.


Sec. 33.208. NOTICE REQUIRED. (a) A school that offers an extracurricular athletic activity shall provide to each student participating in an extracurricular athletic activity and to the student's parent or guardian a copy of the text of Sections 33.201-33.207 and a copy of the University Interscholastic League's parent information manual.


(b) A document required to be provided under this section may be provided in an electronic format unless otherwise requested by a student, parent, or guardian.


Added by Acts 2007, 80th Leg., R.S., Ch. 1296 (S.B. 82), Sec. 1, eff. June 15, 2007.


Sec. 33.209. INCORPORATION OF SAFETY REGULATIONS. The University Interscholastic League shall incorporate the provisions of Sections 33.203-33.207 into the league's constitution and contest rules.


Added by Acts 2007, 80th Leg., R.S., Ch. 1296 (S.B. 82), Sec. 1, eff. June 15, 2007.


Sec. 33.210. IMMUNITY FROM LIABILITY. This subchapter does not waive any liability or immunity of a school district or its officers or employees. This subchapter does not create any liability for or a cause of action against a school district or its officers or employees.


Added by Acts 2007, 80th Leg., R.S., Ch. 1296 (S.B. 82), Sec. 1, eff. June 15, 2007.


Sec. 33.211. LIMITATION ON LIABILITY. A person who volunteers to assist with an extracurricular activity is not liable for civil damages arising out of an act or omission relating to the requirements under Section 33.205 unless the act or omission is willfully or wantonly negligent.


Added by Acts 2007, 80th Leg., R.S., Ch. 1296 (S.B. 82), Sec. 1, eff. June 15, 2007.


SUBCHAPTER G. EXPANDED LEARNING OPPORTUNITIES COUNCIL



Sec. 33.251. DEFINITION. In this chapter, "council" means the Expanded Learning Opportunities Council.


Added by Acts 2013, 83rd Leg., R.S., Ch. 531 (S.B. 503), Sec. 1, eff. June 14, 2013.


Sec. 33.252. EXPANDED LEARNING OPPORTUNITIES. (a) Expanded learning opportunities may be provided during:


(1) an extended school day;


(2) an extended school year; or


(3) structured learning programs outside of the regular school day, including before- and after-school programs and summer programs.


(b) Expanded learning opportunities may be provided by offering:


(1) rigorous coursework;


(2) mentoring;


(3) tutoring;


(4) physical activity;


(5) academic support; or


(6) educational enrichment in one or more subjects, including fine arts, civic engagement, science, technology, engineering, and mathematics.


Added by Acts 2013, 83rd Leg., R.S., Ch. 531 (S.B. 503), Sec. 1, eff. June 14, 2013.


Sec. 33.253. ESTABLISHMENT; PURPOSES. (a) The Expanded Learning Opportunities Council is established to:


(1) study issues concerning expanded learning opportunities for this state's public school students, including:


(A) issues related to creating safe places for children outside of the regular school day, improving the academic success of students who participate in expanded learning opportunities programs, and assisting working families; and


(B) other issues prescribed under Section 33.258; and


(2) make recommendations as provided by Section 33.259 to address issues studied under this subchapter.


(b) In conducting studies under this subchapter, the council shall focus on innovative, hands-on learning approaches that complement rather than replicate the regular school curriculum.


Added by Acts 2013, 83rd Leg., R.S., Ch. 531 (S.B. 503), Sec. 1, eff. June 14, 2013.


Sec. 33.254. SUNSET PROVISION. The council is subject to Chapter 325, Government Code (Texas Sunset Act). Unless continued in existence as provided by that chapter, the council is abolished and this subchapter expires September 1, 2027.


Added by Acts 2013, 83rd Leg., R.S., Ch. 531 (S.B. 503), Sec. 1, eff. June 14, 2013.


Amended by:


Acts 2015, 84th Leg., R.S., Ch. 938 (H.B. 3123), Sec. 2.01, eff. June 18, 2015.


Acts 2019, 86th Leg., R.S., Ch. 596 (S.B. 619), Sec. 4.02, eff. June 10, 2019.


Sec. 33.255. COMPOSITION. The council is composed of 13 members appointed by the commissioner as follows:


(1) two members of the public, including one representing the business community and one parent of a public school student participating in an expanded learning opportunities program in this state;


(2) two members who are involved in research-based expanded learning opportunities efforts in this state so that at least one is involved in efforts to extend the school day or school year and at least one is involved in efforts to provide out of school time before or after the regular school day or during the period in which school is recessed for the summer;


(3) one member representing law enforcement;


(4) one member representing the agency;


(5) one member who is an educator, other than a superintendent, at the elementary school level;


(6) one member who is an educator, other than a superintendent, at the middle or junior high school level;


(7) one member who is an educator, other than a superintendent, at the high school level;


(8) one member who is a public school superintendent;


(9) one member representing a foundation that invests in expanded learning opportunities;


(10) one member representing a nonprofit organization that provides programs concerning good nutrition and prevention of or intervention to address childhood obesity; and


(11) one member who is a provider representing summer camps.


Added by Acts 2013, 83rd Leg., R.S., Ch. 531 (S.B. 503), Sec. 1, eff. June 14, 2013.


Sec. 33.256. MEETINGS. (a) The council shall meet in person at least three times each year and may hold additional meetings by conference call if necessary.


(b) Section 551.125, Government Code, applies to a meeting held by conference call under this section, except that Section 551.125(b), Government Code, does not apply.


Added by Acts 2013, 83rd Leg., R.S., Ch. 531 (S.B. 503), Sec. 1, eff. June 14, 2013.


Sec. 33.257. COMPENSATION. A member of the council may not receive compensation for service on the council.


Added by Acts 2013, 83rd Leg., R.S., Ch. 531 (S.B. 503), Sec. 1, eff. June 14, 2013.


Sec. 33.258. POWERS AND DUTIES. (a) The council shall:


(1) study issues related to expanded learning opportunities for public school students;


(2) study current research and best practices related to meaningful expanded learning opportunities;


(3) analyze the availability of and unmet needs for state and local programs for expanded learning opportunities for public school students;


(4) analyze opportunities to create incentives for businesses to support expanded learning opportunities programs for public school students;


(5) analyze opportunities to maximize charitable support for public and private partnerships for expanded learning opportunities programs for public school students;


(6) analyze opportunities to promote science, technology, engineering, and mathematics in expanded learning opportunities programs for public school students;


(7) study the future workforce needs of this state's businesses and other employers; and


(8) perform other duties consistent with this subchapter.


(b) In carrying out its powers and duties under this section, the council may request reports and other information relating to expanded learning opportunities and students in expanded learning opportunities programs from the Texas Education Agency and any other state agency.


Added by Acts 2013, 83rd Leg., R.S., Ch. 531 (S.B. 503), Sec. 1, eff. June 14, 2013.


Sec. 33.259. STATEWIDE EXPANDED LEARNING OPPORTUNITIES PLAN; REPORT. (a) The council shall develop a comprehensive statewide action plan for the improvement of expanded learning opportunities for public school students in this state, including a timeline for implementation of the plan.


(b) The council shall submit to both houses of the legislature, the governor, and the agency on or before November 1 of each even-numbered year a written report concerning:


(1) the status of the development or implementation of the council's statewide action plan, as applicable;


(2) any action taken to further development or implementation of the plan;


(3) any area that needs improvement in implementing the plan;


(4) any recommended change to the plan; and


(5) programs and services that address expanded learning opportunities outside of the regular school day.


Added by Acts 2013, 83rd Leg., R.S., Ch. 531 (S.B. 503), Sec. 1, eff. June 14, 2013.


Sec. 33.260. GIFTS, GRANTS, AND DONATIONS. The agency may accept on behalf of the council a gift, grant, or donation from any source to carry out the purposes of this subchapter.


Added by Acts 2013, 83rd Leg., R.S., Ch. 531 (S.B. 503), Sec. 1, eff. June 14, 2013.


SUBCHAPTER Z. MISCELLANEOUS PROVISIONS



Sec. 33.901. BREAKFAST PROGRAMS. (a) If at least 10 percent of the students enrolled in one or more schools in a school district or enrolled in an open-enrollment charter school are eligible for free or reduced-price breakfasts under the national school breakfast program provided for by the Child Nutrition Act of 1966 (42 U.S.C. Section 1773), the board of trustees of the school district or the governing body of the open-enrollment charter school shall either:


(1) participate in the national program and make the benefits of the national program available to all eligible students in the schools or school; or


(2) develop and implement a locally funded program to provide free meals, including breakfast and lunch, to each student eligible for free meals under federal law and reduced-price meals, including breakfast and lunch, to each student eligible for reduced-price meals under federal law, provided that the reduced price may not exceed the maximum allowable rate under federal law.


(a-1) A school district is permitted under Subsection (a) to participate in the national program at one or more campuses in the district and provide a locally funded program at one or more other campuses in the district.


(b) A school district campus or an open-enrollment charter school participating in the national school breakfast program provided by the Child Nutrition Act of 1966 (42 U.S.C. Section 1773) or providing a locally funded program in which 80 percent or more of the students qualify under the national program for a free or reduced-price breakfast shall offer a free breakfast to each student.


(c) The commissioner shall grant a waiver of the free breakfast requirements under Subsection (b), not to exceed one year, to a school district campus or an open-enrollment charter school if the board of trustees of the school district or the governing body of the open-enrollment charter school votes to request the waiver at the annual meeting of the board of trustees required under Section 44.004 or an annual meeting of the governing body called to adopt a budget for the open-enrollment charter school for the succeeding fiscal year. Before voting to request a waiver under this subsection, the board of trustees or the governing body shall list the waiver as a separate item for consideration on the meeting's agenda and provide an opportunity for public comment regarding the waiver at the meeting.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995.


Amended by:


Acts 2013, 83rd Leg., R.S., Ch. 130 (S.B. 376), Sec. 1, eff. September 1, 2013.


Acts 2015, 84th Leg., R.S., Ch. 1250 (H.B. 1305), Sec. 1, eff. June 20, 2015.


Sec. 33.902. PUBLIC SCHOOL CHILD CARE. (a) In this section, "school-age students" means children enrolled as students in prekindergarten through grade 7.


(b) Repealed by Acts 2011, 82nd Leg., 1st C.S., Ch. 8, Sec. 21(3), eff. September 28, 2011.


(c) Repealed by Acts 2011, 82nd Leg., 1st C.S., Ch. 8, Sec. 21(3), eff. September 28, 2011.


(d) The Work and Family Policies Clearinghouse may distribute money appropriated by the legislature to any school district for the purpose of implementing school-age child care before and after the school day and during school holidays and vacations for a school district's school-age students. Eligible use of funds shall include planning, development, establishment, expansion, or improvement of child care services and reasonable start-up costs. The clearinghouse may distribute money to pay fees charged for providing services to students who are considered to be at risk of dropping out of school under Section 29.081. The Texas Workforce Commission shall by rule establish procedures and eligibility requirements for distributing this money to school districts.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995. Amended by Acts 1997, 75th Leg., ch. 118, Sec. 1, eff. Sept. 1, 1997.


Amended by:


Acts 2011, 82nd Leg., 1st C.S., Ch. 8 (S.B. 8), Sec. 21(3), eff. September 28, 2011.


Sec. 33.903. COMMUNITY EDUCATION CHILD CARE SERVICES. (a) The agency shall establish a pilot program for the development of community education child care services as provided by this section. From the total amount of funds appropriated to the agency, the commissioner shall withhold an amount specified in the General Appropriations Act and distribute that amount for programs under this section. A program established under this section is required only in a school district in which the program is financed by funds distributed under this section and any other funds available for the program.


(b) The legislature may make appropriations to the agency for the purpose of supporting before- and after-school child care programs in a school district that is operating a community education development project.


(c) The agency shall actively seek federal grants or funds to operate or expand a program established under this section.


(d) The State Board of Education by rule shall establish a procedure for distributing funds to school districts for child care programs under this section. The procedure must include a statewide competitive process by which the agency shall evaluate applications for child care programs submitted by eligible school districts and award funds to those districts whose applications the agency considers to possess the greatest merit. The State Board of Education by rule shall establish guidelines and objectives that the agency shall use in making evaluations for funding determination purposes. A school district is not entitled to administrative or judicial review of the agency's funding determination, except to the extent that the State Board of Education by rule provides for administrative review.


(e) The agency may not consider a school district's application for child care funding unless the application:


(1) contains a resolution by the district's board of trustees or governing body adopting a particular child care plan;


(2) states the anticipated funding requirements for the district's child care program and provides the agency with the data and any analysis used to prepare the funding estimate;


(3) includes or is accompanied by a statement outlining how the proposed project effectuates the goals of this section and complies with the guidelines and objectives established under Subsection (d);


(4) provides that the district will provide before- and after-school care between the hours of 7 a.m. and 6 p.m. for any student in kindergarten through grade eight whose parents or legal guardians work, attend school, or participate in a job-training program during those hours;


(5) specifies that the district's child care program outlined in the application will maintain a ratio of not less than one caregiver per 20 students in kindergarten through grade three and a ratio of not less than one caregiver per 25 students in grades four through eight and will provide age-appropriate educational and recreational activities and homework assistance; and


(6) states that the district has appointed a child care administrator.


(f) A school district's child care administrator shall administer and coordinate the program under the authority of the district superintendent or another administrator the superintendent designates. The child care administrator shall appoint a coordinator to oversee the child care activities at each school site under the authority of the school's principal. Each district is encouraged to collaborate with child care management system contractors and Head Start program providers.


(g) Each school district may provide full-day care for students on school holidays and teacher preparation days and during periods school is in recess, including summer vacation.


(h) A school district may supplement any funds received under this section with funds received through other government assistance programs, program tuition, or private donations. Any tuition charge may reflect only the actual cost of care provided to the student, and the agency or other appropriate governmental agency approved by the commissioner may audit a program to ensure compliance with this subsection. A school district shall use state funds awarded under this section to benefit educationally disadvantaged children before using those funds for the care of other children.


(i) A school district may not use funds awarded under this section for student transportation unless that transportation is incident to an activity related to the curriculum of the child care program.


(j) A school district may use funds awarded under this section to contract with a private entity for providing child care services. Each of those entities shall adhere to the requirements of this section. A contract under this subsection is not effective until approved by the agency. The agency shall review each contract to ensure that the services to be delivered comply with this section. Each contract shall be awarded without regard to the race or gender of the contracting party, notwithstanding any other law.


(k) Each school district receiving funds under this section shall adopt minimum training and skills requirements that each individual providing child care or staff assistance for a district program under this section must satisfy. The agency shall determine whether those minimum requirements fulfill the aims and policies of this section and shall suspend the payment of funds to any district whose minimum requirements fail to fulfill the aims and policies of this section. The State Board of Education by rule shall adopt criteria by which the agency shall evaluate district minimum training and skills requirements. Any suspension order is subject to Chapter 2001, Government Code. A district may seek review of a suspension order under the review process adopted under Subsection (m).


(l) The State Board of Education by rule may authorize a school district to receive technical and planning assistance from a regional education service center.


(m) The agency shall monitor and review programs receiving funds under this section and may suspend funds to a school district whose programs fail to comply with this section. The State Board of Education by rule shall adopt an administrative process to review a suspension. Both a suspension order and the administrative review process are subject to Chapter 2001, Government Code.


Added by Acts 1995, 74th Leg., ch. 260, Sec. 1, eff. May 30, 1995.


Sec. 33.9031. BEFORE-SCHOOL AND AFTER-SCHOOL PROGRAMS. (a) The board of trustees of a school district may establish before-school or after-school programs for students enrolled in elementary or middle school grades. A program established under this section may operate before, after, or before and after school hours.


(b) A student is eligible to participate in a school district's before-school or after-school program if the student:


(1) is enrolled in a public or private school; or


(2) resides within the boundaries of the school district.


(c) A school district shall conduct a request for proposals procurement process to enable the district to determine if contracting with a child-care facility that provides a before-school or after-school program, as defined by Section 42.002, Human Resources Code, to provide the district's before-school or after-school program would serve the district's best interests. Following the request for proposals procurement process, the district may enter into a contract with a child-care facility or implement a before-school or after-school program operated by the district. If the district enters into a contract with a child-care facility, the contract must comply with the requirements of Section 44.031 and may not exceed a term of three years.


(d) The board of trustees of a school district may adopt rules in accordance with Section 11.165 to provide access to school campuses before or after school hours for the purpose of providing a before-school or after-school program.


Added by Acts 2017, 85th Leg., R.S., Ch. 925 (S.B. 1566), Sec. 11, eff. September 1, 2017.


Sec. 33.904. LIAISON FOR CERTAIN CHILDREN IN CONSERVATORSHIP OF STATE. (a) Each school district and open-enrollment charter school shall:


(1) appoint at least one employee to act as a liaison officer to facilitate the enrollment in or transfer to a public school or open-enrollment charter school of a child in the district or area served by the charter school who is in the conservatorship of the state; and


(2) submit the liaison's name and contact information to the agency in a format and under the schedule determined by the commissioner.


(b) The agency shall provide information to the liaisons on practices for facilitating the enrollment in or transfer to a public school or open-enrollment charter school of children who are in the conservatorship of the state.


Added by Acts 2011, 82nd Leg., R.S., Ch. 725 (H.B. 826), Sec. 1, eff. September 1, 2011.


Amended by:


Acts 2013, 83rd Leg., R.S., Ch. 579 (S.B. 832), Sec. 1, eff. June 14, 2013.


For expiration of this section, see Subsection (f).



Sec. 33.906. WEBSITE INFORMATION CONCERNING LOCAL PROGRAMS AND SERVICES AVAILABLE TO ASSIST HOMELESS STUDENTS. (a) Except as provided by Subsection (e), each school that maintains an Internet website shall post on the website information regarding local programs and services, including charitable programs and services, available to assist students who are homeless.


(b) A school to which Subsection (a) applies shall make a good faith effort to compile information described by that subsection and shall post the information compiled in a format and style that is easily understandable by students or parents, as appropriate based on the grade levels the school offers.


(c) A representative of a local program or service available to assist students who are homeless may request to have information concerning the program or service posted on a school's website. A school may determine the information that is posted on the school's website and is not required to post information as requested by the representative.


(d) A school district is not liable for any harm to a student that results in connection with a local program or service referred to on the website of a district school as provided by this section.


(e) This section does not apply to a school within a school district that:


(1) has an enrollment of fewer than 3,000 students; and


(2) is primarily located in a county with a population of less than 50,000.


(f) This section expires September 1, 2025.


Added by Acts 2015, 84th Leg., R.S., Ch. 1035 (H.B. 1559), Sec. 1, eff. June 19, 2015.


Amended by:


Acts 2019, 86th Leg., R.S., Ch. 597 (S.B. 668), Sec. 1.09, eff. June 10, 2019.


Sec. 33.907. DONATION OF FOOD. (a) In this section:


(1) "Donate" has the meaning assigned by Section 76.001, Civil Practice and Remedies Code.


(2) "Nonprofit organization" has the meaning assigned by Section 76.001, Civil Practice and Remedies Code.


(b) A school district or open-enrollment charter school may allow a campus to elect to donate food to a nonprofit organization through a person who is directly and officially affiliated with the campus, including a teacher or counselor, or through a parent of a student enrolled at the campus. The donated food may be received, stored, and distributed on the campus. Food donated by the campus may include:


(1) surplus food prepared for breakfast, lunch, or dinner meals or snacks served from the campus cafeteria, subject to any applicable local, state, and federal requirements; or


(2) food donated to the campus as the result of a food drive or similar event.


(c) The type of food donated under Subsection (b)(1) may include:


(1) packaged unserved food that is packaged on the campus of a school district or open-enrollment charter school and has not been removed from the campus cafeteria;


(2) packaged served food if the packaging and food are in good condition;


(3) whole, uncut produce; and


(4) wrapped raw unserved produce.


(c-1) Food that by law must be maintained at a certain temperature for safety may not be donated unless the campus has maintained the food at the required temperature.


(d) Food donated under this section to a nonprofit organization may be distributed at the campus at any time. Campus employees may assist in preparing and distributing the food as volunteers for the nonprofit organization.


(e) Under this program, a school district or open-enrollment charter school may adopt a policy under which the district or charter school provides food at no cost to a student for breakfast, lunch, or dinner meals or a snack if the student is unable to purchase breakfast, lunch, or dinner meals or a snack.


(f) The commissioner may adopt rules as necessary to implement this section.


Added by Acts 2017, 85th Leg., R.S., Ch. 569 (S.B. 725), Sec. 1, eff. June 9, 2017.


Amended by:


Acts 2021, 87th Leg., R.S., Ch. 610 (S.B. 1351), Sec. 1, eff. September 1, 2021.


Sec. 33.908. GRACE PERIOD POLICY FOR EXHAUSTED OR INSUFFICIENT MEAL CARD OR ACCOUNT BALANCE. The board of trustees of a school district that allows students to use a prepaid meal card or account to purchase meals served at schools in the district shall adopt a grace period policy regarding the use of the cards or accounts. The policy:


(1) must allow a student whose meal card or account balance is exhausted or insufficient to continue, for a period determined by the board, to purchase meals by:


(A) accumulating a negative balance on the student's card or account; or


(B) otherwise receiving an extension of credit from the district;


(2) must require the district to notify the parent of or person standing in parental relation to the student that the student's meal card or account balance is exhausted;


(3) may not permit the district to charge a fee or interest in connection with meals purchased under Subdivision (1); and


(4) may permit the district to set a schedule for repayment on the account balance as part of the notice to the parent or person standing in parental relation to the student.


Added by Acts 2015, 84th Leg., R.S., Ch. 875 (H.B. 3562), Sec. 1, eff. June 18, 2015.


Amended by:


Acts 2017, 85th Leg., R.S., Ch. 925 (S.B. 1566), Sec. 12, eff. September 1, 2017.


Sec. 33.909. PURPLE STAR CAMPUS. (a) In this section, "military-connected student" has the meaning assigned by Section 25.006.


(b) The agency shall designate a school district campus as a Purple Star Campus if the campus applies and qualifies for the designation under this section.


(c) To qualify as a Purple Star Campus, a campus must:


(1) designate a staff member as a military liaison, whose duties include:


(A) identifying military-connected students enrolled at the campus through the Public Education Information Management System (PEIMS);


(B) serving as the point of contact between the campus and military-connected students and their families;


(C) determining appropriate campus services available to military-connected students; and


(D) assisting in coordinating campus programs relevant to military-connected students;


(2) maintain on the campus Internet website an easily accessible web page that includes resources for military-connected students and their families, including information regarding:


(A) relocation to, enrollment at, registration at, and transferring records to the campus;


(B) academic planning, course sequences, and advanced classes available at the campus;


(C) counseling and other support services available for military-connected students enrolled at the campus; and


(D) the military liaison designated under Subdivision (1) and the liaison's duties under that subdivision;


(3) maintain a transition program led by students, where appropriate, that assists military-connected students in transitioning into the campus;


(4) offer professional development for staff members on issues related to military-connected students; and


(5) offer at least one of the following initiatives:


(A) a resolution showing support for military-connected students and their families;


(B) recognition of the Month of the Military Child or Military Family Month with relevant events hosted by the campus; or


(C) a partnership with a local military installation that provides opportunities for active duty military members to volunteer at the campus, speak at an assembly, or host a field trip.


(d) To comply with a requirement under Subsection (c)(2), (4), or (5), a school district campus may partner with the district to provide:


(1) an Internet website web page required under Subsection (c)(2) if the campus does not have an Internet website;


(2) professional development required under Subsection (c)(4); or


(3) an initiative required under Subsection (c)(5).


(e) The agency shall adopt rules as necessary to administer this section.


Added by Acts 2019, 86th Leg., R.S., Ch. 269 (S.B. 1557), Sec. 2, eff. May 28, 2019.


Sec. 33.913. TUTORING PROGRAM. (a) A member of a nonprofit teacher organization or a person who is not a member but meets the requirements under Subsection (b) may participate in a tutoring program in accordance with this section to provide supplemental instruction to students in kindergarten through grade 12 on an individualized or small-group basis.


(b) To participate in the program as a tutor, a person must:


(1) be an active or retired teacher;


(2) apply for the position in a manner specified by the nonprofit organization;


(3) designate in the application whether the person plans to provide tutoring:


(A) for compensation, on a volunteer basis, or both; and


(B) in person, online, or both; and


(4) not be included in the registry of persons not eligible for employment by a public school under Section 22.092.


(c) The superintendent or chief executive officer of each school district or open-enrollment charter school or the person designated by the superintendent or chief executive officer shall:


(1) oversee the tutoring program within the district or school; and


(2) not later than the last day of each semester, submit a report to the board of trustees of the district or the governing body of the school that includes, with respect to that semester:


(A) the number of active or retired teachers who contacted the district or school to offer tutoring services to students in the district or school; and


(B) the number of active or retired teachers who were used by the district or school as a tutor on a volunteer basis or employed by the district or school to provide tutoring services for compensation.


(d) A school district or open-enrollment charter school may use any available local, state, or federal funds to provide compensation to a person participating in the program as a tutor who is providing tutoring for compensation under the program.


(e) If an active or retired teacher who has been approved for participation in the tutoring program contacts a school district or open-enrollment charter school to provide tutoring to students in the district or school and the district or school needs tutoring assistance, the district or school may:


(1) if the teacher is providing tutoring services on a volunteer basis, use the volunteer tutoring services provided by the teacher; or


(2) if the district or school has local, state, or federal funds for purposes of the tutoring program and the teacher is providing tutoring services for compensation, employ the teacher as a tutor.


(f) At least quarterly, each nonprofit organization participating in the tutoring program shall provide to the organization's members:


(1) a description of the tutoring program and guidance on how to participate in the program; and


(2) the contact information of each person described by Subsection (c) for the school district in which the member resides, any open-enrollment charter schools located within that district, and any adjacent districts.


(g) This section does not create a cause of action or liability or an obligation or duty that provides a basis for a cause of action or liability against a nonprofit teacher organization approved by the commissioner for the purpose of participating in the tutoring program for any action taken by a member of the organization participating in the program as a tutor.


Added by Acts 2021, 87th Leg., R.S., Ch. 806 (H.B. 1525), Sec. 15, eff. September 1, 2021.


Added by Acts 2021, 87th Leg., R.S., Ch. 880 (S.B. 1356), Sec. 2, eff. June 16, 2021.

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EDUCATION CODE CHAPTER 33. SERVICE PROGRAMS AND EXTRACURRICULAR ACTIVITIES

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American Counseling Association. (2014). 2014 ACA code of ethics. https://www.counseling.org/docs/default-source/default-document-library/2014-code-of-ethics-finaladdress.pdf

Texas Education Agency. (2018). The Texas model for comprehensive school counseling programs (5th ed.). Texas Counseling Association. https://tea.texas.gov/sites/default/files/Pub_2018_Texas-Model_5th-Edition.pdf

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