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PBIS World | A Complete Tier 1 Through Tier 3 Positive Behavior Interventions & Supports System

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PBIS World is in no way affiliated, associated, or connected with any other website, entity, organization, or federal, state, local, or other government agency, department, program, policy, organization, or initiative.

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Managing Referrals for Disruptive Behavior for School Counselors

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Managing Referrals for Disruptive Behavior for School Counselors

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Managing behavior referrals often fall under the realm of school counseling. However, most school counseling programs have few, if any, behavior management components. Don't worry, we've got you covered! Confident Counselor authors are ready to share their best practices for managing behavior referrals. Heather will cover the details we need to know first when presented with a behavior. Carla has some tips for clarifying the problem with the teacher. Finally, Robyn has some solid advice on how to engage the parents.

Hey there! I'm Heather from The Helpful Counselor Blog & Counseling Resources . Over the past two decades, I've worked as a therapist, school counselor, and special education teacher for students with emotional impairments. I pride myself on my ability to develop rapport and engage the tougher "hard to help" students. There's just something about watching them grow into their full potential!

Has a teacher ever referred a student to you for being disruptive but you were unsure about how to help? Sometimes, uncertainty can leave counselors feeling less than the helpful superstar they are.

The term "disruptive behavior" is extremely broad. It can mean anything that interrupts the classroom. Sometimes teachers will give you a broad description like a student is "angry". But unless we know the details, we won't be able to pinpoint . In order to help, we need to what's behind their anger clarify the problem.

Description of disruptive behaviors.

When does it occur (e.g., time of day, day of the week, subject)?

When did the behavior first begin?

How frequently does the behavior occur?

How long the behavior lasts?

What happened right before the disruptive behavior?

Gathering all of these details will help you narrow down the behavior AND the cause of the disruptive behavior.

Example: A student is extremely argumentative and off-task for most of the day every Friday. Upon speaking with the student, we learn he started visiting his father over the weekend. Although it's not 100% conclusive, there could be a connection and it certainly warrants further exploration!

Another Example: A student talks to the student around him whenever the teacher uses the overhead projector. While speaking with the student, they admit that they can't read what's being projected. The words are blurry. The two examples both contained disruptive behavior, but one of them might be helped with a pair of glasses while the other student may need counseling to learn some coping or anger management skills to help process the changes in his home life.

Hello, I'm Carla Christian, the DIY Counselor. I am a wife to Bill, Mom to three daughters, and Nanna to four grands with one on the way. Spending time with family and advocating for my profession are two things that I am very passionate about. My twenty plus years of experience as an educator have enabled me to create resources for teachers and school counselors. I especially enjoy developing no prep lessons for middle level school counselors

Sometimes it seems my colleagues are saying, "Here, fix this!" When this happens, it is difficult to know how to support the teacher and help the student right at that moment. How does one handle these impromptu encounters? I have found that consultation and collaboration are essential in managing behavioral referrals and helping teachers manage disruptive behaviors in the classroom.

Strategies for those spur of the moment behavior referral conversations

Ask the teacher specific questions: "Where are you in your discipline plan with this student?" "Have you contacted the parent?" "What are the most disruptive behaviors?" The answers provide a starting point to determine how to proceed. (Our school has a uniform discipline plan that teachers are to follow. Parent contact is the first step.) If there has been no parent contact, the teacher should inform the parents of student behavior. After there has been parent contact, consult with the teacher and move to the next step.

Request the teacher fill out a referral form. (This form documents all that the teacher has done prior to the referral and is vital in determining a plan of action.)

Observe the student in different settings. (include classroom, cafeteria, hallway, gym)

Meet with the teacher to discuss information from the referral and observations.

Work with the teacher to develop strategies for addressing student behavior, including behavior goals, behavior tracking charts, positive rewards, seating arrangement, classroom management, etc.

After a designated time, evaluate strategies to determine effectiveness.

If there is no improvement in student behavior, follow-up may include a conference with the parent, referral to a counselor for individual counseling, conference with admin, or a functional behavior assessment and behavior intervention plan.

Hello, I am Robyn from the TPT store Mental Fills. I am a Licensed Clinical Social Worker in California with close to 20 years of experience in the field of Mental Health. I have worked with a broad range of children, teens, and adults in inpatient psychiatric hospitals, residential treatment facilities, and outpatient mental health clinics providing individual and group therapy. Currently, I work full-time in The Department of Mental Health at a military hospital and part-time in private practice. Although I specialize in evidenced based treatment for anxiety, depression, and interpersonal relationships, it is my experience as a parent of a child with special needs in elementary school that has inspired both my TPT resources and my tips on engaging parents of disruptive children.

Reach out to parents early on to share your interest and good intentions of working together. After speaking to a parent in person or over the phone, an online partnership might be a good next step. To promote parent reception and eliminate defensiveness, consider scheduled weekly or biweekly emails:

Review specific goal(s). Keep the email focused on the specific goal that is being worked on. This will help eliminate child blame and focus on strategies that are working or need tweaking. For example, instead of "I am emailing you about David's anger problem," try "I am emailing you today regarding our goal of anger management."

Use language that demonstrates partnership, such as "us, we, our, let's." Although this may show a looseness of boundaries, we want parents to understand we are equally invested in their child's goals and progress; and this avoids blaming statements. A helpful example of positive language is, " work on helping David with coping skills this week."

Invite parent expertise. A newbie mistake is assuming parents are at fault for their child's behaviors. Regularly ask the parent/s for their advice. Ask what has worked for their child before, what is working for the child at home, and what reasonable suggestions the school could try to help their child's behavior. This will not only provide strategies you may not have considered before but helps to improve the parent's feeling of value and connection.

Include positive behaviors and progress towards goals. Similar to children, parents need to feel encouraged and supported. Parents need to hear their children are moving in a positive direction and although there may be a temporary regression, reminders of the steps made forward are necessary to sustain hope. Although this may be a challenge, it will be a critical piece of gaining parent investment.

When sharing updates that include negative behaviors, avoid language that shows judgment or criticism. Simply state the facts. Instead of "David lost control again and rudely threw his pencil. He can't seem to control his anger," try, "David struggled with impulse control today and threw his pencil." Sticking to facts prevents emotional and finger-pointing responses.

Avoid reviewing the negative consequences to their child's behaviors, such as "the teacher and the classmates are tired of his behavior." This will only promote shame and resistance. Instead, focus on the positive consequences that include the both of you working together. For example, "I plan to review coping skills with David this week. I will send home a list of the skills he prefers to practice at home."

Offer help. Even the best of parents feel helpless and inadequate. Instead of imposing recommendations, when appropriate, gently offer solutions. For example, "If you are interested, I have found some useful tips that may work at home, I would be happy to email you." Other suggestions that help support the parent include collaborating with the student's outside therapist and providing updates as needed.

Lastly, although parents can have a negative influence at times, we do not want to take for granted the positive influences they have on your student's success. These emails may seem like a chore at first, but once you create a trusting connection with a parent, the fewer details need to be provided and most importantly, the alliance built aids in improved behaviors. Finally, when writing your email, always put yourself in the parent's shoes and ask yourself, what would I want to read if this was my child?

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Managing Referrals for Disruptive Behavior

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Managing behavior referrals often fall under the realm of school counseling. However, most school counseling programs have few, if any, behavior management components. Don't worry, we've got you covered! Confident Counselor authors are ready to share their best practices for managing behavior referrals.

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Gilmartin, B. (23 April 2021). Parenting children with ADHD [Infographic]. VeryWell Mind. https://www.verywellmind.com/adhd-in-children-20844

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Parenting Strategies for Children with ADHD

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Parenting Strategies for Children with ADHD

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Mental health awareness is an important issue for all educators, who are often the first line of defense for their students. Education professionals have recognized the impact that a student's mental health has on learning and achievement, and they realize that there's a great deal that can be done to help students with mental health issues. As a high school teacher with more than 23 years of experience, I welcome the fact that mental health awareness is finally becoming an important part of a school's function and curriculum.

Seeing the Signs in My Student

A few years ago, a student in my senior class changed drastically in a short period of time. I noticed that Melina no longer did her homework, and she didn't even try on her essays. Previously meticulous in her appearance, Melina would come to school disheveled, wearing the same clothes. When I tried to speak to her, she was uncharacteristically distant and withdrawn. Because I had some training in mental health awareness, I knew Melina was in some sort of trouble.

Luckily, my school had social workers on staff who could speak to Melina and assess her issues. They discovered that Melina was depressed and suicidal, and she needed an immediate psychiatric intervention. Melina was hospitalized for a period of time, but she was able to return to my classroom a few months later. With the help of medication and therapy, she managed to graduate with her class.

Understanding the Impact

The National Alliance on Mental Illness estimates that one in five people live with some sort of mental disorder or disease. Despite the fact that the average age of early signs of mental illness is 14, most individuals don't seek help until adulthood. Underlining the seriousness is the fact that 60 percent of high school students with mental illness don't graduate.
Further reading: Ease Student Anxiety in the Classroom
New York mental health experts recognized that earlier intervention could result in more positive outcomes for these students. Beginning in July 2018, New York will be the first state in the nation to require mental health education for all students. The overall mission of New York's School Mental Health (SMH) program is to promote healthy social, emotional, and behavioral development of students, and "break down barriers to learning so the general well-being of students, families, and school staff can be enhanced in collaboration with other comprehensive student support and services."

The SMH program supports the emotional health and academic growth of all students with the following:

Integrating comprehensive services and support throughout every grade level

Assessing mental health needs through universal, selective, and targeted interventions

Providing access to behavioral and mental health services and programs

Leveraging higher-level personnel, such as those working with the Department of Education, for necessary support and services

Building collaborative relationships between the school and students' families and communities

Spreading Awareness Across the Nation

Until mental health education is a mandatory aspect of all schools, teachers and administrators can work to promote awareness with their students. Key elements to shine a light on include the concept of self-care and responsibility for one's own mental health and wellness, with an emphasis on the fact that mental health is an integral part of health, and the concept of recovery from mental illness.

Teachers and students should be provided with ways to recognize signs of developing mental health problems, and there should be opportunities around the awareness and management of mental health crises, including the risk of suicide or self-harm. Further, instruction should address the relationship between mental health, substance abuse, and other negative coping behaviors, as well as the negative impact of stigma and cultural attitudes toward mental illness.
Further reading: Social-Emotional Learning
Because teens spend most of their day at school, it just makes sense to have mental health awareness and education become part of the curriculum. When we empower students with knowledge, and encourage dialogue, students will be able to get the help they need.

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The Importance of Mental Health Awareness in Schools

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Mental health awareness is an important conversation few schools have with their students. Introducing the right resources can make a huge difference.

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Graeber, D.  (18 September 2013). Psychotic disorders in children and adolescents. Indian Health Service. www.ihs.gov 

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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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Each child is an individual with different social, emotional, and academic strengths and weaknesses. Therefore, their educational needs may vary from one season or school year to the next.

In the first section of our chapter, "School: A Child's World Beyond Home" we cover the legal evolution of the Individual with Disabilities Educational Act (IDEA 2004) and advise a parent how to initiate an Individual Education Plan (IEP), prepare for the IEP meeting (including rehearsal strategies), and locate educational consultants and attorneys.

But the more we talked to people in preparation for this chapter, the more we came to understand that both parents and educators were confused about the construction of an IEP for a student struggling with a bipolar disorder. A model IEP-one that specifically addresses the seasonal variations in mood, energy, attention, motivation, and behavior, as well as one that addresses the frequently co-occurring executive function deficits, needed to be developed.

Therefore, we asked special education advocate, Anne Marie Smith, M. Ed., from Agawam, Massachusetts, to construct an IEP that might provide guidelines for educating a middle school student throughout the school year.

With the hope that the following information is helpful to parents and educators alike, we excerpt the following from The Bipolar Child (pages 305-311.) Also see pages 295-303 in the book for a highly focused and very comprehensive list of accommodations, modifications, and special services that can be incorporated into an IEP.
From The Bipolar Child by Demitri Papolos, M.D. and Janice Papolos (Broadway Books, 2006). All rights reserved.

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Bipolar Children Individual Education Plan (IEP) Model

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Each child is an individual with different social, emotional, and academic strengths and weaknesses. Therefore, their educational needs may vary from one season or school year to the next.

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Accommodations for Students with Bipolar Disorder & Related Disabilities

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Accommodations for Students with Bipolar Disorder & Related Disabilities

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Not all students who have disabilities require specialized instruction. For students with disabilities who do require specialized instruction in the United States, the IDEA controls the procedural requirements and an IEP is developed. "Special education" under IDEA means the child has been identified as having unique educational needs related to his/her disability and is entitled to an Individualized Education Program (IEP) to meet these needs.

The IDEA process is more involved than that of Section 504 of the Rehabilitation Act. The IDEA requires that measurable growth and progress towards written goals and objectives be documented.

For students with disabilities who do not require specialized instruction but need the assurance that they will receive equal access to public education and services, a document is created to outline their specific accessibility requirements. Section 504 is a federal civil rights law. The purpose of Section 504 is to protect persons with disabilities against discrimination for reasons related to their disabilities.

While students with a 504 plan do not require specialized instruction, and specific goals and objectives are not necessarily outlines nor is data tracked, the plan should be reviewed annually to ensure that the student is receiving the most effective accommodations for his/her specific circumstances.

Unlike IDEA, Section 504 does not guarantee that a child with a disability will receive an individualized educational program that is designed to meet the child's individual educational needs. Rather, it guarantees that accommodations will be made relative to their specific medical needs.

Eligibility for protections under Section 504 depends on the child in question having a physical or mental impairment which must substantially limit at least one major life activity. Major life activities include walking, seeing, hearing, speaking, breathing, learning, reading, writing, performing math calculations, working, caring for oneself, and performing manual tasks. Section 504 requires an evaluation that draws information from a variety of sources.

A child who receives Section 504 protections has fewer rights than the child who receives special education services under the IDEA. The child who receives special education services under the IDEA is automatically protected under Section 504.

Section 504 is designed to guarantee that children with disabilities will not be discriminated against. It is also important to understand that if your child does not qualify for special education services under IDEA, your child does not have the procedural protections that are available under the IDEA.

Under Section 504, the child with a disability may receive accommodations and modifications that are not available to children who are not disabled. These accommodations and modifications are also available under IDEA. For example; accommodations could include, but not be limited to, such things as:

Tests taken in a separate location with time limits waived or extended.

The use of a word processor due to fine motor, visual motor deficits.

Shortened assignments.

Standardized tests answers written directly in the test booklet and transferred onto answer sheet by teacher or assistant.

Class notes provided rather than having the student copy from the chalkboard or overhead.

Allowing the child to leave the classroom 2 to 3 minutes early to avoid crowded hallways.

Preferential seating in the classroom.

Provision of a daily assignment sheet to be filled out by the student and verified by the teacher for accuracy. The parent could then check to make sure that all the work is accomplished. This would assist with homework prioritizing and management.

Please note: These are simply examples. All or none of these may be suitable for your child.

Students with bipolar disorder may or may not have a need for specialized instruction provided within an IEP. For some students, simply being granted accommodations that make allowance for the side effects of medications, related anxiety issues, or results of mood changes is sufficient.

Students with bipolar disorder who are well-controlled on medication may or may not be plagued by racing thoughts, distracting thoughts, an inability to concentrate, decreased energy; all of which will require modifications in the teaching environment or instructional strategies.

For other students, the side effects of medications may be significant enough to require changes in instruction provided or curriculum modifications. Some of the common side effects of medications include: tremors (trembling of hands), blurred vision, loss of coordination, slurred speech, sedation, ataxia (unsteady movement), dizziness, seizures. Some students with bipolar disorder may also have one of a number of other disabilities that impacts their access to the general education curriculum; such as vision or hearing impairment, learning disability, processing problems, or other disability. The co-morbidity rates of ADHD, anxiety disorder, conduct disorder, oppositional-defiant disorder and learning disabilities in students with bipolar disorder tell us that we should explore all avenues available to meet the educational needs of our children.

The following accommodations are meant to serve as a resource for parents unsure of what possibilities exist:

Students on some medications may need:

increased access to water, unlimited access to restrooms (particularly students taking Lithium)

decreased reading assignments or having books on tape or computer screen-reading due to blurred vision

modified school arrival, shortened day, scheduling of core content during the student's most alert time, reducing homework and extending deadlines, providing notes, allowing longer or more frequent breaks, allowing exercise or other movement due to sleep impairment or to sedation of medications

provision of notes and listening guides, work monitoring, extended time on assignments, extra set of books for home use, breaking assignments into more manageable pieces, use of checklists, providing written instructions and/or other visual cues, use of word banks on fill-in types of tests and other modifications that aid retrieval/memory, testing in a separate room, or extended test time, use of multiple choice formats, use of oral exams rather than written demands, use of noise-canceling headsets, - all for impaired concentration, memory

reducing or discontinuing homework may be necessary for some students due to difficulties with concentration, sleep patterns, mood irritability. For these students it may be necessary to schedule a resource room period at the beginning of the day to get assignments ready for the day, or at the end of the day to complete assignments before leaving school

preferential seating can be used to help with vision, focus, reduce visual or auditory distraction, allow for discrete monitoring

and while a 504 plan will simply list the type of accommodation needed and the reasons for it/them, an IEP must contain objectives that are written with specific criteria; such as -Given a grade level reading assignment of 1 chapter with 4 comprehension questions, (name) will answer the questions with 60/70/80% accuracy. Or given an assignment containing 5 long division problems, (name) will complete 3/4/5 problems at 80% accuracy.

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Accommodations for Students with Bipolar Disorder and Related Disabilities - International Bipolar Foundation

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CE credits: 1

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

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

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

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

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

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

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

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

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

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

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

An overlooked diagnosis

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

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

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

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

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

Diagnosing in children

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

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

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

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

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

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

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

Early intervention

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

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

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

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

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

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

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

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

Treatment options

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

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

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

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

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

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

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

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

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

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

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

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

Alternative treatments

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

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

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

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

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

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

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

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

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Treating bipolar disorder in kids and teens

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

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Obsessive Compulsive Disorders & Related Disorders - Guide for Parents and Teachers

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Obsessive Compulsive Disorders & Related Disorders - Guide for Parents and Teachers

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While working on a project together, you see a friend packing up their work supplies in a very neat fashion. You can't help but point out that they've organized all their pens to be lined up in order of color and all facing the same direction in their box. "Oh," they reply. "That's just my OCD."

While often thought of as a condition related to neatness and particularness, OCD is often so much more.

Children can be particularly affected by OCD. The onset of symptoms can begin at any time, sometimes as early as three years old.

Parents and teachers need to understand the risk factors to make sure that children and teenagers who are at risk of developing OCD receive appropriate attention.

When treated properly, OCD can be controlled. If it goes unaddressed, it could lead to serious quality-of-life issues, not only for the child but also for family members.

Keep Reading To Learn

The truth about OCD

How to recognize symptoms of OCD in children and adolescents

How to successfully manage and treat OCD in young people

What Is OCD?

Obsessive compulsive disorder is highlighted by a pattern of unwanted and intrusive thoughts, fears, images, or sensations that lead to feelings of distress (including anxiety, disgust, "not just right" sensations) and repetitive behaviors aimed at canceling out that distress.

Usually, these unwanted thoughts are called obsessions. Unwanted, repetitive behaviors or mental acts are called compulsions.

Throughout life, most people will experience unwanted thoughts every so often. If the person doesn't have OCD, these unwanted thoughts won't cause much distress because they won't be interpreted as meaningful. The hallmark of OCD is that obsessions and compulsions lead to a clinically adverse impact on the life of a child.

For example, unwanted thoughts might be so bad that children have trouble sleeping at night. The repetitive behaviors may be so impactful and obstructive that the child has trouble leaving the house to go to school, play sports, or participate in their daily routine.

OCD can be devastating for a child or teen, but there's hope for those who receive proper psychiatric care

The good news is that there has been plenty of research into OCD, and there are treatment options available. Similar to other mental health disorders, the sooner this condition is diagnosed, the faster it can be treated.

For children to get the care they need, it is important to take an in-depth look at the obsessions and compulsions that fuel OCD.

Obsessions: What Are They?

Obsessions, as they relate to OCD, are fears that children, teenagers, and other individuals cannot stop thinking about. People living with OCD are usually aware that something is "off," and they often understand that the thoughts they are having are not normal.

These thoughts can make them anxious, and despite their best efforts, they cannot seem to stop thinking about them.

Some of the most common examples of obsessions include:

Fearfulness that they are going to die or get sick, no matter what they do

Concern that a loved one is going to end up getting sick, hurt, or killed

Worry that they have broken a rule and deserve to be punished severely for it

Fear of touching items because they are potentially dirty

Obsession with making sure that every object is placed in a certain, even, orderly manner

Worry that unless something is done in a specific order, it is going to lead to a bad outcome

The truth is that everyone has unwanted thoughts from time to time. The difference between occasional unwanted thoughts and OCD is that, in OCD, children cannot stop thinking about these thoughts and may be paralyzed by them. Often, these obsessions are so bad that kids cannot think about anything else.

Compulsions: What Are They?

For a child to have OCD, they need to have both obsessions and compulsions.

Compulsions are behaviors or mental acts that are typically repetitive and rigid in nature. These compulsions often take the form of rituals and are designed to counteract stress or prevent fearful outcomes. Kids with OCD have to do these behaviors over and over again in a certain order. If they do not, the obsessions take over, and they are worried that there will be a negative outcome. These behaviors might involve safety, cleanliness, orderliness, or symmetry. They have to be done "just right" or children are compelled to start over.

In a sense, these behaviors are rituals that provide children with a source of power. They feel like if they do these repetitive behaviors in a certain way, they can control what happens next.

Some of the most common examples of compulsions include:

Having to wash or clean things in a certain way every time

Thinking phrases over and over again until it "feels right"

Having to erase and rewrite, redo, or re-read things in a certain manner multiple times

Repeating a certain word or phrase much more often than is necessary until it is said an exact number of times or in exactly the right way

Checking every door in the house multiple times to make sure that is locked or passing in and out of doors several times in a row

Inspecting every light in the house to make sure it is turned off before leaving

Checking each homework assignment a certain number of times to make sure it was done properly

Chewing each bite on each side of the mouth the same number of times

Having to place everything in a specific, even, symmetrical order

Counting all items and objects to certain good numbers to avoid unlucky numbers

It's important to note that compulsions often arise out of adaptive behaviors. For example, it is good for children to double-check their homework to make sure it is done properly. On the other hand, if children end up checking their homework a dozen times to the detriment of other activities, this starts to have a clinically adverse impact on not only their life but the lives of family members as well.

The same can be said of checking to make sure that lights are turned off and doors are locked. It is good to make sure that the house is safe before leaving. However, if this prevents the family from leaving the house, this becomes a major issue.

Reclaiming Her Freedom

Read about one young patient's journey to overcome OCD.
MANAGING HER OCD
How Do You Recognize OCD in Children?

It's important for individuals, such as parents, teachers, and athletic coaches, to be able to recognize the potential signs of OCD in children. The sooner you can intervene at the start of a mental health challenge, the better their chance for a successful outcome.

There are lots of normal developmental rituals that are not attributable to OCD, like bedtime rituals. However, if a ritual is starting to affect how a child functions, that can help identify if it's more than a routine and may point to a sign of OCD.

OCD often develops slowly over time. With a gradual onset of symptoms, coupled with a parent's natural tendency to protect and soothe, it might be hard for adults to pick up on a child's symptoms of OCD when they start appearing.

It might be easier to recognize the impact that OCD has on the quality of life in children and those around them.

There are several things to watch for that may be signs of OCD.

The following aren't always signs of OCD. They are examples of behaviors that may signal that a child is in distress and may need help from a trained professional.

Homework

Children with OCD might take an excessive amount of time to complete their homework. This might include children having to read the same line over and over again, having to write each number perfectly for a math problem, or checking homework repeatedly to the point that it takes a very long time to finish.

Leaving the House

Children with OCD might slow the family down when leaving the house. For example, if a child is taking forever to get ready, then they might be checking every door, window, and light to make sure they are in the "right" positions or condition before leaving. They might throw a temper tantrum about leaving before this routine is finished. This behavior often makes the family chronically late for activities.

Handwashing

Handwashing is one of the most well-known compulsions when it comes to OCD. Handwashing may arise out of obsessions related to germs, feelings of disgust, or other forms of contamination such as "bad emotions" or fears of developing chronic stress, anxiety, or worry. If OCD is tied to handwashing, then it might be helpful to look at the hands for signs of raw, bleeding skin. If children are washing their hands dozens of times per day, the soap is going to make the skin raw, leading to scars, peeling skin, and bleeding.

Drugs or Alcohol

Sometimes when children are struggling to manage a condition, they may turn to substances as a coping mechanism. If a teen is facing mental health challenges, they may feel socially isolated, misunderstood, or overwhelmed. This occasionally leads to substance misuse.

Sleep Habits

OCD often disrupts bedtime or sleep. Children with OCD may have to go through a very specific routine before they get in bed and fall asleep. They may also have a hard time falling asleep if they have intrusive thoughts or worries that are more intense at night. If this routine is disrupted for any reason, they have to start the entire routine over. It is not unusual for OCD to lengthen the bedtime routine by 30 minutes, an hour, or even longer. This deprives children of much-needed sleep, which impacts school performance, emotional development, and relationships with their peers and family members. If sleep is disrupted consistently it can also negatively impact the effectiveness of OCD therapies, including CBT.

Keep in Mind

These behaviors do not include every way that OCD manifests in kids. It also does not mean that if a child experiences difficulty with these, then they have OCD.

These are several examples where a child may have uncomfortable thoughts, feelings, or sensations that are followed by behaviors or avoidance to feel relief from their discomfort or fear.

If this discomfort-relief cycle causes family distress or dysfunction, parents should consider speaking with a trained professional about the possibility of OCD.

Watch Now
Dr. Elizabeth McIngvale shines a light on obsessive compulsive disorder
What Causes OCD in a Child?

Similar to other mental health disorders, there is never a single reason why a child develops OCD.

The following list of risk factors is far from complete but does provide a small glimpse into what could lead to the development of OCD. It is critical to keep in mind that anyone is capable of developing any mental health disorder, including OCD.

Family History, Genetics, and Environment

OCD is heritable. This simply means that if there's someone in your family who has it, there's a higher likelihood that a child might have it. The familial pattern of OCD suggests a genetic component, though there are no specific genes that have been identified to be related to OCD at this point.

When discussing nature vs. nurture, it is important to note the environment plays a role as well. Obsessions and compulsions can be learned over time. If children watch family members and others go through OCD, they may latch onto these behavioral patterns as well. As a result, environmental exposures can play a role in the development of OCD.

Stressful Events

Stressful events can be a risk factor for kids with OCD who may have underlying vulnerabilities. Children who experience trauma may develop PTSD, which can be mistaken for OCD.

While unwanted and intrusive thoughts often occur with trauma and post-traumatic stress disorder (PTSD) and can look similar to OCD, trauma focuses on intrusive thoughts based on the past traumatic event, and OCD typically focuses on future uncertainties and attempts to lessen them.

OCD Can Be Treated and Maintained-Yes, There Is Hope!

It is important to note that there is no cure for OCD. At the same time, there are plenty of ways to manage this condition effectively.

Though people diagnosed with OCD will always have to deal with some symptoms, there are very effective ways to control obsessions and compulsions. Treatment can lead to improvements in quality of life, even if there are minimal symptoms that have to be managed regularly. Over time and with effective treatment, OCD may not have any impact on someone's quality of life.

When it comes to the treatment of a child with OCD, it is important to approach this comprehensively. When all facets of OCD are addressed appropriately, children have the best chance of making a meaningful recovery.

Several components play a role in the treatment of every child with OCD. Like each child's uniqueness, every diagnosis of OCD will respond in its own way to different treatments, and as a result, may require tailoring treatments to the individual to see what works best.

Therapy

Cognitive behavior therapy, usually shortened to CBT, is an effective treatment method for people with OCD. This therapy, and others similar to it, help patients connect behaviors and thoughts.

One of the most important components of CBT is called exposure and response prevention therapy. The goal of this type of therapy is to expose children to a feared object or obsession gradually.

With proper treatment, young people who struggle with OCD can live fulfilling and healthy lives

For example, a child who is afraid of germs might be exposed to dirt. Then, the child, with the guidance of a mental health professional, learns to resist the urge to complete compulsive rituals.

As OCD affects everyone in the family, parents and siblings need to learn how to best support children. Family-based approaches to therapy have been proven to be very successful. Also, there are even parent-led approaches to therapy for kids who are reluctant to go to treatment. The parent learns how to teach their child coping skills.

Even though this type of therapy takes time, it has been shown to vastly improve the quality of life in children with OCD.

Medications

Certain psychiatric medications can help children control the obsessions and compulsions that go along with OCD. If behavioral treatment is difficult to access or appears to be mildly effective, then a serotonin reuptake inhibitor (SRI), a specific class of antidepressant, may be helpful to add to the child's care plan.

Some of the most common antidepressants that might be used in children that have been diagnosed with OCD include:

Anafranil (clomipramine) is used in children ten years of age or older

Fluvoxamine is used in children eight years of age or older

Prozac (fluoxetine) is used in children seven years of age or older

Zoloft (Sertraline) is used in children six years of age or older

If considering medication, parents should speak with doctors in depth about all possibilities to understand the risks and benefits of each medication.

All psychiatric medications have potential side effects. Parents should understand possible side effects, the chances of these side effects developing, know how to spot them, and when to contact their provider about potentially stopping medication.

Many children who are placed on medication for OCD may be able to come off medication once they have learned exposure and response prevention skills and use them regularly.

Each OCD journey is different and should be treated as such by providers and parents alike. For some young people and their families, once-weekly outpatient visits aren't enough. If that's the case, it may be helpful to consider getting a consultation from a psychiatrist for medication. Additional options include a higher level of care, like intensive outpatient or residential treatment or a parent-only approach to help through familial support.

What Should I Do If My Child Might Have OCD?

Parents, caretakers, and family members need to remain vigilant and understand that there is nothing wrong with asking for help for their child. Also, kids and teens need to know that it's perfectly okay-and normal-to reach out for help if they are feeling troubled.

It is important to note that children with OCD are not damaged, broken, or harmed beyond repair. When children with OCD are approached with sympathy and understanding, it is easier for them to open up about their problems.

If you think you know someone who may be struggling with OCD, the first step is to not panic. While the disorder may feel crippling, there are many ways to get help that is tailored to what's needed for each child. Seeking help-and treatment-can provide a child and their family with the tools to feel empowered and in control of their mental health.

A potential diagnosis of OCD should be discussed with the child's care team to determine the next steps. Call your primary care physician or a local mental health facility, like McLean, to find the care you need.

How Does Someone Get Formally Diagnosed With OCD?

Several steps must take place to properly diagnose a child. Usually, this diagnosis is going to be made by a trained professional, such as a psychiatrist or psychologist, along with assistance from other doctors or health care providers, such as a pediatrician.

What to Expect

An evaluation to determine a diagnosis may include both self-and parent-reporting questionnaires and personal interviewing. These interviews include specific questions to identify the presence of obsessions and rituals.

A trained professional sits down and speaks with a child about feelings, thoughts, symptoms, and behavioral patterns. The goal is to identify any specific obsessions or compulsions.

Then, a psychological evaluation takes place in an attempt to identify the reason why these obsessions and compulsions are present. There has to be an anxiety or fear of a negative or "not right" experience that might happen if things are not done in a certain way.

Finally, it is important to determine whether or not these behaviors harm the child's quality of life. During this evaluation, the evaluator often speaks with the family members and friends as well.

To make the official diagnosis, the psychiatrist uses criteria that are published in the Diagnostic and Statistical Manual of Mental Health Disorders, usually shortened to DSM-5. This is published by the American Psychiatric Association and guides mental health professionals.

In diagnosing OCD, it is important to rule out alternative causes of this behavior. Therefore, a physical exam might take place to check for symptoms and problems that could be related to complications of OCD or a possible alternative diagnosis.

If this process is completed and the child meets the criteria for OCD, the treatment and recovery process can begin.

Help Your Child Feel More Like a Kid

Whatever mental health difficulties your child may be dealing with, McLean is here to help. Contact us today at 877.626.8140 to learn more about treatment options for children, teens, and young adults.
YOUTH MENTAL HEALTH
What You've Heard About OCD Likely Isn't True

Amongst mental health disorders, obsessive compulsive disorder is one of the most common. Despite this, there are prominent misconceptions about how OCD presents in individuals that can make it challenging for many to understand the condition.

Each case of OCD is as unique as the person diagnosed with it, and there are many misconceptions about the disorder. Along with many people loosely using the terminology "being OCD" to describe perfectionism, several myths have emerged about OCD.

Myth: People With OCD Want Everything to Be Perfect

People diagnosed with OCD may exhibit perfectionism-related behaviors or have perfectionism-related obsessions. However, they typically stem from attempts to reduce anxiety or distress associated with uncertainty or a specific feared outcome-not because they want everything to be perfect.

Myth: People With OCD Are Just Germaphobes

While it is true that some obsessions and compulsions are related to germs and handwashing, OCD comes in many shapes and forms and often does not manifest only with an aversion to germs.

Myth: People With OCD Should "Just Relax," and It'll Go Away

OCD is a serious mental health disorder. It is a medical condition that deserves the same level of care and compassion as cancer, diabetes, or heart disease. Those of us with OCD would love to relax. However, that may not be achievable through being told to calm down.

If your child is struggling, McLean offers world-class mental health care for children and teens with OCD and related disorders. Let us help you find the treatment option that's right for your child. Contact us today.

Want More Info?

Looking for even more information about OCD in children? You may find these resources helpful.

Interesting Articles and Videos and More

Learn more about youth mental health and what you can do if your child is displaying signs of OCD.

Helpful Links

These organizations may also have useful information:

International OCD Foundation
The mission of the International OCD Foundation is to help people affected by obsessive compulsive disorder and related disorders to live full and productive lives. The IOCDF aims to increase access to effective treatment through research and training, foster a hopeful and supportive community for those affected by OCD and the professionals who treat them, and fight stigma surrounding mental health issues.

OCD Massachusetts
As a non-profit affiliate of the IOCDF, OCD Massachusetts aims to provide public and professional education about OCD to raise awareness and improve the quality of treatment provided in Massachusetts. They also work to improve access to resources for those with OCD and their families and advocate and lobby for the OCD community in Massachusetts.

Not Alone Notes
Not Alone Notes is a nonprofit organization that mails free, handwritten letters to people with OCD and related disorders. Their goal is to remind others they aren't alone, encourage hope, and dispense resources.

Peace of Mind
Now part of the International OCD Foundation, provides educational resources and access to self-help tools, offers scholarship opportunities, supports professional training programs, and spreads awareness about OCD and related disorders.

Books About OCD

Obsessive Compulsive Disorder: Elements, History, Treatments, and Research
by Leslie J. Shapiro
(ABC-CLIO, 2020)

Stuff That's Loud: A Teen's Guide to Unspiraling When OCD Gets Noisy
by Ben Sedley and Lisa W. Coyne
(New Harbinger, 2020)

Acceptance and Commitment Therapy: The Clinician's Guide for Supporting Parents
by Koa Whittingham and Lisa W. Coyne
(Elsevier, 2019)

Understanding OCD: Skills to Control the Conscience and Outsmart Obsessive Compulsive Disorder
by Leslie J. Shapiro
(Praeger, 2015)

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Everything You Need To Know About OCD in Kids and Teens

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While working on a project together, you see a friend packing up their work supplies in a very neat fashion. You can't help but point out that they've organized all their pens to be lined up in order of color and all facing the same direction in their box.

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

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

1. Emotional and Behavior Disorders (EBD)

2. Emotional Conflict (EC)

3. Serious Emotional Disturbance (SED)

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

General Strategies

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

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

Teacher Presentation

Laboratory

Group Interaction and Discussion

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

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

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

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

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

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

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

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

Reading

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

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

2. Reading in group or with others.

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

4. Demonstrating appropriate reading

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

Research

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

2. Use appropriate laboratory and field strategies.

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

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

Field Experiences

1. Use appropriate general strategies.

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

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

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

5. Use a buddy system.

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

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

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

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

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

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

Testing

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

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

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

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

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

Organizations

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

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

Resources

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

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

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

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Fact Sheet Library | NAMI: National Alliance on Mental Illness

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View NAMI's fact sheets that give clear, concise information on mental health topics.

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National Alliance on Mental Health, (2015 March). Bipolar disorder. https://www.nami.org/NAMI/media/NAMI-Media/Images/FactSheets/Bipolar-Disorder-FS.pdf

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Student Guide to Mental Health Infographic

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Student Guide to Mental Health Infographic

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National Alliance on Mental Health, (n.d.). Getting the right start: student guide to mental health. https://www.nami.org/NAMI/media/NAMI-Media/Infographics/NAMI-Getting-the-Right-Start.pdf

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Minnesota Mental Health, (n.d.). Conduct disorder fact sheet. Minnesota Association for Children's Mental Health. http://mnmentalhealth.org/children/fact-sheets

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Childhood schizophrenia is a serious and rare mental health condition that occurs in children younger than 13 years of age. It is a type of schizophrenia that makes sufferers perceive reality inaccurately.

What Is Childhood Schizophrenia?

Childhood Schizophrenia

Also known as childhood-onset schizophrenia (COS), it is a psychiatric disorder that typically develops in children between the ages of 12 & 18 years. Another variant, known as very early-onset schizophrenia, affects an individual before they are 12 or 13 years of age. According to a study , "Childhood-onset schizophrenia (defined by an onset of psychosis by age 12) is a rare and severe form of the disorder that is clinically and neurobiologically continuous with the adult-onset disorder." Further research reveals that psychosis associated with the condition generally occurs under 13 years of age and is considered as very early onset, however when onset is 13 and 17 years, then it is regarded as "adolescent onset." Childhood schizophrenia shares the same symptomatology, effects and diagnostic criteria as schizophrenia in adults, except for the age of onset. However, it can be harder to identify and diagnose COS than schizophrenia in adults. In some cases, the symptoms can worsen over time in children who experience them early. The disorder results in abnormal interpretation of reality in children and leads to different emotional, cognitive & behavioral challenges which adversely affects the sufferer's ability to build healthy interpersonal relationships and function normally in daily life.

A child with this COS may experience certain positive symptoms, such as delusions, hallucinations, disorganized speech and abnormal behavior, before they reach the age of 13. They may also suffer from negative symptoms, such as emotional blunting, apathy or a lack of motivation along with other cognitive issues. Other symptoms may include auditory hallucinations such as hearing bangs or knocks, poor academic performance, irritability or looking for imaginary things. Moreover, additional research shows that nearly half of the children with this condition also tend to experience serious neuropsychiatric symptoms.

The disorder is also related to other neurodevelopmental conditions like attention deficit and hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). "Childhood onset schizophrenia (COS) patients have marked neuropsychological deficits in areas of attention, working memory and executive functions," explains a 2006 study .

However, it should be noted that childhood schizophrenia has not yet been recognized as an official diagnosis. It is extremely difficult to diagnose and treat childhood schizophrenia followed by educational, emotional, and social development. Although there is no specific cure, an individual with this psychiatric disorder can recover with effective treatment. Since it is a chronic condition, it must receive lifelong treatment. It is highly recommended to identify and start the treatment for COS at an early stage to significantly improve a child's long-term outcome.
Read More About Schizophrenia Here
Understanding Childhood Schizophrenia

Schizophrenia is a significant psychiatric illness in the world of psychology and it is more prevalent in adults than in children and adolescents. However, when it occurs in children, the condition can cause:

optical hallucinations of objects and people that are not really present

auditory hallucinations of music, voices, or other sounds that are not real

delusions of threats or dangers that are not connected to the reality

trouble making friends and maintaining relationships

damaged speech and other communication skills

improper and abnormal behavior

Apart from these, when trying to understand the condition, certain aspects of the disorder must also be considered, such as:

There is no known cause of the condition

It's likely a genetic condition, inherited from one of the family members

The condition affects boys a tad more than girls during childhood, however, affects men and women equally during adolescence and adulthood

The condition has no known cure but can be controlled effectively when identified early and treated with therapy, medications, and support

Symptoms Of Childhood Schizophrenia

Childhood Schizophrenia

COS revolves around a range of problems associated with thinking, behavior, or emotions, just like schizophrenia in adults. The signs and symptoms may differ from one child to another, however, it usually involves delusions, hallucinations, or disorganized speech, along with an impaired ability to function. While such symptoms in adults generally start in their mid to late 20s, it is uncommon in children which starts before the age of 13.

Here are the symptoms of childhood schizophrenia which may worsen over time:

1. Early Signs And Symptoms
The earliest signs of COS may be defined by developmental problems, such as:

Late walking

Late or unusual crawling

Language delays

Other strange motor behaviors, for example, rocking or arm flapping

Such symptoms are also common in children with pervasive developmental disorders, thus ruling out these developmental disorders is the first step in the diagnosis.

2. Symptoms in adolescents
Schizophrenia symptoms in teenagers are similar to those in adults, however, they are more difficult to recognize. The symptoms include:

Irritability or depressed mood

Poor performance at school

Trouble sleeping

Withdrawal from friends and family

Strange behavior

Lack of motivation

Substance use

3. Symptoms in later age
As children with the disorder age, more common signs and symptoms of the disorder begin to appear which may include:
A. Delusions

This is a symptom where the person develops false beliefs that have nothing to do with reality. For example, the person may think someone is trying to harm him/her, trying to insult through comments or gestures, or another person in love with him/her, all of which are not even true in reality.

B. Hallucinations

These usually involve seeing or hearing things that don't exist, thereby, leaving a serious impact impairing normal functioning and daily activities.

C. Disorganized Thinking

Disorganized thinking and disorganized speech go hand in hand. Productive communication can be impaired, and answers to questions may be partly or entirely unrelated.

D. Extremely Disorganized Motor Behavior

This may refer to childlike silliness to random anxiety. Since the behavior is not goal-oriented, which makes it hard to do tasks. Such behavior may include resistance to instructions, bizarre posture, excessive and useless movements, etc.

E. Negative Symptoms

This refers to decreased ability to function normally, for example, neglecting personal hygiene or lack of emotion. Also, the person is characterized by a reduced ability to engage in everyday activities.

When COS begins, symptoms take time to build to show up. The early signs and symptoms are vague enough not to get recognized, or parents may attribute them to a developmental phase. With time, however, the symptoms become extremely severe and more noticeable. Eventually, a child may develop the symptoms of psychosis, including hallucinations, delusions, and difficulty organizing thoughts.

Childhood Schizophrenia And Brain Structure

According to some researchers, COS may be associated with a deficit of gray matter in the neuronal cell bodies of the brain. It includes brain areas which regulate sensory perception, emotions, memory, muscle control, decision making and speech. Research shows that lower levels of gray matter in COS affected adolescents' brains have been observed as compared to healthy individuals of the same age. "There is emerging evidence that gray matter (GM) is reduced in patients with schizophrenia," add the researchers. It is observed in both male and female patients and this deficit is not related to severity of the symptoms. However, lower gray matter levels can affect cognitive performance. Another 2004 study revealed that loss of cortical GM volume in patients with COS tend to be diagnostically specific. It adds "Recent anatomical brain magnetic resonance imaging (MRI) studies show a striking post-psychotic progressive loss of cortical gray matter (GM) in patients with childhood-onset schizophrenia (COS), which appears greater than that seen for adult patients."

However, a 2016 study found that prolonged and effective treatment can help to increase grey matter volume significantly. Particularly in the bilateral cerebellum, left superior occipital cortex, insula, the bilateral prefrontal cortex and the right thalamus. "Atypical antipsychotics could modulate brain morphology involving the thalamus, cortical grey matter and cerebellum," adds the study.
Read More About Brain Health Here
Causes Of Childhood Schizophrenia

Research shows that it is "a neurodevelopmental disorder with a multifactorial etiology." Although, there may not be any specific known causes of COS, it is believed that the disease is influenced by the following factors:

1. Genetics

While there is no single cause for childhood schizophrenia, experts believe that the disease is caused due to an inherited chemical imbalance in the brain. If a combination of genes passed down by both parents, it can lead to this disorder. If one of the parents has the disorder, chances are high that the child will also develop it. The presence of a schizophrenic sibling also leaves a chance for the child to develop the disease. In other words, the risk of developing this condition in a child increases if more than one family member has the disease. "Evidence suggests there is a significant heritable component to COS. There are multiple genes and genetic mutations that have been hypothesized as being integral to COS and its hereditary nature," says a study .

The study also says that the age of the paternal parent is a risk factor that determines the development of childhood schizophrenia. Precisely, if the age of the paternal parent is 30 or above at the time of conception, the chances are high that the child may develop the condition. This concept is assumed as cell mutation occurs as paternal age increases, although the entire mutation process is not yet understood. Evidence also suggests that a family history of mental illness may increase the chances of developing COS. According to a 2009 study , "Examination of familial transmission of known candidate risk genes was carried out, and a 10% rate of cytogenetic abnormalities was found."

2. Complications During Pregnancy

According to a 2013 study , "At least in part, events occurring within the intrauterine (within the uterus) or perinatal (during pregnancy) environment at critical times of brain development underlies emergence of the psychosis observed during adulthood, and brain pathologies that are hypothesized to be from birth." Though it's not certain, doctors are of the opinion that a child's schizophrenia may be linked to certain complications and environmental factors that affect the mother during pregnancy. Such factors can be:

lack of proper nutrition for the mother during pregnancy

exposure to viruses during pregnancy

extreme stress

prenatal infections

exposure to particular hormonal or chemical agents

drug or alcohol use while pregnant

exposure to certain viruses or infections

Who Is At Risk

Although the exact cause of schizophrenia is not known, there are a few particular factors that seem to increase the risk of developing COS such as:

Having schizophrenia in family history

Increased immune system activation, such as from inflammation or autoimmune diseases

Older age of the father, 30 or above

Complications during pregnancy and birth, such as malnutrition and exposure to toxins or viruses that may affect brain development

Taking mind-altering drugs during the teen years

Diagnostic Criteria Of Childhood Schizophrenia

"The gold standard for diagnosis remains the use of unmodified DSM criteria, based on extensive collateral information," explains a 2013 study. The diagnostic criteria for childhood schizophrenia are the same as adult schizophrenia as per DSM IV-TR, which includes the following.

1. Characteristic Symptoms

Two or more of the following symptoms should be present in the patient for a period of 1 month.

delusions

hallucinations

disorganized speech

grossly disorganized or catatonic behavior

negative symptoms

2. Social or Occupational Dysfunction

For a notable amount of time since the onset of the condition, one or more major areas of functioning such as work, interpersonal relations, or self-care are considerably below the level accomplished prior to the onset.

3. Duration

Continuous signs of the disturbance should remain for at least 6 months. This 6-month period must include at least 1 month of symptoms that meet Criterion A and may consist of periods of prodromal or residual symptoms.

4. Schizoaffective and Mood Disorder Exclusion

Schizoaffective Disorder and Mood Disorder With Psychotic Features must be ruled out as-

No major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms

If mood episodes have transpired during active-phase symptoms, the total span was shorter relative to the duration of the active and residual periods.

5. Substance/General Medical Condition Exclusion

The disorder is not due to any direct physiological effects of a substance or a general medical condition.

7. Relationship to a Pervasive Developmental Disorder

If there is a record of autistic disorder or another pervasive developmental disorder, the additional diagnosis of schizophrenia will be made only if prominent delusions or hallucinations are also present for at least a month.

Diagnosis Process Of Childhood Schizophrenia

Symptoms such as disorganized speech and behavior are also associated with other disorders of childhood-onset such as autism spectrum disorder, obsessive-compulsive disorder, and attention-deficit hyperactivity disorder. Thus, it is essential to consider other common disorders of childhood before connecting symptoms to schizophrenia. Hence, in the process of diagnosing childhood schizophrenia, the doctor must rule out other mental health disorders first along with determining that the symptoms are not a result of substance abuse, medication, or a medical condition. The process of diagnosis may involve:

1. Physical Exam

This is done to rule out other problems resulting in the symptoms and to check for any related complications.

2. Tests And Screenings

This step involves tests that enable the elimination of other similar symptoms followed by screening for alcohol and drugs. The doctor may also suggest imaging studies, such as an MRI or CT scan.

3. Psychological Evaluation

This step is defined by observing the appearance and behavior, inquiring about thoughts, feelings, and behavior patterns, including any feelings of causing self-harm or hurting others. It also evaluates the capacity to think and function at an age-appropriate level along with assessing mood, anxiety, and possible psychotic symptoms. The doctor also discusses family and personal history.

Complications Associated With Childhood Schizophrenia
If left untreated, childhood schizophrenia can lead to severe emotional, behavioral, and health complications such as:

Anxiety disorders & panic disorders

Obsessive-compulsive disorder (OCD)

Depression

Inflicting self-injury

Substance abuse such as alcohol, other drugs, or tobacco

Family conflicts

Social isolation

Lack of ability to live independently, attend school or work

Health and medical problems

Being victimized

Legal and financial problems, and homelessness

Aggressive behavior

Suicidal behavioral pattern or tendency for self-harm & commit suicide

When To See A Doctor

It can be a challenge for the parents to handle vague behavioral changes in their child. Additionally, parents may receive some sort of an alert from the child's teacher or other school staff about the changes in the child's behavior. Thus, one must seek medical help if the child:

has developmental delays compared with other siblings or peers

has stopped doing daily hygiene activities such as bathing or dressing

no longer wants to socialize

is performing poorly in academics

has strange eating rituals

shows excessive mistrust towards others

shows a lack of emotion or shows emotions inappropriate for a particular situation

has strange thoughts and fears

confuses dreams or television for reality

has eccentric ideas, behavior, or speech

has violent or aggressive behavior or agitation

However, these signs or symptoms do not mean that a child has childhood schizophrenia. These could also mean that there is another mental health disorder such as depression or an anxiety disorder, or a medical condition. Suicidal thoughts and behavior may also be common among children or teens with this disorder. Thus, parents must seek medical care as soon as possible if they have concerns about their child's behavior or development.

Treatment Of Childhood Schizophrenia

After a child is diagnosed with COS, the doctor will explain to the parents its possible causes, effects, and long-term consequences. Precisely, the doctor will give a thorough overview of the condition. Following this, the doctor along with the parents agree upon a treatment plan consisting of psychotherapy and medication along with school and community support that will work towards the betterment of the child and the family. The parents along with the child will have the opportunity to ask questions along with bringing up any or all concerns, worries, and fears. This way, the clinical team will be able to provide the information and support the child and the family needs.

The treatment is generally conducted by a child psychiatrist experienced in treating schizophrenia. The team of people who will be treating the condition may be available in clinics with experience in schizophrenia treatment. The team may include:

Psychiatrist, psychologist, or another therapist

Social worker

Psychiatric nurse

Pharmacist

Family members

Case manager to coordinate care

Schizophrenia in children is a lifelong treatment, even during periods when the symptoms seem to go away. The treatment in itself is challenging for a child with schizophrenia. Some common effective treatment options for COS typically include the following:

Medications

Psychotherapy

Life Skills Training

Hospitalization

1. Medications

The antipsychotics that are prescribed for children are also used for adults with schizophrenia. Research shows that "antipsychotic medications are considered as the first-line treatment" for patients with COS. Antipsychotic drugs are usually effective at controlling or treating delusions, hallucinations, loss of motivation, and lack of emotion. When it comes to treatment with antipsychotics, the doctor aims to manage the symptoms effectively at the lowest possible dose. Over time, the doctor may introduce different medications, combinations, or different doses. Depending on the symptoms, other medications such as antidepressants or anti-anxiety drugs may also help.
Here are commonly prescribed medications for childhood-onset schizophrenia:
A. Second-Generation Antipsychotics

Newer, second-generation medications, also known as atypical antipsychotics, are popular among the doctors for the treatment of childhood schizophrenia as they have fewer side effects than first-generation antipsychotics. According to a 2015 study , "Atypical antipsychotics (AAPs) have been successfully used in early-onset schizophrenia (EOS)." However, these medicines can result in weight gain, high cholesterol, high blood sugar, and heart disease. Some examples of second-generation antipsychotics as approved by the Food and Drug Administration (FDA) are:

Aripiprazole (Abilify)

Quetiapine (Seroquel)

Olanzapine (Zyprexa)

Risperidone (Risperdal)

B. First-Generation Antipsychotics

These first-generation medications are, in most cases, as effective as second-generation medicines when it comes to controlling delusions and hallucinations. However, apart from the similar side-effects as mentioned in second-generation medication, they may also cause frequent and potentially significant neurological side effects. First-generation antipsychotics are cheaper than second-generation antipsychotics and this is a significant factor, especially when considering long-term treatment. Some examples of first-generation antipsychotics as approved by the FDA are:

Haloperidol for children 3 years and older

Chlorpromazine for children 13 and older

Perphenazine for children 12 years and older

C. Side Effects and Risks of Medications

According to a research conducted in 2014, "In spite of rapidly growing antipsychotic prescription rates for young patients in many countries, most antipsychotic medications have not been specifically approved to treat EOS (early-onset schizophrenia), mainly because such medications have not been thoroughly tested in the young." All antipsychotic medicines have side-effects and potential health risks, some of which are life-threatening as well. These side-effects in children and teenagers may differ from those in adults, and sometimes they may be more serious. However, studies show that weight gain is one of the most common side effects of antipsychotics in children, adolescents and young adults

Since children do not have much capacity to understand or communicate medication problems, parents must consult the doctor to discuss possible side-effects and risks. Parents must be aware of all the possible side-effects and report it to the doctor as soon as they see it. Be alert for problems in your child, and report side effects to the doctor as soon as possible. The doctor may be able to adjust the dose or change medications and limit side effects.

2. Psychotherapy

Apart from medication, psychotherapy or talk therapy, can also manage the symptoms and help a child cope with the disorder. Some of the most recommended and effective psychotherapies for this disorder may include:

A. Cognitive Therapies

According to a 2012 study , cognitive therapies (CTs) can prove to be effective for high-risk individuals. However, CT can be even more effective when combined with other therapies that focus on different aspects of functioning such as family interventions, cognitive rehabilitation, social problem solving, along with school interventions & occupational therapy for vocational development. The researcher found that cognitive behavioral therapy (CBT) can yield more benefits when focused on social functioning. The study adds "CBT and supportive counseling both improved social adjustment at 12 months, and patients in the CBT group were less likely to convert to psychosis."

Cognitive behavioral therapy, with a skilled therapist, can help a child to learn coping tips to manage stress and daily life challenges with the onset of schizophrenia. The therapy helps in lowering the symptoms, thereby enabling a child to make friends and succeed at school. The therapist must help the child to understand his/her condition that will further help him/her cope with symptoms, and stick to the treatment plan.

B. Family Therapy

Family therapy is designed to benefit the child and the parents while supporting and educating both parties. Family therapy can also help improve communication, work out conflicts, and cope with stress related to a child's condition.

According to a 2012 study , some other psychotherapeutic interventions that childhood schizophrenia are:

Cognitive enhancement therapy

Cognitive remediation therapy

Multifamily psycho-education

Supportive counseling

Psychoeducation

Social skills training

Individualized psychological treatments

The study adds "psychotherapeutic interventions may thus be an important platform to alleviate psychotic relapse, re-admission, and medication compliance; systematic validation of such measures however is warranted."

3. Life Skills Training

For children with schizophrenia, treatment plans are built to help them learn life skills that will enable a child to function at age-appropriate levels when possible. Skills training may include:

A. Social & Academic Skills Training

Helping a child to learn social and academic skills is an imperative part of treatment for this condition. Children with schizophrenia usually have troubled relationships and school problems. They may also have trouble carrying out normal daily tasks such as bathing or dressing.

B. Vocational Rehabilitation & Supported Employment

This aims at helping people with schizophrenia to prepare for a job, find one, and helps to keep the job.

4. Hospitalization

Hospitalization becomes mandatory during crisis periods or when the symptoms become severe. This is helpful for the child's safety and makes sure that the child is getting enough nutrition, sleep, and hygiene. At times, the hospital setting is the safest and best way to get symptoms under control quickly.
Read More About Treatment Of Schizophrenia Here
How Parents Can Help

Childhood Schizophrenia

While it is essential to treat the condition with the help of a professional, parents should also participate actively to reduce the symptoms via home and lifestyle remedies. Here are ways to get the most out of the treatment plan.

1. Follow Doctor's Instructions

Parents should make sure to provide their children with medicines as prescribed by the doctor, in terms of time and dosage. Even if they feel there are no current symptoms, they must continue the medicine to avoid the symptoms from coming back. Stopping the medicines suddenly may lead to further development of the symptoms and this may make it extremely difficult for the doctor to understand the best and safest dose for the child.

2. Consult the Doctor for Other Medications:

Parents must frequently consult the doctor who is treating their child for the disorder. They should inform the doctor about any progress or side effects. Moreover, before the child takes any over-the-counter medications, vitamins, minerals, herbs, or other supplements, it is essential to consult the doctor to avoid further complications.

3. Look for Warning Signs

Parents and children should stay alert for any warning signs displaying the factors that trigger the symptoms, cause relapse, or prevent a child from carrying out daily activities. In such situations, parents must chalk a plan to handle such situations where the symptoms might come back. Additionally, they must contact the child's doctor or therapist in case of any noticeable changes in symptoms, to check the situation from worsening.

4. Foster Physical Activity & Healthy Eating Habits

Some medications for schizophrenia may result in weight gain and high cholesterol in children. Parents must discuss with the doctor to come up with a nutrition and physical activity plan for the child that will help manage weight gain while taking care of heart health.

5. Avoid substances

Alcohol, street drugs, and tobacco should be avoided at any cost as such substances only worsen schizophrenia symptoms or interfere with antipsychotic medications.

Coping And Supporting With Childhood Schizophrenia

Childhood Schizophrenia

Coping and supporting a condition that requires lifelong treatment can be extremely daunting, not only for the child but also for the parents and the rest of the family. Medications tend to leave unwanted side-effects that can further give rise to resentful feelings. Thus, to cope with childhood schizophrenia, there are certain things that one must do, such as:

1. Gather Knowledge

Having adequate knowledge about the condition can help parents and the child to feel hopeful while staying committed to the treatment plan. Education can also help friends and other family members to understand the condition and act more compassionately with the child.

2. Support Groups

Parents should join support groups where they can meet other families with the same condition. This way, they can discuss the condition within the group and learn various ways to cope with the condition. This way, the child's parents will also feel that they are not alone in this journey and fight against the condition.

3. Professional Help

Parents should always consider seeking professional help, especially when they feel confused and distressed by their child's condition.

4. Stay Goal-Oriented

Dealing with childhood schizophrenia is a lifelong process. However, a family can overcome all the obstacles if they stand together, stay motivated, and focus on the treatment goals.

5. Seek Healthy Outlets

A family must explore the various ways to channel energy or frustration, such as participating in hobbies, exercise, and recreational activities. They should also seek support from friends and family as well and socialize adequately.

6. Spend Some Alone Time

Although managing childhood schizophrenia is a family activity, it is necessary for both children and parents to spend some healthy alone time to cope and unwind.

Prevention Of Childhood Schizophrenia

Early identification and treatment may help parents to control the symptoms of childhood schizophrenia before it leads to any serious complications. Early treatment is essential to limit psychotic episodes, which can be extremely terrifying to a child and his/her parents. While an ongoing treatment can help improve a child's long-term outlook, it will not prevent or cure the condition completely.

Final Thoughts And Outlook

Childhood schizophrenia is a lifelong condition. It is not possible to cure or prevent it, however, early treatment can manage it. If a child has a diagnosis of this condition, his/her family and caregivers can help the child by gathering knowledge about the condition, trying to learn how the child feels, and ensuring that they receive continuous treatment. Depending on the type and severity of the symptoms, treatment can help many people with this condition, thereby enabling them to go to work while enjoying fulfilling relationships.

Childhood Schizophrenia At A Glance

1. Childhood schizophrenia occurs in children between the ages of 12 & 18 years.

2. Childhood schizophrenia may be associated with a deficit of gray matter in the neuronal cell bodies of the brain.

3. If left untreated, childhood schizophrenia can lead to severe emotional, behavioral, and health complications.

4. The condition has no known cure but can be controlled effectively when identified early and treated with therapy, medications, and support

5. Schizophrenia in children is a lifelong treatment, even during periods when the symptoms seem to go away.

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Understanding Childhood Schizophrenia: Symptoms, Causes, Diagnosis And Treatment

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Childhood schizophrenia is a serious and rare mental health condition that occurs in children younger than 13 years of age. It is a type of schizophrenia that makes sufferers perceive reality inaccurately. Also known as childhood-onset schizophrenia (COS), it is a psychiatric disorder that typically develops in children between the ages of 12 & 18 years.

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Schizophrenia is one of the most complex of all mental health disorders. It is a severe, chronic, and disabling disturbance of the brain that causes distorted thinking, strange feelings, and unusual behavior and use of language and words.
What causes schizophrenia?
There is no known single cause responsible for schizophrenia. It is believed that a chemical imbalance in the brain is an inherited factor which is necessary for schizophrenia to develop. However, it is likely that many factors - genetic, behavioral, and environmental - play a role in the development of this condition.

Schizophrenia is considered to be multifactorially inherited. Multifactorial inheritance means that "many factors" are involved. The factors are usually both genetic and environmental, where a combination of genes from both parents, in addition to unknown environmental factors, produce the trait or condition. Often, one gender (either males or females) is affected more frequently than the other in multifactor traits. There appears to be a different threshold of expression, which means that one gender is more likely to show the problem, over the other gender. Slightly more males develop schizophrenia in childhood; however, by adolescence, schizophrenia affects males and females equally.
Who is affected by schizophrenia?
Schizophrenia is uncommon in children under the age of 12 and hard to identify in the early phases. A sudden onset of the psychotic symptoms of schizophrenia frequently occurs in middle to late adolescence. Statistics indicate that schizophrenia affects approximately 2.4 million Americans. A child born into a family with one or more family members affected by schizophrenia has a greater chance of developing schizophrenia than a child born into a family with no history of schizophrenia.

After a person has been diagnosed with schizophrenia in a family, the chance for a sibling to also be diagnosed with schizophrenia is 7 to 8 percent. If a parent has schizophrenia, the chance for an adolescent to have the disorder is 10 percent. Risks increase with multiple affected family members.
What are the symptoms of schizophrenia?
In adolescents with schizophrenia, behavior changes may occur slowly, over time, or have a sudden onset. The adolescent may gradually become more shy and withdrawn. They may begin to talk about bizarre ideas or fears and begin to cling more to parents. One of the most disturbing and puzzling characteristics of schizophrenia is the sudden onset of its psychotic symptoms. "Psychotic" refers to ideas, perceptions, or feelings that are grossly distorted from reality. The following are the most common symptoms of schizophrenia. However, each adolescent may experience symptoms differently.

Early warning signs of schizophrenia in adolescents may include:

distorted perception of reality (difficulty telling dreams from reality)

confused thinking (i.e., confusing television with reality)

detailed and bizarre thoughts and ideas

suspiciousness and/or paranoia (fearfulness that someone, or something, is going to harm them)

hallucinations (seeing, hearing, or feeling things that are not real such as hearing voices telling them to do something)

delusions (ideas that seem real but are not based in reality)

extreme moodiness

severe anxiety and/or fearfulness

flat affect (lack of emotional expression when speaking)

difficulty in performing schoolwork

social withdrawal (severe problems in making and keeping friends)

disorganized or catatonic behavior (suddenly becoming agitated and confused, or sitting and staring, as if immobilized)

odd behaviors (i.e., an older child may regress significantly and begin acting like a younger child)

The symptoms of schizophrenia are often classified as positive (symptoms including delusions, hallucinations, and bizarre behavior), negative (symptoms including flat affect, withdrawal, and emotional unresponsiveness), disorganized speech (including speech that is incomprehensible), and disorganized or catatonic behavior (including marked mood swings, sudden aggression, or confusion, followed by sudden motionlessness and staring).

The symptoms of schizophrenia in adolescents are similar to adults, however, adolescents, more often (in 80 percent of diagnosed cases), experience auditory hallucinations and typically do not experience delusions or formal thought disorders until mid-adolescence or older. The symptoms of schizophrenia may resemble other problems or psychiatric conditions. Always consult your adolescent's physician for a diagnosis.
How is schizophrenia diagnosed?
Schizophrenia in children and adolescents is usually diagnosed by a child and adolescent psychiatrist. Other mental health professionals usually participate in the completion of a comprehensive mental health evaluation to determine individualized treatment needs.
Treatment for schizophrenia:
Specific treatment for schizophrenia will be determined by your adolescent's physician based on:

your adolescent's age, overall health, and medical history

extent of the condition

type of schizophrenia

your adolescent's tolerance for specific medications or therapies

expectations for the course of the condition

your opinion or preference

Schizophrenia is a major psychiatric illness. Treatment for schizophrenia is complex. A combination of therapies is often necessary to meet the individualized needs of the child or adolescent with schizophrenia. Treatment is aimed at reducing the symptoms associated with the disorder. Types of treatment that may be helpful to a child or adolescent with schizophrenia may include:

medications (also called psychopharmacological management; to reduce the symptoms of schizophrenia), including the following:

antipsychotic medications (previously known as "neuroleptics") - medications that act against the symptoms of psychotic illness, but do not cure the illness. This specialized class of medications can reduce symptoms or reduce the severity of symptoms, and is used primarily to treat the pervasive, intrusive, and disturbing thoughts of a person with schizophrenia. They are designed to help minimize the severity of delusions and hallucinations the adolescent is experiencing.

mood stabilizing agents, such as lithium or valproic acid, especially in the initial phase of an illness episode

individual and family psychotherapy (including supportive, cognitive, and behavioral therapy)

specialized educational and/or structured activity programs (i.e., social skills training, vocational training, speech and language therapy)

self-help and support groups

Prevention of schizophrenia:
Preventive measures to reduce the incidence of schizophrenia are not known at this time. However, identification and early intervention can improve the quality of life experienced by children and adolescents with schizophrenia. Further, treatment is most successful when symptoms of the first psychotic episode are addressed properly and promptly. It is crucial for an adolescent who is prescribed medications for the treatment of schizophrenia to remain adherent to the regimen. Dosages and types of medications may need to be adjusted periodically to maintain effectiveness. Always consult your adolescent's physician for more information.
(This information is made available by the MUSC Children's Hospital)

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Schizophrenia Ages 13-18 - The Whole Child

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Schizophrenia is one of the most complex of all mental health disorders. It is a severe, chronic, and disabling disturbance of the brain that causes distorted thinking, strange feelings, and unusual behavior and use of language and words. What causes schizophrenia? There is no known single cause responsible for schizophrenia.

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National Association of School Psychologists (NASP)

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Mentally healthy children are more successful in school and life. Good mental health is critical to children's success in school and life. Research demonstrates that students who receive social-emotional and mental and behavioral health support achieve better academically. School climate, classroom behavior, engagement in learning, and students' sense of connectedness and well-being all improve as well. Mental health is not simply the absence of mental illness but also encompasses wellness promotion; social, emotional, and behavioral health; and the ability to cope with life's challenges. Left unmet, mental health problems are linked to costly negative outcomes such as academic and behavior problems, dropping out, and delinquency. Mental and behavioral health problems not only affect students' short-term classroom engagement, but also interfere with long-term development of positive relationships and work-related skills.

There is a growing and unmet need for mental and behavioral health services for children and youth. According to the U.S. Department of Health and Human Services, one in five children and adolescents experience a mental health problem during their school years. Examples include stress, anxiety, bullying, family problems, depression, learning disability, and alcohol and substance abuse. Serious mental health problems, such as self-injurious behaviors and suicide, are on the rise, particularly among youth. Unfortunately, many children and youth do not receive the help they need, and disparities in access to care exist among low-income communities and minoritized youth. Among the 3.8 million adolescents ages 12-17 who reported a major depressive episode in the past year, nearly 60% did not receive any treatment, according to a 2019 report by the Substance Abuse and Mental Health Services Administration. Of the adolescents who do get help, nearly two thirds do so only in school.

Schools are an ideal place to provide mental and behavioral health services to children and youth. Schools provide an ideal context for prevention, intervention, positive development, and regular communication between school and families. Schools also offer caring relationships and regular, consistent connections between students and staff both in person and virtually. School-employed mental health professionals (i.e., school psychologists, school counselors, school social workers, and school nurses) know the students, parents, and other staff, which contributes to accessibility of services. Research shows that students are more likely to seek counseling when services are available in schools. In some cases, such as rural areas, schools provide the only mental health services in the community. Comprehensive, culturally responsive school mental health services can help address inequities in access and help reduce the stigma associated with receiving mental health services by making it part of the fabric of the school system.

Comprehensive school mental and behavioral health services support the mission and purpose of schools: learning. All services provided in schools should be appropriate to the learning environment; those that are not risk being ineffective or even counterproductive. Just as children are not simply small adults, schools are not merely private clinics with white boards. Being trained to work within the school culture is essential to being effective (and cost-effective). School psychologists have specialized training in child development, mental health, learning, diversity, culturally responsive services, and school systems and law. Their unique expertise lies in how these elements interact to shape children's behavior, learning, and overall adjustment.

Comprehensive school mental health services are essential to creating and sustaining safe schools. Increased access to mental health services in schools is vital to improving the physical and psychological safety of our students and schools, as well as academic performance and problem-solving skills. Culturally responsive school mental health supports that encompass social-emotional learning, mental wellness, behavioral health, resilience, and positive connections between students and adults are essential to creating a school culture in which students feel safe and empowered to report safety concerns, which is proven to be among the most effective school safety strategies. Additionally, in the aftermath of a crisis, school-employed mental health professionals provide supports that facilitate a return to normalcy, are sustainable, and can help to identify and work with students with more intense or ongoing needs.

Providing a continuum of school mental and behavioral health services is critical to effectively addressing the breadth of students' needs. Comprehensive mental health services are most effective when provided through a multitiered system of supports (MTSS). MTSS encompasses the continuum of need, enabling schools to promote mental wellness for all students, identify and address problems before they escalate or become chronic, and provide increasingly intensive, data-driven services for individual students as needed. Access to adequate staffing of school-employed mental health professionals, like school psychologists, is essential to the quality and effectiveness of these services.

School psychologists provide a continuum of services that connect mental health, behavior and learning, school and home, and school and community services. Meeting the full continuum of student needs requires collaboration and coordination. Typically, community providers offer supplementary or intensive services that go beyond school capacities. An MTSS approach facilitates collaboration while ensuring that services provided in school are appropriate to the learning context and those that are provided after school hours are appropriately linked to and supported in the school setting. Partnerships are most effective when they are coordinated by school-employed mental health professionals, are defined by clear memoranda of understanding, and reinforce an appreciation for the unique contribution each group makes to creating more seamless and comprehensive service delivery. This not only reduces gaps, redundancy, and conflict, it also reduces stress on families and supports their roles as primary caregivers and decision makers regarding their child's development.

School psychologists are part of a team of school-employed mental health professionals who provide these services. Improving staffing ratios for these professionals is critical to adequately supporting students' mental and behavioral health. For more information on school-based mental health services and the role of school psychologists, visit www.nasponline.org.

Please cite this document as:

National Association of School Psychologists. (2021). Comprehensive School-Based Mental and Behavioral Health Services and School Psychologists [handout]. Author.

© 2021, National Association of School Psychologists, 4340 East West Highway, Suite 402, Bethesda, MD 20814, 301-657-0270, www.nasponline.org

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Comprehensive School-Based Mental and Behavioral Health Services and School Psychologists

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Mentally healthy children are more successful in school and life. Good mental health is critical to children's success in school and life. Research demonstrates that students who receive social-emotional and mental and behavioral health support achieve better academically. School climate, classroom behavior, engagement in learning, and students' sense of connectedness and well-being all improve as well.

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Guide Response Service Referral Process Guide

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

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During my first year as a high school counselor, a parent came to speak to me about her daughter. The student was a bright and beautiful young lady with a bubbly personality who I had the pleasure of meeting prior to her mother's visit. Although she was thin (she was a dancer), I hadn't noticed just had thin she had become in the last month. In that meeting, mom shared with me her concerns about her daughter's well being and how she had just been diagnosed with Anorexia Nervosa. During our time together, we discussed a safety plan for her at school, particularly during lunchtime. For a year, my office would be a place where this student could visit, eat, talk, and even rest. Although I was not a specialist in eating disorders, I knew what this family was experiencing. Unfortunately, my family had dealt with the painful reality of an eating disorder by one of my sisters. Though I could not make her symptoms go away or "talk" her out of her feelings about herself, just being there was powerful.

As a school counselor, you may or may not work with a student who has an eating disorder. Regardless, being aware of the symptoms of an eating disorder is an important step in assisting students in their road to recovery. In 2010, Lynn Shellcross wrote an article about the growing problem of eating disorders among elementary school aged children. When eating disorders are not identified early in students, they have the potential of growing into high school students who are at risk for serious illness and even death. Shellcross referenced researchers who found it imperative that counselors, whether school, mental health, college, or family, have an understanding of the deadliness of eating disorders. In order to understand eating disorders, counselors must be aware that it is not about food, but the student's inability to control the world around them. Students who suffer from an eating disorder often present in our office with anxiety and go to great links to hide their disorder. Having knowledge about eating disorders and the importance of early detection is important in identifying students who may be suffering from this mental health issue.

What is an Eating Disorder?

According to the National Eating Disorders Association, eating disorders are "serious but treatable illnesses with medical and psychiatric aspects." The DSM-5 recognizes several types of eating disorders in their diagnosis including: Anorexia Nervosa, Bulimia, Binge Eating Disorder, and Other Specified Feeding or Eating Disorder (OSFED). Although people with eating disorders concentrate on food and weight, the reality is that eating disorders often coexist with depression, anxiety, and obsessive compulsive disorder. According to the Academy for Eating Disorders, there are nine truths people, particularly school staff, should know about eating disorders.

These truths include:

Although a student may look healthy, he or she may be extremely ill.
Parents are not to blame, and should be considered allies in recovery.
An eating disorder diagnosis is a health crisis that disrupts daily life functioning (including academic success).
Having an eating disorder is not a choice, but is a serious "biologically influenced illness." Eating disorders affect students of "all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses."
Eating disorders increase the risk for both suicide and death due to medical complications.
Biology and environmental factors can enhance the development of eating disorders.
Biology alone does not predict the development eating disorders.
Early detection and intervention are important for full recovery!

See Kati Morton's videos about the different types of eating disorders.

Recognizing an Eating Disorder

Since school staff are with students at least seven hours a day, we are at an advantage of identifying when a student is experiencing a mental or physical illness. In fact, early detection of an eating disorder is the first step to treatment and healing. So, who are the students we should be most concerned about having an eating disorder? According to the BodyWise Eating Disorder Booklet, there are signs that educators should be aware of in adolescents who are at risk for developing an eating disorder (students experiencing these signs may or may not have an eating disorder).

Be aware of the following students:

complain about their bodies being too fat even if they appear to be normal weight or thin

talk about being on a diet or avoiding certain foods because they are too fattening

overweight and appear sad

teased about their weight

obsessed about maintaining a low weight to enhance their performance in sports, modeling, or dancing

Other signs and symptoms include:
Physical Emotional Behavioral

Weight loss or fluctuation Complaints about being too fat Constant dieting
Constantly feeling faint, tired, or cold Comments about feeling worthless Constant exercising
Dry hair/skin Frequently going to the bathroom Perfectionism

Not only is early detection important for the student to get treatment, but it is important to prevent a student from academic failure. According to the National Eating Disorders Association, an eating disorder can profoundly impact a student's cognitive function and the ability to learn. Some of the impacts on their ability to learn include:

low iron levels which decrease memory function

irritability caused by headaches, lethargy, or nausea

reduction in concentration and focus due to constant dieting

obsessive thoughts with grades due to perfectionist tendencies

withdrawal, apathy, and social isolation from feelings of self worthlessness

increased absenteeism as a result of physical illness

If this is the first time you have considered learning more or promoting eating disorders awareness, this post may have some helpful information for you!
National Eating Disorder Awareness Week

This week is National Eating Disorders Awareness Week. Both the National Eating Disorders Association (NEDA) and Anorexia Nervosa & Associated Disorders have created booklets with guidelines for teachers, school nurses, school psychologists, coaches, and counselors who work with students identified as having an eating disorder, their friends, and their parents. In addition to promoting awareness, NEDA and ANRED are encouraging early detection for students through a three minute screening and self help screening.

Want to get involved? Check out these events.

February 22nd - Google Hangout-Early Intervention and Eating Disorders (2 PM EST)

February 22nd- Twitter Chat-Awareness to Action 8 PM EST)

February 23rd - Twitter Chat-Getting Healthy: The Many Faces of Eating Disorder Recovery

February 24th-Day of Action-Promoting Education Regarding Eating Disorders

Need more information? Check out these additional resources.

Booklets & Pamphlets for Educators
NEDA Educator Booklet
ANAD School Guidelines
National Institute of Mental Health Brochure on Eating Disorders (Downloadable)

Guidelines for School Counselors
Cutting, Eating Disorders and Confidentiality

Facts and Webinars About Eating Disorders
Anorexia Fact sheet
Binge Eating Disorder Fact Sheet
Athletes and Eating Disorders
Fast Facts on Eating Disorders
Kati Morton's Videos on Eating Disorders
Webinars on Eating Disorders
The Truth About Eating Disorders
NEDIC Webinars

What Does Recovery Look Like Webinar

Referral Information

Eating Disorder Referral Information (US)
Eating Disorder Information (UK)

Websites and Associations
Academy for Eating Disorders Facebook Page
Eating Disorder Foundation
International Association of Eating Disorders Professionals Foundation - Offers courses and certifications in eating disorder education.
EDAC - Eating Disorders Association of Canada
ANZAED - Australia and New Zealand Academy for Eating Disorders
Eating Disorders Hope
Teens Health
Chats and Conferences
Twitter Chat - March 9th-12:00 PM-Treatment and Recovery
ANAD Eating Disorder Conference - September 9, 2016
International Conference on Eating Disorders - May 5-7, 2016, San Francisco, CA

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It's Not About Food: Eating Disorders Awareness

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During my first year as a high school counselor, a parent came to speak to me about her daughter. The student was a bright and beautiful young lady with a bubbly personality who I had the pleasure of meeting prior to her mother's visit.

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Eating Disorders: 10 warning signs you should look out for

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Overview

It's normal to feel nervous in some social situations. For example, going on a date or giving a presentation may cause that feeling of butterflies in your stomach. But in social anxiety disorder, also called social phobia, everyday interactions cause significant anxiety, self-consciousness and embarrassment because you fear being scrutinized or judged negatively by others.

In social anxiety disorder, fear and anxiety lead to avoidance that can disrupt your life. Severe stress can affect your relationships, daily routines, work, school or other activities.

Social anxiety disorder can be a chronic mental health condition, but learning coping skills in psychotherapy and taking medications can help you gain confidence and improve your ability to interact with others.
Social anxiety disorder care at Mayo Clinic
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Symptoms

Feelings of shyness or discomfort in certain situations aren't necessarily signs of social anxiety disorder, particularly in children. Comfort levels in social situations vary, depending on personality traits and life experiences. Some people are naturally reserved and others are more outgoing.

In contrast to everyday nervousness, social anxiety disorder includes fear, anxiety and avoidance that interfere with relationships, daily routines, work, school or other activities. Social anxiety disorder typically begins in the early to mid-teens, though it can sometimes start in younger children or in adults.

Emotional and behavioral symptoms

Signs and symptoms of social anxiety disorder can include constant:

Fear of situations in which you may be judged negatively

Worry about embarrassing or humiliating yourself

Intense fear of interacting or talking with strangers

Fear that others will notice that you look anxious

Fear of physical symptoms that may cause you embarrassment, such as blushing, sweating, trembling or having a shaky voice

Avoidance of doing things or speaking to people out of fear of embarrassment

Avoidance of situations where you might be the center of attention

Anxiety in anticipation of a feared activity or event

Intense fear or anxiety during social situations

Analysis of your performance and identification of flaws in your interactions after a social situation

Expectation of the worst possible consequences from a negative experience during a social situation

For children, anxiety about interacting with adults or peers may be shown by crying, having temper tantrums, clinging to parents or refusing to speak in social situations.

Performance type of social anxiety disorder is when you experience intense fear and anxiety during speaking or performing in public but not in other types of more general social situations.

Physical symptoms

Physical signs and symptoms can sometimes accompany social anxiety disorder and may include:

Blushing

Fast heartbeat

Trembling

Sweating

Upset stomach or nausea

Trouble catching your breath

Dizziness or lightheadedness

Feeling that your mind has gone blank

Muscle tension

Avoiding common social situations

Common, everyday experiences may be hard to endure when you have social anxiety disorder, including:

Interacting with unfamiliar people or strangers

Attending parties or social gatherings

Going to work or school

Starting conversations

Making eye contact

Dating

Entering a room in which people are already seated

Returning items to a store

Eating in front of others

Using a public restroom

Social anxiety disorder symptoms can change over time. They may flare up if you're facing a lot of changes, stress or demands in your life. Although avoiding situations that produce anxiety may make you feel better in the short term, your anxiety is likely to continue over the long term if you don't get treatment.

When to see a doctor

See your doctor or a mental health professional if you fear and avoid normal social situations because they cause embarrassment, worry or panic.

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Causes

Like many other mental health conditions, social anxiety disorder likely arises from a complex interaction of biological and environmental factors. Possible causes include:

Inherited traits. Anxiety disorders tend to run in families. However, it isn't entirely clear how much of this may be due to genetics and how much is due to learned behavior.

Brain structure. A structure in the brain called the amygdala (uh-MIG-duh-luh) may play a role in controlling the fear response. People who have an overactive amygdala may have a heightened fear response, causing increased anxiety in social situations.

Environment. Social anxiety disorder may be a learned behavior - some people may develop significant anxiety after an unpleasant or embarrassing social situation. Also, there may be an association between social anxiety disorder and parents who either model anxious behavior in social situations or are more controlling or overprotective of their children.

Risk factors

Several factors can increase the risk of developing social anxiety disorder, including:

Family history. You're more likely to develop social anxiety disorder if your biological parents or siblings have the condition.

Negative experiences. Children who experience teasing, bullying, rejection, ridicule or humiliation may be more prone to social anxiety disorder. In addition, other negative events in life, such as family conflict, trauma or abuse, may be associated with this disorder.

Temperament. Children who are shy, timid, withdrawn or restrained when facing new situations or people may be at greater risk.

New social or work demands. Social anxiety disorder symptoms typically start in the teenage years, but meeting new people, giving a speech in public or making an important work presentation may trigger symptoms for the first time.

Having an appearance or condition that draws attention. For example, facial disfigurement, stuttering or tremors due to Parkinson's disease can increase feelings of self-consciousness and may trigger social anxiety disorder in some people.

Complications

Left untreated, social anxiety disorder can control your life. Anxieties can interfere with work, school, relationships or enjoyment of life. This disorder can cause:

Low self-esteem

Trouble being assertive

Negative self-talk

Hypersensitivity to criticism

Poor social skills

Isolation and difficult social relationships

Low academic and employment achievement

Substance abuse, such as drinking too much alcohol

Suicide or suicide attempts

Other anxiety disorders and certain other mental health disorders, particularly major depressive disorder and substance abuse problems, often occur with social anxiety disorder.

Prevention

There's no way to predict what will cause someone to develop an anxiety disorder, but you can take steps to reduce the impact of symptoms if you're anxious:

Get help early. Anxiety, like many other mental health conditions, can be harder to treat if you wait.

Keep a journal. Keeping track of your personal life can help you and your mental health professional identify what's causing you stress and what seems to help you feel better.

Set priorities in your life. You can reduce anxiety by carefully managing your time and energy. Make sure that you spend time doing things you enjoy.

Avoid unhealthy substance use. Alcohol and drug use and even caffeine or nicotine use can cause or worsen anxiety. If you're addicted to any of these substances, quitting can make you anxious. If you can't quit on your own, see your health care provider or find a treatment program or support group to help you.

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Social anxiety disorder (social phobia) - Symptoms and causes

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Learn more on this disorder where everyday interactions cause significant worry and self-consciousness because you fear being judged negatively by others.

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The term dysfunction is defined as "any impairment, disturbance, or deficiency in behavior" on the part of an individual person, between people in a relationship, or among family members. Dysfunction can manifest as poor communication, frequent conflict, emotional or physical abuse, and much more.

Dysfunctional relationships or situations often serve as motivation for people to seek help, often in the form of psychotherapy.

Examples of Dysfunctional Behavior

Examples of dysfunctional behavior within families can include situations such as when a family member, parent, or caregiver:

Engages in compulsive behavior such as gambling or overworking

Engages in emotionally, physically, or sexually abusive behavior

Misuses drugs or alcohol

Uses threats of violence

Allows children to drink alcohol or use drugs

Fails to provide children with emotional support

Relies on a child to provide emotional or financial support

Uses an authoritarian style of parenting in which there is no flexibility

Abuses or neglects children

Cannot provide basic needs such as food and shelter for children

Doesn't address or manage violence or inappropriate behavior

A parent or caregiver in a dysfunctional family might view their children or other family members as property or as things they can control, abuse, or use as an outlet for negative emotions.

Causes of Family Dysfunction

There are many potential causes of family dysfunction. Dysfunction is often the result of a parent or caregiver not getting the emotional support they need. As a result, they are unable or don't know how to provide their children with emotional support.

If a parent or caregiver is abusive, it's possible they themselves experienced abuse as a child-whether emotional, physical, or sexual. For instance, a child who is verbally abused may grow up confusing feelings like anger and love, so they may express themselves with yelling and aggression as an adult in their close relationships.

Mental Health Conditions

If a parent or caregiver experiences severe symptoms of a mental health disorder such as depression, bipolar disorder, post-traumatic stress disorder (PTSD), or a personality or mood disorder, and these symptoms are not appropriately treated, they may contribute to dysfunction within the family dynamic.

Someone with a mental health condition may find it difficult to perform daily tasks or support their family, especially if they aren't receiving adequate treatment or if they don't have a support system of loved ones to step in and help. A child's needs may go unmet and they may experience the added stress of seeing their parent struggle and not being able to help.

One study found that severe symptoms of mental health conditions like depression can often result in a parent treating a child harshly or disengaging from the relationship with their child.

Substance Use

Substance use disorder can also contribute to family dysfunction. If a member of the family misuses drugs or alcohol, all members of the family can experience stress as a result. Coping with addiction in the family may lead to other members of the family feeling neglected.

A parent or family member may also struggle with other types of addiction like overeating or gambling. If, for example, a family member is spending money on the object of their addiction and are unable to pay for basic needs like rent or food, it's likely that everyone in the family will feel stressed and insecure as a result.

Socioeconomic Status

Families who are at a socioeconomic disadvantage, or those who have low income, tend to experience additional stress levels, especially in single-parent households.

A parent or caregiver might struggle to provide food and shelter; they may also work long hours in harsh conditions. Some may have multiple children or family members to support financially. These burdens can contribute to family dysfunction, particularly if the parent is not receiving any support themselves.

Low-income communities generally have less access to mental health services, which can make it even more difficult for a parent or caregiver to get the support that they need. Unfortunately, they may end up taking their negative feelings out on their children or other family members.

The Effects of Dysfunction on Children

When dysfunctional patterns become the standard in a family, the detrimental effects on the children are significant and can be carried into their adult relationships. Some of the potentially damaging effects for children include:

One study found that people who endured stress during childhood as a result of a parent or caregiver's poor mental health experienced more stress into adulthood compared to people who weren't exposed to the same type of stress as children.

If a child's parents or caregivers don't provide them with adequate emotional support, they may grow up not knowing how to prioritize or express their needs or feeling that their needs are unimportant.

Children who've experienced familial dysfunction may even repeat patterns of abuse in their future relationships. They may unconsciously seek out partners who are abusive in similar ways as their parents or they themselves may abuse their partners or children.

Acknowledging dysfunction within your family, how it's affected you, and/or how you contribute to it is the first step in healing.

Getting Help for Family Dysfunction

If your family is experiencing dysfunction for any reason, there is help available. Outside of traditional therapy, there are accessible resources to help you and your family address dysfunctional patterns. Many communities have mental health centers that offer free information and counseling.

Family Therapy

Family therapy may be a good option for those experiencing the effects of dysfunction. Family therapy has been shown to be extremely effective in helping families learn new ways of communicating, solving problems, and supporting each other.

Family therapy sessions usually last 50 minutes to an hour and continue once a week for up to 12 weeks. Oftentimes, families will enter therapy looking to resolve a specific issue such as one family member's uncontrolled anger.

A therapist would work with your family as a unit to discuss how you're all communicating, how you can all respond to incidents of anger more effectively, and teach you how to set goals for productively handling future incidents.

If you have health insurance, check with your plan about coverage for mental and behavioral health services as well as providers that are in-network (which means that the provider is contracted with your insurance and your plan will likely cover more of the cost). If you don't have insurance, you can still research family therapists. Some therapists offer a sliding payment scale based on your income, so be sure to inquire about this prior to booking a session.

Individual Therapy

Whether your family seeks family therapy or not, online or in-person therapy can be a helpful option for anyone in the family. Individual therapy includes working one-on-one with a therapist who can address the underlying causes or effects of family dysfunction with the individual family member seeking help.

For example, if you have learned any negative beliefs as a result of family dysfunction, such as "I don't matter," or "My needs aren't important," a therapist who offers cognitive behavioral therapy (CBT) can work with you to reframe these beliefs into more positive ones. If you are contributing to dysfunction within your family, CBT can help you understand the roots behind your behavior and how to replace negative actions with healthy coping mechanisms.

Support Groups

There are also online or in-person support groups that may offer support for what you're going through in your family. Some support groups are tailored for people coping with specific mental health conditions as well as their friends and family members.

Self-Help Resources

There are also mental health apps, podcasts, and books that cover specific types of family dysfunction and offer practical advice for you and your family to start addressing maladaptive patterns.

Religious Counseling

If you are part of a religious group, you may seek advice from a religious leader as well. Some religious leaders may meet with your entire family and offer words of support and encouragement as you cope with dysfunctional patterns.

Get Advice From The Verywell Mind Podcast

A Word From Verywell

Whether you are coping with family dysfunction right now or you are dealing with the aftermath of a tumultuous childhood experience, remember that you are not alone. Therapy can be very effective in addressing the causes, effects, and trauma of family dysfunction, giving you or your family a roadmap for healing.

Be sure to prioritize your own physical and emotional safety. Family dysfunction may not change overnight, but you should do your best to ensure your own health and the health of your children as best you can.

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How Dysfunctional Behavior Affects Families

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The term dysfunction is defined as "any impairment, disturbance, or deficiency in behavior" on the part of an individual person, between people in a relationship, or among family members. Dysfunction can manifest as poor communication, frequent conflict, emotional or physical abuse, and much more.

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Busser, J.K.(2012). The school counselor’s role in addressing eating disorder symptomatology among adolescents. American Counseling Association: Vistas Online, Article 97. https://www.counseling.org/knowledge-center/vistas