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Aricle-Parental Involvement in Intensive Treatment for Adolescent Panic

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Anxiety-Comorbidity of Attention Deficit Hyperactivity Disorder and Generalized

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Relaxation Techniques for Panic Disorder

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Panic Attacks-panic attacks, causes, symptoms, diagnosis, treatment & pathology

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Panic Attacks-panic attacks, causes, symptoms, diagnosis, treatment & pathology

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Panic disorder - panic attacks, causes, symptoms, diagnosis, treatment & pathology

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The School Counselor’s Role in Addressing Eating Disorder

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Book-How to Nourish Your Child Through an Eating Disorder

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Book-How to Nourish Your Child Through an Eating Disorder

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Book-How to Nourish Your Child Through an Eating Disorder

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Book-What Every Parent Needs to Know About Eating Disorders

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Book-What Every Parent Needs to Know About Eating Disorders

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welcome to the international association of eating disorders professionals foundation!

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Welcome to the International Association of Eating Disorders Professionals Foundation!

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Welcome to the International Association of Eating Disorders Professionals Foundation!

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The maximum amount of time allowed to pass between the parents' request and/or agreement to conduct the evaluation to the IEP development differs from state to state, but most regulations cite a time line somewhere between fifty and 120 days. (Note: In some states the meeting at which the IEP is written is called by the somewhat misleading phrase Admission, Review Dismissal meeting-the ARD meeting.)

Whatever it's called in your state, you will have a lot to prepare so that the meeting is productive and so that the school personnel understand the necessity of the accommodations. Being prepared will also ensure that the IEP is well written.

Parents must be prepared to educate the school team, develop a resource binder, rehearse the meeting beforehand, and decide who will be at the meeting with them (the child psychiatrist, an advocate, an educational lawyer).

Any written materials about early-onset bipolar disorder that you want the special education team at school to review (perhaps the article What is Juvenile Bipolar Disorder?) should be sent about two weeks before the scheduled meeting so that the IEP team will have time to digest the materials and better understand how to write the IEP. Few could skim and grasp the implications of this illness and construct an IEP in the hour or two allotted to the process without prior knowledge about the student's challenges and illness.

Preparing the Binder

The three-ring binder should carry a picture of your child on the front, his or her name and grade on the spine, and be divided into sections inside. These should include:

1. Important contacts and telephone numbers.

2. Reports or letters from the professionals working with your child. An example would be letters from the psychiatrist or therapist with any recommendations they have for your child's education.

3.Results you have from private assessments such as the neuropsychological testing. These test results should support your child's need for an IDEA classification.

4.The complete list of accommodations from this article.

5. The sample IEP from The Bipolar Child website. This sample IEP will help you with your input at the IEP meeting.

6.The Behavior/Symptom/Accommodation chart from this article is a visual aide to help the IEP team better understand how to interpret disruptive behaviors and recommend how to develop interventions which will reduce these unruly behaviors.

7.Examples of your child's work which exemplify areas of difficulty and areas of giftedness.

8. A copy of Jennifer Bollero's beautifully written and reasoned article called "Playing Hearts, Not Poker" available at the Harbor House Press Law site. No parent should leave home for an IEP meeting without reading or re-reading this article.

Educating the Team About Accommodations
That Will Benefit Your Child

Since a parent usually understands the illness and the side effects of the medications better than anyone, he or she should be ready to spell out a list of symptoms and medication side effects and proposed modifications in the academic schedule to accommodate the child's difficulties and to make the school day more productive and comfortable for the student.

Hopefully, by the time the education team sits down to write the IEP, the parents can provide the independent neuropsychological assessment which can pinpoint any specific learning disabilities, learning styles, and possible weaknesses in the domains of executive functions. (This neuropsychologist's report should make recommendations for the academic arena and these recommendations should be addressed in the IEP also.)

We thought it would be helpful to divide the modifications into categories where parents and educators could see at a glance which symptoms the student has and which accommodations will have to be incorporated into the IEP. Four categories the IEP team should consider when developing an appropriate IEP for a student with a mood disorder are:

I. Symptoms caused by the mood disorder

II. Side effects of the medications used to treat the condition

III. Attention and organizational difficulties

IV. Specific learning disabilities

(Click here to view all the symptoms and accommodations)

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How to Prepare for the IEP Meeting - Juvenile Bipolar Research Foundation

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The maximum amount of time allowed to pass between the parents' request and/or agreement to conduct the evaluation to the IEP development differs from state to state, but most regulations cite a time line somewhere between fifty and 120 days. (Note: In some states the meeting at which the IEP is written is called by...

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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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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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Finding the motivation to make positive lifestyle changes can be hard for anyone. For teenagers, it can be especially difficult when parents are the ones telling them to do it. But if they've fallen into unhealthy habits like vaping or alcohol abuse, change can be beneficial. Motivational interviewing is a form of therapy that creates a safe, non-judgmental environment for teens to establish their own goals and values and see how changing unhealthy behaviors can benefit them in the long run.

This series of articles comes from the Child Mind Institute, with most available in English and Spanish. Why might teens be resistant to therapy and how can parents and others to help them get the treatment they need? The articles explain how motivational interviewing can help teens gain the self-confidence to make important behavioral changes. To read more about motivational interviewing, and to connect with the articles in both English and Spanish, please visit CPIR's abstract.

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Center for Parent Information and Resources | Your Central Hub for Parent Centers Serving Families of Children With Disabilities

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Finding the motivation to make positive lifestyle changes can be hard for anyone. For teenagers, it can be especially difficult when parents are the ones telling them to do it. But if they've fallen into unhealthy habits like vaping or alcohol abuse, change can be beneficial.

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Individuals with Disabilities Education Act

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Individuals with Disabilities Education Act (IDEA)

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The U.S. Department of Education’s Individuals with Disabilities Education Act website brings together department and grantee IDEA information and resources. The IDEA makes available a free appropriate public education to and ensures special education and related services to eligible children with disabilities.

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Definition

Students with emotional disorders are a very heterogeneous group with a wide range of issues that are unique to each individual. However, there are some key characteristics that are used to define this disability category, mostly relating to issues of personal identity and emotional well-being. An emotional disorder may be present if a student responds to a situation with an inappropriate behavior or emotion, and particularly, if this emotion is depression or long term unhappiness. Students with emotional disorders typically have a very difficult time maintaining personal relationships with others, and these personal problems lead to physical symptoms in time. If the student has difficulty learning, but there is no intellectual or sensory cause of this difficulty, then an emotional disorder may be to blame. This disability category does include some mental illnesses such as schizophrenia.

It should be noted that one or more of the previously mentioned characteristics has to be present for an extended period of time, and must have a negative impact on the student's academic performance before being considered an emotional disorder. Signs of an emotional disorder need to be taken seriously, as they can lead to physical aggression and self-injurious behavior. However, care must also be taken to recognize the difference between emotional disturbance and general teenage angst. There are as many causes of emotional disturbance in children as there are children in this category, but they can generally be divided into either biological causes, environmental causes, or a combination of the two.

Prevalence

The U.S. Department of Education reports 5,971,495 students receiving special education services in the 2003-2004 school year. Of that number, roughly 7.7%, or 461,055 students, received special education services based on a classification of emotional disturbance. However, within this group of 461,055 students, there was a definite disproportionally between gender, race and socioeconomic background. African-American students were far more likely to be diagnosed as emotionally disturbed than white students, reflecting possible race bias in this category. Research has pointed to a direct correlation between low income status and emotional disorders, but the exact reasons for this correlation are unknown.

Characteristics

Each student with an emotional disturbance will have characteristics that are unique to that individual. However, these students will all share deficits in three specific areas, namely emotional development, behavioral development, and cognitive development.

These students may have specific emotional characteristics/conditions such as anxiety disorder, mood disorder, oppositional defiant disorder, conduct disorder, and schizophrenia. Not addressing any one of these disorders with the appropriate support system could have potentially tragic results. Behavioral characteristics of an emotional disorder include externalizing behavior and conversely internalizing behavior. The former can result in problem behavior and physical aggression while the latter results in depression and anxiety. Finally, students with emotional disorders have a number of academic issues as well, and each year half of the students in this category drop out of school entirely.

One intriguing possible contributing factor to emotional disturbance can be found in deficits in communication. An estimated 71% of students with emotional disorders also have expressive and receptive language disorders that impact their ability to understand and communicate with peers and adults.

Impact on Learning

Students with emotional disorders can be found at every level of cognitive functioning, but the majority of these students tend to have low average intelligence. Most achieve below grade level in academic achievement, with the greatest deficits in both math and spelling. Many have a coexisting learning disability of some type. Students that exhibit externalizing behaviors are at the greatest risk for continued deficits in academic functioning. Students with emotional disorders are less likely to attend post-secondary school than students in many other disability categories. An effective educational program for students with emotional disorders will provide emotional and behavioral supports that foster the replacement of problem behaviors with more appropriate behaviors. Positive behavior support systems are one especially effective strategy to achieve this goal, as are the implementation of wraparound services.

Teaching Strategies

Wraparound planning is a collaborative process that has shown great promise in supporting students with emotional disorders, both in research and in more practical application. This planning process brings all of the involved service providers (i.e., adult rehabilitation services, mental health services, guidance counselor) and individuals together to create a natural support system that is founded on the strengths of the individual student and the community in which that student lives. The family is an integral part of this process, and the overall goal is to devise a program that will capitalize on the strengths and interests of the student while utilizing community resources for placement and intervention.

Generally, academic achievement and problem behaviors often go hand-in-hand for students with emotional disorders. To put this another way, the more difficulty they have with a classroom task, the more likely that maladaptive behavior will result. Supporting the academic performance of these students will thus have the added benefit of decreasing externalizing and internalizing behaviors. Best practices for students with emotional disorders are often best practices for all students. A strategy such as allowing students to choose between classroom tasks, for example, is an effective way to decrease problem behaviors in general. Consistent and specific praise is also a great technique to utilize with all students in the classroom, but can be particularly effective with students with emotional disorders.

It is very important to not make assumptions about any family of a child with an emotional disorder. Many emotional disorders have an organic cause, and the parents of the child may well be loving and supportive in every way. However, some of these students have indeed been abused in some fashion in their young lives, and this too can be a cause of emotional or behavioral issues. Trust can be a very large issue for these children. Forming a relationship with these students that is built on empathy, trust, and mutual respect can often be the solution to many problem behaviors, and can have a lasting impact of the emotional development of the child.

Assistive Technology

Some modification in instruction will be necessary to allow a student with an emotional disorder to demonstrate mastery in a number of academic areas, and most especially in the area of writing. Word processing software can be an excellent supplementary aid for these students, allowing them to edit and revise their work as they produce it. These programs can strengthen spelling skills and writing cohesion simply by making the writing process easier overall. Of particular benefit are word processing programs that read the text as it is typed, providing an additional audio cue for the student.

Organizations

There are a number of excellent organizations that can help support classroom instruction for students with emotional and behavioral disabilities. The information presented in this module is intended as just a very brief description of emotional disorder and its impact on learning. Much more in-depth information and instructional strategies can be accessed through the following organizations:

American Academy of Child and Adolescent Psychiatry

The AACAP (American Academy of Child and Adolescent Psychiatry) is the leading national professional medical association dedicated to treating and improving the quality of life for children, adolescents, and families affected by these disorders. Composed of over 7,500 child and adolescent psychiatrists and other interested physicians, its members actively research, evaluate, diagnose, and treat psychiatric disorders and pride themselves on giving direction to and responding quickly to new developments in addressing the health care needs of children and their families.

Public Information Office
3615 Wisconsin Ave., NW
Washington, DC 20016-3007

Web: www.aacap.org

Center on Positive Behavioral Interventions and Supports

The OSEP-funded National Technical Assistance Center on Positive Behavior and Intervention Supports was established to address the behavioral and discipline systems needed for successful learning and social development of students. The Center provides capacity-building information and technical support about behavioral systems to assist states and districts in the design of effective schools.

5262 University of Oregon
Eugene, OR 97403-5262

Email: pbis@oregon.uregon.edu
Web: www.pbis.org

Center for Disability and Development

Dept. of Educational Psychology
4225 Texas A&M University
College Station, TX 77843-4225

Council for Exceptional Children

The Council for Exceptional Children (CEC) is the largest international professional organization dedicated to improving educational outcomes for individuals with exceptionalities, students with disabilities, and/or the gifted. CEC advocates for appropriate governmental policies, sets professional standards, provides continual professional development, advocates for newly and historically underserved individuals with exceptionalities, and helps professionals obtain conditions and resources necessary for effective professional practice.

1110 North Glebe Road, Suite 300
Arlington, VA 22201-5704

Federation of Families for Children's Mental Health

This organization is dedicated exclusively to helping children with mental health needs and their families achieve a better quality of life. They provide leadership to develop and sustain a nationwide network of family-run organizations; focus the passion and cultural diversity of our membership to be a potent force for changing how systems respond to children with mental health needs and their families; help policy-makers, agencies, and providers become more effective in delivering services and supports that foster healthy emotional development for all children.

1101 King Street, Suite 420
Alexandria, VA 22314

Email: ffcmh@ffcmh.org
Web: www.ffcmh.org

National Alliance for the Mentally Ill (NAMI)

NAMI is the National Alliance on Mental Illness, the nation's largest grassroots organization for people with mental illness and their families. NAMI is dedicated to the eradication of mental illnesses and to the improvement of the quality of life for persons of all ages who are affected by mental illnesses. NAMI members and friends work to fulfill our mission by providing support, education, and advocacy.

Colonial Place Three
2107 Wilson Boulevard, Suite 300
Arlington, VA 22203-3754

Web: www.nami.org

Mental Health America

Mental Health America is dedicated to helping ALL people live mentally healthier lives. They work to fulfill this mission by education the public about ways to preserve and strengthen mental health; advocating for access to effective care; fostering innovation in research, practice, services and policy; and providing support to individuals and families.

2001 N. Beauregard Street, 12th Floor
Alexandria, VA 22311

Web: www.nmha.org

National Mental Health Information Center

The National Mental Health Information Center was developed for users of mental health services and their families, the general public, policy makers, providers, and the media. They provide free information about mental health via a toll-free number, their website, and more than 600 publications.

P.O. Box 42557
Washington, DC 20015

Web: www.mentalhealth.org

References

Hunt, N., and Marshall, K. (2006). Exceptional children and youth. Boston, MA: Houghton Mifflin Company.

National Dissemination Center for Children with Disabilities (2004). Fact Sheet 5. Retrieved February 1, 2008 from www.nichcy.org/pubs/factshe/fs5txt.htm.

Turnbull, A., Turnbull, R. & Wehmeyer, M. L. (2007). Exceptional lives. Special education in today's schools. Upper Saddle River, NJ: Pearson Merrill Prentice Hall.

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Students with emotional disorders typically have a hard time maintaining relationships, and these personal problems may lead to physical symptoms in time.

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

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

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

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

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

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

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

* The child's parent or caregiver

* General and special education teachers

* The school principal

* The child's parent or caregiver

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

* At least one special education teacher

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

* A district representative with authority over special education services

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

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

* Specific accommodations, supports, or services for the child

* Names of who will provide each service

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

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

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

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

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

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

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

* How the child will participate in standardized tests

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

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

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

How to resolve disputes

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

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

* Mediation

* Alternative dispute resolution

* Impartial hearing

* Complaint to the Office for Civil Rights (OCR)

* Lawsuit

* Mediation

* Due process complaint

* Resolution session

* Civil lawsuit

* State complaint

* Lawsuit

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

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

About the author

About the author

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

Reviewed by

Reviewed by

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

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

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

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At a glance

The Individuals with Disabilities Education Act (IDEA) requires public schools to provide special education services to eligible students.

IDEA covers 13 disability categories.

Not every student who struggles in school qualifies.

The Individuals with Disabilities Education Act (IDEA) requires public schools to provide special education and related services to eligible students. But not every child who struggles in school qualifies. To be covered, a child's school performance must be "adversely affected" by a disability in one of the 13 categories below.

1. Specific learning disability (SLD)

The "specific learning disability" (SLD) category covers a specific group of learning challenges. These conditions affect a child's ability to read, write, listen, speak, reason, or do math. Here are some examples of what could fall into this category:

SLD is the most common category under IDEA. In the 2018-19 school year, around 33 percent of students who qualified did so under this category.

2. Other health impairment

The "other health impairment" category covers conditions that limit a child's strength, energy, or alertness. One example is ADHD, which impacts attention and executive function.

3. Autism spectrum disorder (ASD)

ASD is a developmental disability. It involves a wide range of symptoms, but it mainly affects a child's social and communication skills. It can also impact behavior.

Various mental health issues can fall under the "emotional disturbance" category. They may include anxiety disorder, schizophrenia, bipolar disorder, obsessive-compulsive disorder, and depression. (Some of these may also be covered under "other health impairment.")

5. Speech or language impairment

This category covers difficulties with speech or language. A common example is stuttering. Other examples are trouble pronouncing words or making sounds with the voice. It also covers language problems that make it hard for kids to understand words or express themselves.

6. Visual impairment, including blindness

A child who has eyesight problems is considered to have a visual impairment. This category includes both partial sight and blindness. If eyewear can correct a vision problem, then it doesn't qualify.

Kids with a diagnosis of deafness fall under this category. These are kids who can't hear most or all sounds, even with a hearing aid.

The term "hearing impairment" refers to a hearing loss not covered by the definition of deafness. This type of loss can change over time. Being hard of hearing is not the same thing as having trouble with auditory or language processing.

Kids with a diagnosis of deaf-blindness have both severe hearing and vision loss. Their communication and other needs are so unique that programs for just the deaf or blind can't meet them.

10. Orthopedic impairment

An orthopedic impairment is when kids lack function or ability in their bodies. An example is cerebral palsy.

11. Intellectual disability

Kids with this type of disability have below-average intellectual ability. They may also have poor communication, self-care, and social skills. Down syndrome is one example of a condition that involves an intellectual disability.

12. Traumatic brain injury

This is a brain injury caused by an accident or some kind of physical force.

13. Multiple disabilities

A child with multiple disabilities has more than one condition covered by IDEA. Having multiple issues creates educational needs that can't be met in a program designed for any one disability.

Having a disability is not enough to qualify for special education. The disability has to have an "adverse effect" on a child's education.

Key takeaways

Each of the 13 disability categories in IDEA can cover a range of difficulties.

Dyslexia, dyscalculia, and written expression disorder fall under the "specific learning disability" category.

"Other health impairment" can cover ADHD.

About the author

About the author

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

Reviewed by

Reviewed by

Rayma Griffin, MA, MEd has spent 40 years working with children with learning and thinking differences in the classroom and as an administrator.

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See a list of the 13 IDEA disability categories. Find out which disabilities can qualify kids for special education.

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Students with Disabilities & Section 504 of the Rehabilitation Act of 1973

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Students with Disabilities & Section 504 of the Rehabilitation Act of 1973

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Check out my latest presentation built on emaze.com, where anyone can create & share professional presentations, websites and photo albums in minutes.

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COUN-Anxiety vs Anxiety Disorders Infographic

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Depression : Understanding and Treating Depression

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ADHD: What parents need to know about attention deficit hyperactivity disorder

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Postgrad Med. Author manuscript; available in PMC 2013 Jul 26.

Published in final edited form as:

Abstract

Attention deficit/hyperactivity disorder (ADHD) is among the most common neurobehavioral disorders presenting for treatment in children and adolescents. ADHD is often chronic with prominent symptoms and impairment spanning into adulthood. ADHD is often associated with co-occurring disorders including disruptive, mood, anxiety, and substance abuse. The diagnosis of ADHD is clinically established by review of symptoms and impairment. The biological underpinning of the disorder is supported by genetic, neuroimaging, neurochemistry and neuropsychological data. Consideration of all aspects of an individual's life needs to be considered in the diagnosis and treatment of ADHD. Multimodal treatment includes educational, family, and individual support. Psychotherapy alone and in combination with medication is helpful for ADHD and comorbid problems. Pharmacotherapy including stimulants, noradrenergic agents, alpha agonists, and antidepressants plays a fundamental role in the long-term management of ADHD across the lifespan.

Keywords: ADHD, ADD, comorbidity, treatment

INTRODUCTION AND OVERVIEW

Attention-deficit/hyperactivity disorder (ADHD) is among the most common neurobehavioral disorders presenting for treatment in children 1, 2. It carries a high rate of comorbid psychiatric problems such as oppositional defiant disorder (ODD), conduct disorder, mood and anxiety disorders, and cigarette and substance use disorders 3. Across the life span, the social and societal costs of untreated ADHD are considerable, including academic and occupational underachievement, delinquency, motor vehicle safety, and difficulties with personal relationships 3-5,6.

ADHD affects an estimated 4% to 12% of school-aged children worldwide 7 with survey and epidemiologically derived data showing that 4 to 5% of college aged students and adults have ADHD 8. In more recent years, the recognition and diagnosis of ADHD in adults have been increasing although treatment of adults with ADHD continues to lag substantially behind that of children 8, 9. In contrast to a disproportionate rate of boys diagnosed with ADHD relative to girls in childhood, in adults, an equal number of men and women with ADHD are presenting for diagnosis and treatment 10.

PSYCHIATRIC COMORBIDITY

During the past decade, epidemiological studies have documented high rates of concurrent psychiatric and learning disorders among individuals with ADHD 3, 11, 12,13. Consistent with childhood studies, studies of ADHD adults have found high rates of childhood conduct disorder as well as adult antisocial disorders in these subjects 3.

Mood & Anxiety

Anxiety often confounds the diagnosis and treatment of ADHD 3, 11, 12. High rates of the various anxiety symptoms exist in ADHD and may manifest as social, generalized or panic-like symptoms. Similarly, ADHD increases the likelihood of having a depressive disorder by at least two-fold 8, 14. Interestingly, recent data suggest that stimulant treatment of ADHD over time may decrease the ultimate risk for anxiety and depressive disorders 15.

A growing literature reports the co-occurrence of bipolar disorder and ADHD. Systematic studies of children and adolescents indicate rates of ADHD ranging from 57% to 98% in bipolar children; and conversely, rates of bipolar disorder in 22% of ADHD children and adolescents 16. There continues to be much controversy about the validity of the concurrent diagnoses of ADHD and severe mood instability or bipolar disorder. Whereas ADHD is characterized by the typical cognitive and hyperactive/impulsive features of the disorder, bipolar disorder (BPD) is characterized by mood instability, pervasive irritability/rage, grandiosity, psychosis, cyclicity, and lack of response to structure 17. When individuals experience both sets of symptoms, they may suffer from both ADHD and BPD 17.

Substance Use Disorders

Combined data from retrospective accounts of adults and prospective observations of youth indicate that juveniles with ADHD are at increased risk for cigarette smoking and substance abuse (SA) during adolescence 18. ADHD adolescents and adults become addicted to cigarette smoking at twice the rate compared to non-ADHD individuals 19, 20. ADHD youth disproportionately become involved with cigarettes, 19 which increases the risk for subsequent alcohol and drug use 21. Individuals with ADHD tend to have more severe substance abuse and maintain their addictions longer compared to their non-ADHD peers 19, 22-24.

Concerns of the abuse liability of stimulants and the potential kindling of substance abuse secondary to early stimulant exposure in ADHD children have been raised. 25 These concerns are based largely on data from animal studies. 25 However, the preponderance of clinical data and consensus in the field do not appear to support such a contention. For example, in a prospective study of ADHD girls followed into adolescence, a significant reduction in the risk for SA was reported in treated compared to untreated ADHD youth 26 with no increase (or decreased) SUD risk associated with stimulant treatment into adulthood 27.

DIAGNOSING ADHD

ADHD can be reliably diagnosed in children, adolescents, and adults 28. Using the current guidelines, the child or adult patient must meet the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)29. It is important to note, however, that the DSM-IV-TR criteria for ADHD symptoms were derived from youth to age 17 years and therefore were not specifically tailored to adults and hence, may not always "fit" adults with the disorder 28, 30. The symptoms of the disorder are categorized as follows: inattention-difficulty sustaining attention and mental effort, forgetfulness, and distractibility; hyperactivity-fidgeting, excessive talking, and restlessness; and impulsivity-difficulty waiting one's turn and frequent interruption of others. The DSM-IV-TR criteria also include onset by age 7, impaired functioning in at least 2 settings (home, work, school, job), and more than 6 months of duration 30. Three subtypes of the syndrome are currently recognized: predominantly inattentive, predominantly hyperactive-impulsive, and the combined type, which is the most common and typically more severe and with more comorbidity 29, 31, 32. Between 90 to 95% of adolescents and adults with ADHD manifest the inattention cluster of symptoms at least as a component of their disorder 31. Of interest, the combined subtype of ADHD may simply represent a more severe and debilitating presentation of ADHD (e.g. more symptoms) and there may be relatively more stability of the subtype with development 32, 33.

To meet the diagnostic criteria for the inattentive or hyperactive-impulsive subtypes, an individual must have 6 or more of the 9 symptoms from either group of criteria (18 possible traits in all) 30. For the combined subtype, an individual must have 6 or more inattentive symptoms and 6 or more hyperactive-impulsive symptoms. To warrant the ADHD diagnosis, symptoms must cause significant impairment. Adults diagnosed with the disorder must have had childhood onset and persistent and current symptoms, although allowance is made for incomplete persistence of full criteria (ADHD-in partial remission) or lack of clear childhood symptoms (ADHD NOS).

Of interest, whereas clinicians are concerned as to the possibility of purposely misrepresenting or over-reporting of ADHD symptoms by college students or adults, data suggest the opposite may be operant. Mannuzza et al. 34 in a prospective 16-year follow-up of children with ADHD now at a mean age of 25, found that of the 176 individuals with a well characterized past history of ADHD, only 28% of the adults through direct interviews were identified as having childhood ADHD. These data further highlight issues around the relatively poor sensitivity of recalling symptoms (and establishing the diagnosis of ADHD) by adult self-report, particularly when not anchoring symptoms in childhood.

The diagnosis of ADHD is made clinically with scales used in an ancillary manner. The patient's symptoms, severity of impairment, possible comorbidity, family history, and psychosocial stressors may be determined during the patient and/or parent interview. In pediatric evaluations, the adolescent's behavior and parent-child interaction are observed, and the child's school, medical, and neurological status are evaluated 2. A number of diagnostic and follow-up scales are available (see www.schoolpsychiatry.org)35. Symptom scales used with all age groups (to assess home, school, and job performance) include, but are not limited to, the ADHD Symptom Checklist, SNAP-IV Teacher and Parent Rating Scale, Conners Rating Scales-Revised,, Brown Attention-Deficit Disorder Scales for Children, and the ADHD Symptoms Rating Scale 36. Although these tools quantify behavior deviating from norms, they should not be used alone to make or refute the diagnosis.

Diagnosing adults involves careful querying for developmentally appropriate criteria from the DSM-IV-TR concerning the childhood onset, persistence, and current presence of symptoms 29. Diagnostic aids are available for adult ADHD 36,37. For instance, the Adult Self Report Scale, Conners Adult ADHD Scales, and Brown Attention scales for adults are among instruments available to assist in the diagnosis of ADHD36,37. For a briefer screening of adults, the World Health Organization Adult ADHD self-report scale ( Figure 1 ) can be downloaded ( www.who.org) and has been validated as a manner of identifying those at risk for ADHD who necessitate further screening 38.

Follow-up studies show that prominent symptoms and impairment related to the disorder persist into adulthood in approximately one-half of cases 39, 40. There appears to be developmental variance in the ADHD symptom profile across the life span 31, 32, 39-41. Longitudinally derived data in ADHD youth growing up indicate that the symptom cluster of hyperactivity and impulsivity decays over time, while the symptoms of inattention largely persist 32, 39-41,31. In support of this notion, data derived from a group of clinically referred adults with ADHD indicate that approximately half of adults endorse clinically significant levels of hyperactivity/impulsivity, but 90% endorse prominent attentional symptoms 32,31.

A substantial body of literature implicates abnormalities of brain structure and function in the pathophysiology of both childhood and adult ADHD 42-48,49-51. We have known for decades that ADHD youth show impaired performance on tasks assessing vigilance, motoric inhibition, organization, planning, complex problem solving, and verbal learning and memory 52, 53. Prominent neuropsychologically-derived executive dysfunction is associated with learning disabilities and poorer overall prognosis over time in ADHD youth 54. Similar findings are emerging in adults with ADHD 52. While neuropsychological testing is not used clinically to diagnose ADHD in adults, such testing aids in identifying learning disabilities, sub average intelligence, and specific information processing deficits.

PATHOPHYSIOLOGY AND GENETICS

Neurobiology

ADHD has been conceptualized as a disorder affecting "frontal" circuitry due to associated deficits in executive cognitive functioning. Structural imaging studies have documented diffuse abnormalities in children and adults with ADHD. A large study by Castellanos and colleagues 55 reported smaller total cerebrum, cerebellum, and the four cerebral lobes that did not change over time. A structural magnetic resonance imaging (MRI) study 56 in adults with and without ADHD also revealed a smaller anterior cingulate cortex (ACC) and dorsolateral prefrontal cortex (DLPFC). The DLPFC controls working memory that involves the ability to retain information while processing new information. These differences are thought to account for deficits in goal-directed and on task behavior in ADHD. The ACC is thought to be a key region of regulation involving the ability to focus on one task and choose between options.

Investigators have also examined the developmental pattern of cortical maturation in ADHD. Shaw and colleagues 57 reported a delay in cortical thickness among ADHD patients. The pattern of brain development, from sensorimotor to associative areas, was similar in children with and without ADHD. However, the age of peak development was delayed in those with ADHD. Using the same measure of cortical thickness data in adults, Makris and associates 58 have shown that cortical thickness is not normalized and that the areas of the brain that are affected in children with ADHD remain affected in adulthood. In this study the DLPFC, parietal areas, and ACC had thinner measures of cortical thickness in adults with ADHD than in adults without ADHD.

Functional magnetic resonance imaging (fMRI) has been used to examine brain activity during selective cognitive challenges in individuals with ADHD. One study that measures brain activity using a neuropsychological test (go/no-go) found that both youth and adults with ADHD showed attenuated activity in the frontostriatal regions of the brain that are key for inhibitory control and for attention (prefrontal cortex and caudate) 59. Adults with ADHD also activated non-frontostriatal regions (ACC, parietal areas) moreso than controls. The amount of brain activation observed correlated closely with the degree of efficiency on the task in both children and adults with ADHD.

The results of fMRI studies were reviewed by Casey and Durston 60 who hypothesized that top-down and bottom-up control systems were affected in ADHD. They speculated that bottom-up neural systems detect the regularities and irregularities in the environment to activate the frontal brain systems to alter behavior. These systems are key regulators of maintaining sustained attention vs. shifting attention due to sensory input. Casey and Durston 60 posited that the striatum regulates what to expect (type of task), the cerebellum regulates when to expect it (timing of task), and the parietal lobe alerts one to novel or newer competing stimuli.

Interestingly, medication may normalize some of these functional deficits. Bush and colleagues published a study showing that 7 weeks of treatment with methylphenidate normalized activation in the ACC 61. Those receiving medication showed increases in activation of the ACC and DLPFC at follow-up as compared to baseline and to those receiving placebo treatment. Hence, those areas of the brain that were underactive in adults without treatment normalized with treatment.

The neurobiology of ADHD is strongly influenced by genetic factors. As highlighted in a special issue of Science dedicated to the human genome project, ADHD is among the most recognized genetic-based disorders in psychiatry 62. Family studies of ADHD have shown that the relatives of ADHD children are at high risk for ADHD, comorbid psychiatric disorders, school failure, learning disability and impairments in intellectual functioning 63. Additional lines of evidence from twin, adoption and segregation analysis studies suggest that the familial aggregation of ADHD has a substantial genetic component. Twin studies find greater similarity for ADHD and components of the syndrome between monozygotic twins compared with dizygotic twins 64, 65. Faraone and colleagues 66 in a meta-analysis of the various studies reported on the mean heritability of ADHD. Heritability refers to the amount of genetic influence for a particular condition. A coefficient of 1 indicates an entirely genetically influenced phenomenon, while a 0 indicates no genetic influence. Depression, anxiety, panic, and even Asthma had mean heritability rates below 50%. In contrast, two of the most biologically related psychiatric disorders, schizophrenia and autism, are heritable at ~75%. ADHD falls in this higher range as well, with work by Rietveld and associates showing a mean heritability rate of 75% 67.

As with many complex neuropsychiatric conditions, multifactorial causation is thought to be involved in ADHD; an additive effect of multiple vulnerability genes interacting with environmental influences. Pooled analyses reveal that there is not one single gene associated with ADHD 66. The disorder is thought to result from a combination of small effects from a number of genes (polygenetic). Some of the candidate genes that have been identified thus far relate to synthesis, packaging, release, detection and recycling of dopamine or catecholamines including the post-synaptic DRD4, dopamine transporter, and SNAP 25 genes; as well as others related to other neurotransmitters such as serotonin. Clearly, more work is necessary in disentangling the relationship of candidate genes in producing specific phenocopies of ADHD, as well as response prediction to psychosocial and pharmacological intervention.

TREATMENT

The management of ADHD includes consideration of two major areas: non-pharmacological (educational remediation, individual and family psychotherapy) and pharmacotherapy 2. Support groups for children and adolescents and their families, as well as adults with ADHD, provide an invaluable and inexpensive environment in which individuals are able to learn about ADHD and resources available for their children or themselves. Support groups can be accessed by calling an ADHD hotline or a large support group organization (i.e. Children and adults with ADHD-CHADD, Adults with ADHD-ADDA,), or by accessing the internet.

Specialized educational planning based on the child's difficulties is necessary in a majority of cases 68. Since learning disorders co-occur in one-third of ADHD youth, ADHD individuals should be screened and appropriate individualized educational plans developed. Parents should be encouraged to work closely with the child's school guidance counselor who can provide direct contact with the child as well as serve as a valuable liaison for teachers and school administrators. The school's psychologist can be helpful in providing cognitive testing as well as assisting in the development and implementation of the individualized education plan. Educational adjustments should be considered in individuals with ADHD with difficulties in behavioral or academic performance. Increased structure, predictable routine, learning aids, resource room time, and checked homework are among typical educational considerations in these individuals. Similar modifications in the home environment should be undertaken to optimize the ability to complete homework. For youth, frequent parental communication with the school about the child's progress is essential.

PSYCHOSOCIAL TREATMENTS

Clinicians have at their disposal a variety of psychosocial interventions for ADHD (for review see 68, 69). Apart from traditional psychotherapy, which addresses underlying emotions, tutors are available to help children develop strategies for improving academic performance and interpersonal relations. Tutors can assist the child with skills in organization and prioritization, as well as act as mentors, advocates, and motivational figures.

Parent training is often conducted using the antecedent behavior consequence model, and is implemented using various methods, including small and large parent training groups, parent training with individual families, videotapes, and behavioral sessions that include children 70. In the academic setting, virtually all children with ADHD must cope with organizational and behavioral demands and expectations. Classroom behavioral interventions often involve training the teacher in use of these methods.

Teachers can conduct individual and class-wide interventions using antecedents and/or consequence methods 71. Antecedent interventions are based on an understanding of the range of antecedents (eg, boredom, peer provocation, unclear inconsistent rules) that precipitate behavioral problems. Antecedent/consequence interventions involve understanding antecedents to inappropriate behavior and reinforcing appropriate behavior with rewards. Consequence interventions involve the judicious use of punishment to encourage appropriate classroom behavior.

Accommodations should be considered to assist the child with ADHD. For instance, other behavioral strategies can be used in the classroom setting to facilitate attention 72. These include placing the child with ADHD in proximity to the teacher, eliminating environmental distractions, and arranging seating in traditional rows rather than clusters. Lessons that involve novelty and stimulation in easy and repetitive tasks rather than new or difficult ones have been shown to benefit the child with ADHD. Additional interventions shown to be effective in the academic setting include peer-mediated interventions and token economies.

Exciting new work has shown that cognitive therapies 73 and cognitive behavioral therapy have been shown effective in medicated adults with ADHD who manifest residual ADHD symptoms 74-77. Social skills remediation for improving interpersonal interactions and coaching for improving organization and study skills may be useful adjuncts to treatment, although there generalizeability remains debated. Little data exists for the use of neurofeedback, cerebellar training, attention or memory training, or ophthalmic manipulation for the treatment of core ADHD symptoms 71.

PHARMACOTHERAPY

Medications remain a mainstay of treatment for children, adolescents, and adults with ADHD (see Table 1 ). In fact, NIH-funded multisite studies support that medication management of ADHD is the most important variable in outcome (for core ADHD symptoms) in context to multimodal treatment at least over the first year to two of treatment 78-80. The stimulants, noradrenergic agents, and alpha agonists comprise the available agents for ADHD. The medications used in ADHD have been observed to have pharmacological responsivity across the lifespan for school-aged children, adolescents, and adult groups with ADHD.

TABLE 1

Generic class
(Brand name)

DAILY
DOSE
(MG/KG)

DAILY
DOSAGE
SCHEDULE

TYPICAL
DOSING
SCHEDULE**

COMMON ADVERSE EFFECTS

Stimulants

Amphetamine

0.3-1.5

-Insomnia

Short-acting
(Dexedrine-tablets)

Twice or
three times

5-30 mg BID to
TID

-Decreased appetite, weight loss
-Tic exacerbation

Intermediate-acting
(Adderall, Dexedrine spansules)

Once or
twice

5-30 mg BID

-Rebound phenomena (short acting
preparations)

Extended-release
(Adderall-XR; Vyvanse)

Once

10-70 mg QD

Methylphenidate

-Insomnia

Short acting
(Ritalin, Metadate; Focalin)

0.5.0-2.0
(< 1 mg for
d-MPH or
patch)

Twice to
four times

5-40 mg BID to
QID

-Decreased appetite, weight loss
-Tic exacerbation
-Depression, anxiety

Intermediate-acting
(Ritalin SR, Metadate SR)

Once or
twice

10-60 mg QD to
BID

-Rebound phenomena (short acting
preparations)
- Increased blood pressure/ pulse

Extended-release
(Concerta; Metadate CD; Focalin
XR; Daytrana Patch)

Once

10-90 mg QD

Noradrenergic Agents

Atomoxetine (Strattera)

1.0-2.0

Once or
twice

25-140 mg QD

-GI Upset, nausea
-Sedation, insomnia
-Agitation

Alpha Agonists

Guanfacine
(Intuniv [Extended-release;
Tenex*)

30-100
mcg/kg

Twice

0.5-1 mg TID
1-4 mg daily

-Similar to clonidine but less sedation

Clonidine*
(Catapress)

3-10
mcg/kg

Twice or
three times

0.05-0.1 mg TID

-Sedation, dry mouth, depression
-Confusion (with high dose)

Modafinil *

Once or
twice

100-400 mg QD

-Insomnia
-Weight loss

Antidepressants *

Tricyclics (TCAs)*
e.g., Imipramine, Desipramine,
Nortriptyline (NT)

2.0-5.0
(1.0-3.0
for NT)

Once or
twice

25-300 mg QD
(25-150 mg QD
for NT)

-Dry mouth, constipation
-Weight loss
-Vital sign and ECG changes

Bupropion*
(Wellbutrin short acting and
sustained release-SR, XL)

1.0-6.0

Once to
three times

75-100 mg TID
150-200 BID
(SR); 150-450
XL

-Irritability, insomnia
-Risk of seizures
-Contraindicated in bulimics

Stimulants

The stimulant class medications are among first line agents for pediatric and adult groups with ADHD based on their extensive efficacy and safety data 1. The most commonly used compounds in this class include methylphenidate-based (Ritalin, Concerta, Focalin, Metadate, Daytrana and others) and amphetamine-based (Adderall, Dexedrine, Vyvanse) formulations. Stimulants are sympathomimetic drugs which increase intrasynaptic catecholamines (mainly dopamine and norepinephrine) by inhibiting the presynaptic reuptake mechanism and releasing presynaptic catecholamines 81. Whereas methylphenidate is specific for blockade of the dopamine and noradrenergic transporter proteins, amphetamines (in addition to blocking the dopamine and noradrenergic transporter protein) release catecholaminergic stores and cytoplasmic dopamine and noradrenaline directly into the synaptic cleft (for review see 1, 81).

Given the need to additionally treat ADHD outside of academic settings (i.e. social, homework, driving) and to reduce the need for in school dosing and likelihood for diversion, there has been a shift to the extended release preparations of the stimulants. Extended release preparations diminish afternoon wear-off and rebound and appear to manifest less abuse liability compared to their immediate-release counterparts 82, 83. The extended release stimulants include methylphenidate (trade names: Concerta, Daytrana Patch, Focalin XR, Metadate CD, Ritalin LA) and amphetamine formulations (trade names: Adderall XR, Vyvanse). The literature suggests more similarities than differences in response to the various available stimulants 1, 84. However, based on different mechanisms of action and individual tolerability, some patients who lack a satisfactory response or manifest adverse effects to one stimulant may respond favorably to another. Stimulants should be initiated at the lowest available dosing once daily and increased every three to seven days until a response is noted or adverse effects emerge.

Stimulants appear to work in all age groups of individuals with ADHD. For instance, a controlled multi-site study in preschoolers showed improvement in ADHD symptoms and structured tasks; however, the response was less robust with a higher side effect burden compared to other age groups 85. There has been a great interest in the use of stimulant treatment in adults with ADHD. There have been approximately 40 studies of stimulants demonstrating moderate efficacy 86. Currently FDA approval is only for the extended-release preparation of stimulants in adults.

Predictable short-term adverse effects include reduced appetite, insomnia, edginess, and GI upset 87. Elevated vital signs may emerge necessitating baseline and on-drug monitoring. Although stimulants may produce anorexia and weight loss, their effect on ultimate height remains less certain 88, 89. Whereas a number of studies have indicated potential growth delay earlier in treatment, normalization appears to occur with chronic treatment. Longitudinal studies suggest that the majority of ADHD youth with tics can tolerate stimulant medications 90; however, up to one-third of children with tics may have worsening of their tics with stimulant exposure 91. Current consensus suggests that stimulants can be used in youth with comorbid ADHD plus tics with careful monitoring for stimulant-induced tic exacerbation.

Warnings have also highlighted potential cardiovascular adverse events. Data suggest that rates of sudden and catastrophic adverse cardiovascular effects are no higher on stimulants and nonstimulants to treat ADHD compared to the general population 92. Based on guidelines from the American Academy of Pediatrics 93, 94, history and symptoms referable to structural heart disease should be queried prior to starting and during treatment with medications (see Figure 2 ) including family history of premature death, congenital heart disease, palpitations, syncopal episodes, dizziness, or chest pain 93, 94. Blood pressure and pulse monitoring at baseline and periodically thereafter is recommended whereas ECG monitoring is optional 93, 94.

Despite lingering concerns of stimulant abuse, there is a paucity of scientific data supporting that stimulant-treated ADHD individuals systematically abuse their medication 95 and the preponderance of recent data continue to suggest reductions of cigarette smoking and substance abuse associated with treatment19, 26. However, data suggest that diversion of stimulants to non-ADHD youth continues to be a concern 96, 97. Families should closely monitor stimulant medication, and college students receiving stimulants should be advised to carefully store their medication 96. Two studies have shown less abuse liability associated with extended-release relative to immediate release MPH 82, 83.

Atomoxetine

Atomoxetine is a potent norepinephrine-specific reuptake inhibitor that has been studied in youths and adults 98, 99. Atomoxetine has been shown to be effective in long-term use 100. Atomoxetine has also been shown particularly useful in comorbid ADHD. In a noninferiority study in children with ADHD and tic disorder, atomoxetine reduced tic severity while improving ADHD symptoms. Children with ADHD and clinically significant anxiety responded more favorably to atomoxetine than placebo with reductions in both anxiety and ADHD scores 101. Likewise, data in young adults with ADHD has shown that 12 week treatment with atomoxetine in recently abstinent alcoholics (4-30 days) was associated with significant reductions in ADHD and heavy drinking (not relapse) compared to placebo 102. In clinical trials, atomoxetine is associated with nausea, GI distress, and sedation most commonly reported. Patients may rarely experience hostility, irritability, and/or suicidality. There is currently a black box warning for rare, but potentially serious, hepatitis (see http://www.strattera.com/pages/index) 103. While routine liver function monitoring is not recommended, careful informed consent with patients and their families can enhance vigilance for warning signs and symptoms.

Antihypertensives/alpha agonists

The antihypertensives guanfacine and clonidine are alpha-adrenergic agonists; an extended-release preparation of guanfacine is FDA approved. Whereas clonidine affects alpha receptors more broadly, guanfacine appears to be more selective for the alpha 2a receptor. Improvements in both attention and hyperactivity/impulsivity have been demonstrated with the alpha agonists 104. The alpha agonists have been used for the treatment of core ADHD as well as associated tics, oppositional defiant behavior, aggression, and sleep disturbances, particularly in younger children 105.

Multisite combination studies using alpha agonists and stimulants have been conducted in youth with ADHD and ADHD plus tics. Interestingly, all studies have shown that the combination was more effective than either agent alone in improving ADHD and/or tics 106-109,110. In these studies, no clinically meaningful adverse cardiovascular events were observed 106, 107. Cardiovascular monitoring by ECG remains optional. Adverse effects with the alpha agonists include sedation, fatigue, mood, and the potential for rebound hypertension with abrupt discontinuation.

Several additional medications have demonstrated benefit in controlled trials, but have not been approved by the FDA for the treatment of ADHD. The antidepressant bupropion has been shown effective for ADHD in controlled trials of children 111 and adults 112, 113. Additionally, open trials in adolescents with ADHD and depression 114 and adults with ADHD and bipolar disorder 115 have suggested a further utility for this agent. Given its utility in reducing cigarette smoking, improving mood, lack of monitoring requirements, and general tolerability, bupropion is often used as an agent for complex ADHD patients with substance abuse or a mood disorder. Adverse events include activation, irritability, insomnia, and in rare cases, seizures.

The tricyclic antidepressants (TCAs) such as imipramine are effective in controlling abnormal behaviors and improving cognitive impairments associated with ADHD, but less so than the majority of stimulants 116. The TCAs are particularly useful when other FDA approved agents fail and/or when oppositionality, anxiety, tics, sleep, or depressive symptoms co-occur within ADHD. Unwanted side effects include sedation, weight gain, dry mouth, and constipation. Blood levels should be measured periodically and, since TCAs prolong the cardiac repolarization, ECG monitoring is recommended but not required to screen for arrhythmia risk. TCAs can be fatal in overdose and need to be stored carefully, particularly if toddlers are in the family.

Modafinil is currently approved as treatment for narcolepsy and has been shown effective in pediatric, but not adult, trials of ADHD 117. Modafinil has not been approved by the FDA for the treatment of ADHD due to safety concerns (rare but potentially serious erythema multiforme).

SUMMARY

In summary, ADHD is a prevalent world-wide, heterogeneous disorder that frequently persists through adolescence into adult years. ADHD continues to be diagnosed by careful history with an understanding of the developmental presentation of normal behavior and symptoms of the disorder. ADHD has been reconceptualized as a more chronic condition with approximately one-half of children continuing to exhibit symptoms and impairment of the disorder into adulthood 39, 40.. Most individuals with ADHD have a comorbid disorder: including oppositional, conduct, anxiety, or mood disorders 3, 11, 12.. In addition, ADHD carries with it significant impairment in academic, occupational, social, and intrapersonal domains necessitating treatment. Converging data strongly support a neurobiological and genetic basis for ADHD with catecholaminergic dysfunction as a central finding.

Psychosocial interventions such as educational remediation, structure/routine, and cognitive-behavioral approaches should be considered in the management of ADHD. Contemporary work exhibiting improved outcomes associated with specific cognitive therapies in adults with ADHD has been demonstrated. An extensive literature supports the effectiveness of pharmacotherapy not only for the core behavioral symptoms of ADHD but also improvement in linked impairments. Similarities between pediatric and adult groups in the presentation, characteristics, neurobiology, and treatment response of ADHD support the continuity of the disorder across the lifespan.

​

Attention-deficit/hyperactivity disorder is a heterogenous disorder that is prevalent worldwide and frequently persists from adolescence into adult years. Attention-deficit/hyperactivity disorder continues to be diagnosed by careful history with an understanding of the developmental presentation of normal behavior and symptoms of the disorder. It has been reconceptualized as a more chronic condition, with approximately half of children continuing to exhibit symptoms and impairment into adulthood.39, 40 Most individuals with ADHD have a comorbid disorder, including oppositional, conduct, anxiety, or mood disorders.3, 11, 12 In addition, ADHD carries with it significant impairment in academic, occupational, social, and intrapersonal domains necessitating treatment. Converging data strongly support a neurobiological and genetic basis for ADHD, with catecholaminergic dysfunction as a central finding.

Psychosocial interventions such as educational remediation, structure/routine, and cognitive behavioral approaches should be considered in the management of ADHD. Contemporary work exhibiting improved outcomes associated with specific cognitive therapies in adults with ADHD has been demonstrated. Extensive literature supports the effectiveness of pharmacotherapy not only for the core behavioral symptoms of ADHD but also improvement in linked impairments. Similarities between pediatric and adult groups in the presentation, characteristics, neurobiology, and treatment response of ADHD support the continuity of the disorder across the lifespan.

Acknowledgments

This article was in part underwritten by K24 DA016264 to Timothy Wilens, MD.

Footnotes

Conflict of Interest Statement
Timothy Wilens, MD discloses conflicts of interest with Abbott, AstraZeneca, Eli Lilly and Co., McNeil Pharmaceuticals, Merck, the National Institutes of Health (National Institute on Drug Abuse), Novartis, and Shire. Thomas Spencer, MD discloses conflicts of interest with Cephalon, Eli Lilly and Co., GlaxoSmithKline, Janssen Pharmaceutical, McNeil Pharmaceuticals, the National Institute of Mental Health, Novartis, Pfizer, and Shire.

REFERENCES

28. Barkley R, Biederman J. The case against a specific age of onset criterion for attention deficit hyperactivity disorder. American Journal of Psychiatry. 1997 [[ PubMed] Google Scholar]

110. Wilens T, Youcha SH, Lyne A, Grannis K, Children A, Findling RL. A multisite placebo-controlled trial of morning or evening dosed extended-release guanfacine in combination with psychostimulants in children and adolescents; Paper presented at: Scientific Meetings of the Society of Biological Psychiatry; 2010; New Orleans: May, 2010. [ Google Scholar]

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Attention deficit/hyperactivity disorder (ADHD) is among the most common neurobehavioral disorders presenting for treatment in children and adolescents. ADHD is often chronic with prominent symptoms and impairment spanning into adulthood. ADHD is often ...

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Conduct Disorder & Oppositional Defiant Disorder

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Conduct Disorder & Oppositional Defiant Disorder

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COUN-How to Readh and Teach Children and Teens with ADHD

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What are Signs of OCD in Children and Teens?

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What are Signs of OCD in Children and Teens?

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What Are Signs of OCD in Children and Teens?

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All kids have worries and doubts. But kids with obsessive-compulsive disorder (OCD) often can't stop worrying, no matter how much they want to. And those worries frequently compel them to behave in certain ways over and over again.

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Obsessive-compulsive disorder (OCD) is a mental health condition characterized by obsessions and compulsions that interfere with daily life.

OCD was formerly classified as an anxiety disorder because people affected by this mental illness often experience severe anxiety as a result of obsessive thoughts. They may also engage in extensive rituals in an attempt to reduce the anxiety caused by obsessions.

In the newest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), OCD was moved to its own disorder class of "Obsessive-Compulsive and Related Disorders." Related conditions in the class include body-dysmorphic disorder, hoarding disorder, and trichotillomania.

Symptoms of OCD

Symptoms of OCD usually appear gradually and can be long-lasting if not treated. People with OCD may experience symptoms of obsessions, compulsions, or both. Such symptoms interfere with many areas of life including school, work, relationships, and normal daily functioning.

Obsessions

Obsessions are thoughts, images, or ideas that won't go away, are unwanted, and are extremely distressing or worrying ("What if I become infected with a deadly disease?" or "What if I hurt someone?").

Some common symptoms of obsessions include:

Distressing violent thoughts or images

A need to have everything in a certain order

Fear of germs

Unwanted thoughts of forbidden or taboo topics such as sex or religion

Compulsions

Compulsions are behaviors that have to be done over and over again to relieve anxiety. Compulsions are often related to obsessions. For example, if you are obsessed with being contaminated, you might feel compelled to wash your hands repeatedly. However, this is not always the case.

Some common compulsions include:

Counting things over and over again

Excessive washing or cleaning

Ordering things in a particular or symmetrical way

Repeated checking (such as checking that the door is locked or that the oven is off)

It is important to be aware that not all habits or repetitive behaviors are synonymous with compulsions. Everyone has repeated thoughts or engages in double-checking things from time to time. In order to be diagnosed with OCD, their experience is characterized by:

An inability to control their thoughts or behaviors, even when they recognize that they are excessive or irrational

Spending an hour or more a day on these obsessions and compulsions

Experiencing significant distress or problems and disruptions in daily life because of these thoughts and behaviors

OCD is a relatively common disorder that by some estimates about 2.3% of people over their lifetime. It is experienced equally by men and women and affects all races and cultures.

OCD usually begins around late adolescence/young adulthood, although young children and teenagers can also be affected. Parents and teachers often miss OCD in young children and teenagers, as they may go to great lengths to hide their symptoms.

The exact causes of OCD are not known, but there are a few factors that are believed to play a role.

Biological factors: Abnormal neural circuits in the brain are associated with OCD. If you have OCD, certain parts of your brain may have difficulty inhibiting and "turning off" obsessive thoughts and impulses to turn off. As a result, you may experience obsessions and/or compulsions. The breakdown of this system may be related to serotonin and other neurotransmitter abnormalities.​

Family history: You may also be at greater risk if there is a family history of the disorder. Research has shown that if you, a parent, or a sibling have OCD, there is about a 25% chance that another first-degree family member will also have it.

Genetics: Although a single "OCD gene" has not been identified, OCD may be related to particular groups of genes.

Stress: Stress of all types including unemployment, relationship difficulties, problems at school, illness, or childbirth can be triggers for symptoms of OCD.

People who are vulnerable to OCD describe a strong need to control their thoughts and may believe that their obsessive thoughts mean they are going crazy or will lose control. While many people can have recurrent, strange or unusual thoughts when feeling stressed, if you are vulnerable to OCD, it may be difficult to ignore or forget about these thoughts. In fact, because these thoughts seem so dangerous, you end up paying even more attention to them, which sets up a vicious cycle.

Obsessive-compulsive disorder can present in a few different ways. Some people experience only obsessions, more commonly people experience both obsessions and compulsions, even if the compulsive behavior is only mental. There are no official subtypes of OCD, but research suggests that the most common obsessions and compulsions tend to center on certain themes:

Cleanliness or fear of contamination

A need for order, symmetry, or perfection

Taboo or forbidden thoughts

Potential harm to oneself or others

Parents should also be aware of a subtype of OCD in children triggered by certain infections such as strep throat, in which the child's own immune system attacks the brain. Pediatric Autoimmune Neuropsychiatric Disorders (PANDAS) associated with streptococcal infections by some estimates may account for up to 25% of the children who have OCD.

Unlike normal OCD, which develops slowly, in contrast to other forms of OCD, PANDAS OCD develops quickly and has a variety of other symptoms associated with it.

Treatments for OCD may include medications, psychotherapy, or a combination of the two.

Medication

There are a variety of medications that are effective in reducing the frequency and severity of OCD symptoms. Many of the medications that are effective in treating OCD, such as Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline), Anafranil (clomipramine), and Luvox (fluvoxamine) affect levels of serotonin. Additional types of medications that affect other neurotransmitters in the brain may also be used.

Psychotherapy

Psychological therapies are also highly effective treatments for reducing the frequency and intensity of OCD symptoms. Effective psychological treatments for OCD emphasize changes in behavior and/or thoughts.

When appropriate, psychotherapy can be done alone or combined with medication. The two main types of psychological therapies for OCD are cognitive behaviorial therapy (CBT) and exposure and response prevention (ERP) therapy.

OCD can be a chronic, long-lasting condition that may worsen with time, so it is important to get professional treatment. In addition to talking to your doctor or mental health professional, there are also a number of self-help strategies that you can use to help manage your symptoms:

Practice good self-care strategies that will help you cope with stress. Stress can often trigger OCD symptoms, so it is important to rely on effective and healthy coping methods. Research has shown that sleep disturbances are linked to more severe OCD symptoms. In addition to sleep, regular physical exercise and a healthy diet are lifestyle choices you can make that will make it easier to manage the stress and worries that life throws at you.

Try relaxation techniques. Add some effective tools such as meditation, deep breathing, visualization, and progressive muscle relaxation to your relaxation rituals.

Find support. Consider joining a support group such as those found on the International OCD Foundation's online support group website. Such groups can be helpful to talk to people who have had the same experiences as you. Social support is important for mental well-being, and support groups can be a helpful resource.

Additional Reading

By Owen Kelly, PhD
Owen Kelly, PhD, is a clinical psychologist, professor, and author in Ontario, ON, who specializes in anxiety and mood disorders.

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Obsessive-compulsive disorder (OCD) is a mental disorder in which people experience disruptive obsessions and compulsions. Learn more about OCD.

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School Mental Health Referral Pathways (SMHRP) Toolkit 

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School Mental Health Referral Pathways (SMHRP) Toolkit 

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Addressing Mental Health in School Crisis Prevention & Response

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Addressing Mental Health in School Crisis Prevention & Response

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

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

Listen for ongoing or severe traumatic stress symptoms.

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

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

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

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

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

Steps for making a referral

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

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

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

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

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

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

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

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

Keep the door open.

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

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

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

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

Effective mental health treatment for traumatic stress

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

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

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

Do you have experience working with children after trauma?

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

What is your success rate?

How do you work with parents?

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

Online resources - help in finding a mental health professional

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

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

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

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

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

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

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

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When and How to Refer for Mental Health Care

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

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Child Mind Institute | Transforming Children’s Lives.

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The Child Mind Institute is an independent nonprofit dedicated to transforming the lives of children struggling with mental health and learning disorders.