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Behaviour Problems

Children who meet criteria for a behavioural disorder such as conduct disorder or oppositional defiant disorder have a pattern of behaviours characterised as aggressive or antisocial.

Most children misbehave, or are aggressive, defiant or have tantrums from time to time. That's perfectly normal. To reach a diagnosis of conduct disorder or oppositional defiant disorder, the behaviours have to be more frequent and/or more severe than their same aged peers. But it is important to remember that many children who meet diagnosis of a conduct disorder or oppositional defiant disorder are not necessarily doing different kinds of things compared to their same aged peers, it is just that they stand out for how much or how intensely they do them.

How common are they?

Conduct problems are the most common mental health disorder and found in approximately 5 to 6% of the normal population of children in primary and secondary school. It is about twice as common in boys than girls. Why that might be is not entirely clear. Some people have suggested it is to do with gender socialisation practices; some suggested it is more to do with male biology; others have suggested that perhaps girls have similar rates of antisocial behaviour, but more as relational aggression (e.g., within friendships and harming others' social status) than as overt physical aggression (e.g., fighting and arguing) and so gets noticed less. Probably it is a complicated mix of all those reasons and some others. However, it may be interesting to note that the peak of aggressive behaviour in human development is reliably between 18 and 36 months ("the terrible twos") and that boys and girls reach similar peak levels, although girls' socialisation, away from the aggressive peak, appears to be quicker than boys; perhaps because of their more rapid language development.

Different types - which settings?

It is also important to realise that for some children their conduct disorder is found across settings, for example at home and at school; whereas for other children it can be found only in one place but not the other. Some children only pose significant behavioural challenges at home, others only at school; so it is very important to get the parents' perspective on how the child presents at home and see if some learning and collaboration can be established.

Different types - socialised?

Some children with conduct problems are able to maintain relatively good social relationships with other children, whereas others may get excluded from their peer group, typically because of a history of hurting or harming their peers. These children with less socialised conduct problems are at particular risk of failing to get opportunities to develop more prosocial behaviours, which could address some of their problems, or at least mitigate them.

The course of development

A diagnosis of either oppositional defiant disorder or conduct disorder is not fixed for life - it is certainly not the case that most children with these problems will go on to live seriously antisocial adult lives. The typical course of a child with conduct problems is, over time, to become less antisocial by the time of adulthood. However, research shows that those children who do "recover" from conduct problems by adulthood, remain at risk of living less prosocial and well-functioning adult lives; as if the opportunities they have missed out upon growing up - in education and in the community - have left a legacy on their social development. Therefore, it is extremely important to help these children recover as soon as possible and thereby promote as much opportunity to develop helpful, caring and considerate social relationships with others; as well as to reach their academic potential through education.

While most children do recover over time, there is a small group of children - especially those who started with problems in the early years and whose problems persisted into secondary school - who are more likely to have persistent antisocial behaviour into their adult lives (the so-called "early starter, life course persistent" cohort). These children often have other, frequently neurodevelopmental components to their presentation which seem to make their difficulties more entrenched. However, although intervening with these children may be harder, it is still possible and can be very effective

Co-occurring problems

Children and young people with conduct problems frequently stand out because of aggressive and antisocial behaviours, but a significant number of these children also have other problems that may get "masked" by their overtly negative behaviour.

For example, approximately ¼ of children with conduct disorder will also have ADHD; the two things occur so commonly, that they have their own specific psychiatric disorder called "hyperkinetic conduct disorder". Note that ADHD does not make children naughty, but in some children it can contribute, or at least cooccur, with behaviour problems. Remember that treating ADHD effectively is very important, but it may or may not have an impact on a child's challenging behaviours. They are different things

A further significant proportion of children with conduct problems (probably around 20%) also present with problems to do with anxiety and/or low mood. These are problems that can very easily be masked by challenging behaviours. It may be helpful to remember, as a rule of thumb, that "bad" children can also be "sad" children.

There are also other neurodevelopmental problems that can often cooccur and complicate presentation of conduct problems, including low IQ ("intellectual disability") and autism spectrum disorders.

From an educational viewpoint, conduct problems are also associated with poor academic performance and especially literacy. In the research, again, there has been some debate as to whether conduct problems drive down educational attainment in literacy because children do not engage in school, or whether struggling to read and engage in school triggers increases in behaviour problems, perhaps as a way of avoiding or managing these difficulties in class.

Probably, it is a mixture of both these processes, to a greater or lesser extent and differs for different children. However, there is clear evidence that the co-occurrence of behaviour problems, plus ADHD plus impaired literacy has especially poor outcomes for the life chances of children and these children would benefit from being identified and fast tracked for appropriate interventions across education and CAMHS working together.

What to do - Overview

From the perspective of a teacher, or indeed a parent, whether or not a child quite meets criteria for a diagnosis of a conduct problem may be less important than the experience of persistent antisocial or aggressive behaviour. Luckily, the types of interventions that work for children who present with diagnostic levels of behaviour problems, also work for the children who are just below threshold or at risk of developing them. The same kind of things tend to work.

It is also true that the same kinds of approaches tend to work for older children as for younger children. However, interventions tend to be more effective for younger children because older children have more influences beyond the immediate classroom setting that could be feeding into and maintaining the pattern of behaviours. In general, the earlier in a child's life an intervention is started, the greater the improvement is likely to be.

What to do - Balancing Opportunities & Limits

Intervention will seek to balance a) the opportunity for positive, prosocial behaviours (which are noticed and praised) alongside b) consistent boundaries and limits. Generally, approaches that only prioritise one of these components tend to be much less effective.

What to do - Limits

A challenge for any adult attempting to set effective limits for a child with conduct problems is to make them consistent and relevant to the behaviours being addressed. This is why careful observation is incredibly important. Of course, for a teacher, setting limits for one or two disruptive children in a class, has to be balanced with the behaviour management approaches taken for the whole class.

While some children can have effective limit setting working for them as part of a broader whole class approach, there will be others who need something more specific and tailored to their needs. Often this will require an additional pair of hands to make it effective (perhaps, for example, as identified in an EHCP).

What to do - Maintaining gains

Whatever else, while behaviour management techniques that enable the whole class to continue working and which limit the impact of a child with conduct problems are extremely important, they must always be paired alongside opportunities for positive and prosocial interactions if you want any gains in positive behaviour to be maintained.

But this can be extremely hard for any of us to manage - so do get support from your peers and other professionals (see below).

Getting help - getting the information

Unfortunately, there has been an increasing tendency for children with conduct problems not to be formally diagnosed in CAMHS services, and therefore they have become less likely to receive appropriate and effective treatment. Hence, schools will often be the first time the possibility of conduct problems is raised about the child. If you are concerned that a child in your class may have conduct problems, then it is worth keeping track of the kinds of behaviours that are concerning you, as well as how frequent and/or severe they are, compared to his or her same aged peers, so you can use this information when you seek out help.

Getting help - which services

There are a number of services that can help with children with conduct problems in schools. In some areas CAMHS services may be able to help; as may social care. Educational psychologists may be able to assess and advise individual children and consider their management in a whole classroom context. There are also an increasing number of education mental health practitioners who are trained in a range of evidence-based approaches, including parenting interventions for conduct problems.

It could also be helpful to review the MindEd resources.
Dr Matt Woolgar, Consultant Clinical Psychologist Conduct Problems Clinic and Adoption and Fostering Team South London & Maudsley NHS Foundation Trust

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Conduct Disorder: Tips For Teachers Fact Sheet - Nip in the Bud

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Behaviour Problems Children who meet criteria for a behavioural disorder such as conduct disorder or oppositional defiant disorder have a pattern of behaviours characterised as aggressive or antisocial. Most children misbehave, or are aggressive, defiant or have tantrums from time to time. That's perfectly normal.

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The Mental Health Center at Destination Hope offers treatment for a variety of mood disorders such as depression, anxiety, bipolar disorders, & eating disorders.

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Treatment for Mood Disorders

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Links updated, November 2021
This information in Spanish

The mental health of our children is a natural and important concern for us all. The fact is, many mental disorders have their beginnings in childhood or adolescence, yet may go undiagnosed and untreated for years. ( 1)

We refer to mental disorders using different "umbrella" terms such as emotional disturbance, behavioral disorders, or mental illness. Beneath these umbrella terms, there is actually a wide range of specific conditions that differ from one another in their characteristics and treatment. These include (but are not limited to):

anxiety disorders;

bipolar disorder (sometimes called manic-depression);

conduct disorders;

eating disorders;

obsessive-compulsive disorder (OCD); and

psychotic disorders.

You may be reading this fact sheet with one of these specific disorders in mind, or you may be looking for information about emotional disturbances in general. In either case, keep reading to find out what different emotional distubances have in common, how they are defined in federal law, and where to find more detailed information on specific disorders.
Quick-Jump Menu
Definition
IDEA defines emotional disturbance as follows:
We've chosen to use the term "emotional disturbance" in this fact sheet because that is the term used in the nation's special education law, the Individuals with Disabilities Education Act (IDEA).

"...a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child's educational performance:

(A) An inability to learn that cannot be explained by intellectual, sensory, or health factors.

(B) An inability to build or maintain satisfactory interpersonal relationships with peers and teachers.

(C) Inappropriate types of behavior or feelings under normal circumstances.

(D) A general pervasive mood of unhappiness or depression.

(E) A tendency to develop physical symptoms or fears associated with personal or school problems." ( 2)

As defined by IDEA, emotional disturbance includes schizophrenia but does not apply to children who are socially maladjusted, unless it is determined that they have an emotional disturbance. ( 3)

Characteristics

As is evident in IDEA's definition, emotional disturbances can affect an individual in areas beyond the emotional. Depending on the specific mental disorder involved, a person's physical, social, or cognitive skills may also be affected. The National Alliance on Mental Illness of Southern Arizona puts this very well:

Mental illnesses are medical conditions that disrupt a person's thinking, feeling, mood, ability to relate to others and daily functioning. Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a diminished capacity for coping with the ordinary demands of life. ( 4)

Some of the characteristics and behaviors seen in children who have an emotional disturbance include:

Hyperactivity (short attention span, impulsiveness);

Aggression or self-injurious behavior (acting out, fighting);

Withdrawal (not interacting socially with others, excessive fear or anxiety);

Immaturity (inappropriate crying, temper tantrums, poor coping skills); and

Learning difficulties (academically performing below grade level).

Children with the most serious emotional disturbances may exhibit distorted thinking, excessive anxiety, bizarre motor acts, and abnormal mood swings.

Many children who do not have emotional disturbance may display some of these same behaviors at various times during their development. However, when children have an emotional disturbance, these behaviors continue over long periods of time. Their behavior signals that they are not coping with their environment or peers.

Causes

No one knows the actual cause or causes of emotional disturbance, although several factors-heredity, brain disorder, diet, stress, and family functioning-have been suggested and vigorously researched. A great deal of research goes on every day, but to date, researchers have not found that any of these factors are the direct cause of behavioral or emotional problems.

According to NAMI, mental illnesses can affect persons of any age, race, religion, or income. Further:

Mental illnesses are not the result of personal weakness, lack of character, or poor upbringing. Mental illnesses are treatable. Most people diagnosed with a serious mental illness can experience relief from their symptoms by actively participating in an individual treatment plan. ( 5)

Frequency

Of the 74.5 million children in the United States, an estimated 17.1 million have or have had a psychiatric disorder. ( 6) Half of all psychiatric illness occurs before the age of 14, and 75% by the age of 24. The most common psychiatric disorders in childhood are anxiety disorders, AD/HD and disruptive behavior, depression and bipolar disorders, and eating disorders. ( 7)

Help for School-Aged Children

IDEA requires that special education and related services be made available free of charge to every eligible child with a disability, including preschoolers (ages 3-21). These services are specially designed to address the child's individual needs associated with the disability-in this case, emotional disturbance, as defined by IDEA (and further specified by states). In the 2016 school year, more than 349,000 children and youth with emotional disturbance received these services to address their individual needs related to emotional disturbance. ( 8)

Determining a child's eligibility for special education and related services begins with a full and individual evaluation of the child. Under IDEA, this evaluation is provided free of charge in public schools.
10 Basic Steps in Special Education Questions Often Asked by Parents about Special Education Services Evaluating Children for Disability Developing Your Child's IEP
There is a lot to know about the special education process, much of which you can learn here on the CPIR site. We invite you to read the wide range of publications we offer on the topic, especially:

A Look at Specific Emotional Disturbances

As we mentioned, emotional disturbance is a commonly used umbrella term for a number of different mental disorders. Let's take a brief look at some of the most common of these.

We all experience anxiety from time to time, but for many people, including children, anxiety can be excessive, persistent, seemingly uncontrollable, and overwhelming. An irrational fear of everyday situations may be involved. This high level of anxiety is a definite warning sign that a person may have an anxiety disorder.

The term "anxiety disorder" is a broad term covering several different disabilities that share the core symptom of irrational fear. These include such different disorders as generalized anxiety disorder, panic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), social anxiety disorder (also called social phobia), and specific phobias. ( 9)

According to the Anxiety Disorders Association of America, anxiety disorders are the most common psychiatric illnesses affecting children and adults. ( 10) They are also highly treatable. Unfortunately, only about 36.9% of those affected receive treatment. ( 11)

Also known as manic-depressive illness, bipolar disorder is a serious medical condition that causes dramatic mood swings from overly "high" and/or irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes in mood. ( 12)

For most people with bipolar disorder, these mood swings and related symptoms can be stabilized over time using an approach that combines medication and psychosocial treatment. ( 13)

Conduct Disorder

Conduct disorder refers to a group of behavioral and emotional problems in youngsters. Children and adolescents with this disorder have great difficulty following rules and behaving in a socially acceptable way. ( 14) This may include some of the following behaviors:

aggression to people and animals;

destruction of property;

deceitfulness, lying, or stealing; or

truancy or other serious violations of rules. (15)

Treatment will depend on the child's symptoms, age, and general health. It will also depend on how severe the condition is. Treatment may include:

helping the child learn how to better solve problems, communicate, and handle stress, as well as how to control impulses and anger (what's known as cognitive-behavioral therapy);

family therapy;

peer group therapy (to help better social and interpersonal skills); and

medications (although these are not typically used to treat conduct disorder). (16)

Eating disorders are characterized by extremes in eating behavior-either too much or too little-or feelings of extreme distress or concern about body weight or shape. Females are much more likely than males to develop an eating disorder. ( 17)

Anorexia nervosa and bulimia nervosa are the two most common types of eating disorders. Anorexia nervosa is characterized by self-starvation and dramatic loss of weight. Bulimia nervosa involves a cycle of binge eating, then self-induced vomiting or purging. Both of these disorders are potentially life-threatening. ( 18)

Binge eating is also considered an eating disorder. It's characterized by eating excessive amounts of food, while feeling unable to control how much or what is eaten. Unlike with bulimia, people who binge eat usually do not purge afterward by vomiting or using laxatives. ( 19)

According to the National Eating Disorders Association:

Treating an eating disorder generally involves a combination of psychological and nutritional counseling, along with medical and psychiatric monitoring. Treatment must address the eating disorder symptoms and medical consequences, as well as psychological, biological, interpersonal, and cultural forces that contribute to or maintain the eating disorder... Many people utilize a treatment team to treat the multi-faceted aspects of an eating disorder. ( 20)

Obsessive-Compulsive Disorder

Often referred to as OCD, obsessive-compulsive disorder is actually considered an anxiety disorder (which was discussed earlier in this fact sheet). OCD is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions). Repetitive behaviors (handwashing, counting, checking, or cleaning) are often performed with the hope of preventing obsessive thoughts or making them go away. Performing these so-called "rituals," however, provides only temporary relief, and not performing them markedly increases anxiety. ( 21)

A large body of scientific evidence suggests that OCD results from a chemical imbalance in the brain. ( 22) Treatment for most people with OCD should include one or more of the following:

therapist trained in behavior therapy;

Cognitive Behavior Therapy (CBT);

medication (usually an antidepressant). (23)

"Psychotic disorders" is another umbrella term used to refer to severe mental disorders that cause abnormal thinking and perceptions. Two of the main symptoms are delusions and hallucinations. Delusions are false beliefs, such as thinking that someone is plotting against you. Hallucinations are false perceptions, such as hearing, seeing, or feeling something that is not there. Schizophrenia is one type of psychotic disorder. ( 24) There are others as well.

Treatment for psychotic disorders will differ from person to person, depending on the specific disorder involved. Most are treated with a combination of medications and psychotherapy (a type of counseling). ( 25)

More about School

As mentioned, emotional disturbance is one of the categories of disability specified in IDEA. This means that a child with an emotional disturbance may be eligible for special education and related services in public school. These services can be of tremendous help to students who have an emotional disturbance.

Typically, educational programs for children with an emotional disturbance need to include attention to providing emotional and behavioral support as well as helping them to master academics, develop social skills, and increase self-awareness, self-control, and self-esteem. A large body of research exists regarding methods of providing students with positive behavioral support (PBS) in the school environment, so that problem behaviors are minimized and positive, appropriate behaviors are fostered. (See the resource section at the end of this fact sheet for more information on PBS.) It is also important to know that, within the school setting:

For a child whose behavior impedes learning (including the learning of others), the team developing the child's Individualized Education Program (IEP) needs to consider, if appropriate, strategies to address that behavior, including positive behavioral interventions, strategies, and supports.

Students eligible for special education services under the category of emotional disturbance may have IEPs that include psychological or counseling services. These are important related services available under IDEA and are to be provided by a qualified social worker, psychologist, guidance counselor, or other qualified personnel.

Recognizing and Addressing the Impact of COVID-19 | As young people return to in-person schooling in the 2021-2022 school year, they may bring with them the impact of the pandemic's trauma. This makes it essential that schools consider the possibility that many students will need to be re-evaluated to determine if they need additional services, especially behavioral support and mental health services, than they needed prior to COVID-19. Two resources of great relevance to reopening schools and returning students are the following:

Other Considerations

Children and adolescents with an emotional disturbance should receive services based on their individual needs, and everyone involved in their education or care needs to be well-informed about the care that they are receiving. It's important to coordinate services between home, school, and community, keeping the communication channels open between all parties involved.

The Importance of Support

Families often need help in understanding their child's disability and how to address the needs that arise from the disability. Help is available from psychiatrists, psychologists, and other mental health professionals that work in the public or private sector. There is also a network of mental health support operating in every state as well as locally.

To locate systems of support in your community or state, visit the organizations we've listed below. They can connect you with local resources, including support groups that provide connection and understanding, information, referral, and advocacy for those living with emotional disturbance.

There are also support groups available from organizations that address specific mental disorders under the umbrella term of emotional disturbance. See the resources at the end of this fact sheet to identify some of these groups.

Resources of More Information

AACAP | American Academy of Child and Adolescent Psychiatry | AACAP offers Facts for Families, a series in English, Spanish, and several other languages that includes many briefs on specific mental disorders, including the ones mentioned in this publication.

AACAP also operates different Resource Centers, which offer consumer-friendly definitions, answers to frequently asked questions, clinical resources, expert videos, Facts for Families, and much more. Visit the Resource Center home page if you are concerned with one of the following:

Anxiety Disorders

Autism

Bipolar Disorder

Conduct Disorder

Depression

Oppositional Defiant Disorder

NIMH | National Institute of Mental Health | NIMH is clearly a source of authoritative information on specific mental disorders. Phone: 1.866.615.6464. TTY: 1.866.415.8051

NAMI | National Alliance on Mental Illness | NAMI is an excellent source of information and connection on mental illness, including the individual disorders mentioned in this fact sheet. NAMI's website and toll-free helpline are available in English and Spanish.

SAMHSA is the Substance Abuse & Mental Health Services Administration. It offers many resources to consumers, including:.

Detailed information on specific emotional disturbances, or related issues such as positive behavior supports, is also available from these sources:

Anxiety Disorders Association of America | https://adaa.org/

Center on Positive Behavioral Interventions and Supports | The PBIS Center provides research-based information on how to provide behavioral supports to children who need them. | https://www.pbis.org

Conduct Disorders | A soft place to land for battle-weary parents
https://www.conductdisorders.com/community/

Encyclopedia of Mental Disorders | http://www.minddisorders.com/index.html

National Eating Disorders Association
1.800.931.2237 | www.nationaleatingdisorders.org

Something Fishy | (eating disorders)
https://www.something-fishy.org

**Highly Rated Resource! This resource was reviewed by 3-member panels of Parent Center staff working independently from one another to rate the quality, relevance, and usefulness of CPIR resources. This resource was found to be of "High Quality, High Relevance, High Usefulness" to Parent Centers.
________________________________________

References

2 | Code of Federal Regulations, Title 34, §300.8(c)(4)(i)

3 | Code of Federal Regulations, Title 34, §300.8(c)(4)(ii)

5 | Ibid.

7 | Ibid.

11 | Ibid.

13 | Ibid.

14 | American Academy of Adolescent and Child Psychiatry. (2013, August). Conduct disorder: Facts for families. Washington, DC: Author. Available online at:
http://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/Facts_for_Families_Pages/Conduct_Disorder_33.aspx

15 | Ibid.

16 | Johns Hopkins Medicine Health Library. (n.d.). Conduct disorder in children. Baltimore, MD: Author. Online at:
https://www.hopkinsmedicine.org/healthlibrary/conditions/mental_health_disorders/conduct_disorder_90,P02560

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Links updated, November 2021 This information in Spanish The mental health of our children is a natural and important concern for us all. The fact is, many mental disorders have their beginnings in childhood or adolescence, yet may go undiagnosed and untreated for years.

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Centers for Disease Control and Prevention

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Children sometimes argue, are aggressive, or act angry or defiant around adults. A behavior disorder may be diagnosed when these disruptive behaviors are uncommon for the child's age at the time, persist over time, or are severe. Because disruptive behavior disorders involve acting out and showing unwanted behavior towards others they are sometimes called externalizing disorders.

Oppositional Defiant Disorder

When children act out persistently so that it causes serious problems at home, in school, or with peers, they may be diagnosed with Oppositional Defiant Disorder (ODD). ODD usually starts before 8 years of age, but no later than by about 12 years of age. Children with ODD are more likely to act oppositional or defiant around people they know well, such as family members, a regular care provider, or a teacher. Children with ODD show these behaviors more often than other children their age.

Examples of ODD behaviors include

Often being angry or losing one's temper

Often arguing with adults or refusing to comply with adults' rules or requests

Often resentful or spiteful

Deliberately annoying others or becoming annoyed with others

Often blaming other people for one's own mistakes or misbehavior

Learn more about ODD
Conduct Disorder

Conduct Disorder (CD) is diagnosed when children show an ongoing pattern of aggression toward others, and serious violations of rules and social norms at home, in school, and with peers. These rule violations may involve breaking the law and result in arrest. Children with CD are more likely to get injured and may have difficulties getting along with peers.

Examples of CD behaviors include

Breaking serious rules, such as running away, staying out at night when told not to, or skipping school

Being aggressive in a way that causes harm, such as bullying, fighting, or being cruel to animals

Lying, stealing, or damaging other people's property on purpose

Learn more about CD
Treatment for disruptive behavior disorders

Starting treatment early is important. Treatment is most effective if it fits the needs of the specific child and family. The first step to treatment is to talk with a healthcare provider. A comprehensive evaluation by a mental health professional may be needed to get the right diagnosis. Some of the signs of behavior problems, such as not following rules in school, could be related to learning problems which may need additional intervention. For younger children, the treatment with the strongest evidence is behavior therapy training for parents, where a therapist helps the parent learn effective ways to strengthen the parent-child relationship and respond to the child's behavior. For school-age children and teens, an often-used effective treatment is a combination of training and therapy that includes the child, the family, and the school.

Get help finding treatment

Here are tools to find a healthcare provider familiar with treatment options:

Managing Symptoms: Staying Healthy

Being healthy is important for all children and can be especially important for children with behavior or conduct problems. In addition to behavioral therapy and medication, practicing certain healthy lifestyle behaviors may reduce challenging and disruptive behaviors your child might experience. Here are some healthy behaviors that may help:

Engaging in regular physical activity, including aerobic and vigorous exercise

Eating a healthful diet centered on fruits, vegetables, whole grains, legumes (for example, beans, peas, and lentils), lean protein sources, and nuts and seeds

Getting the recommended amount of sleep each night based on age

Strengthening relationships with family members

Prevention of disruptive behavior disorders

It is not known exactly why some children develop disruptive behavior disorders. Many factors may play a role, including biological and social factors. It is known that children are at greater risk when they are exposed to other types of violence and criminal behavior, when they experience maltreatment or harsh or inconsistent parenting, or when their parents have mental health conditions like substance use disorders, depression, or attention-deficit/hyperactivity disorder (ADHD). The quality of early childhood care also can impact whether a child develops behavior problems.

Although these factors appear to increase the risk for disruptive behavior disorders, there are ways to decrease the chance that children experience them. Learn about public health approaches to prevent these risks:

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Behavior or Conduct Problems in Children | CDC

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Children sometimes argue, are aggressive, or act angry or defiant around adults. A behavior disorder may be diagnosed when these disruptive behaviors are uncommon for the child's age at the time, persist over time, or are severe. Learn about behavior or conduct problems in children.

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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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Mental health problems ranging from depression to bipolar disorder are known as mood disorders, or affective disorders. In any of these disorders, a serious change in mood shapes your child's emotional state. Unlike a normal bad mood a child feels occasionally, a mood disorder involves thoughts and feelings that are intense, difficult to manage, and persistent. A mood disorder is a real medical condition, not something a child will likely just "get over" on his own.

Today, clinicians and researchers believe that mood disorders in children remain one of the most underdiagnosed health problems. Mood disorders that go undiagnosed can put kids at risk for other conditions, like disruptive behavior and substance use disorders, that remain after the mood disorder is treated. Children and teens with a mood disorder don't always show the same symptoms as adults. So it can be difficult for parents to recognize a problem in their child, especially since he or she may not easily express his or her thoughts or feelings.

The most common mood disorders in children and adolescents include:

Major depression. A depressed or irritable mood, lasting at least two weeks.

Persistent depressive disorder (dysthymia). A chronic, low-grade, depressed or irritable mood for at least 1 year.

Bipolar disorder. Periods of persistently elevated mood followed by periods of depressed or flat emotional response.

Disruptive mood dysregulation disorder. A persistent irritability and extreme inability to control behavior.

Premenstrual dysmorphic disorder. This includes depressive symptoms, irritability, and tension before menstruation.

Mood disorder due to a general medical condition. Many medical illnesses, including cancer, injuries, and chronic medical illnesses, can trigger symptoms of depression.

Substance-induced mood disorder. Symptoms of depression due to drug use, the effects of a medication, or exposure to toxins.

Girls are at least twice as likely as boys to develop depression. Boys and girls are equally likely to develop bipolar disorder and obsessive-compulsive disorder.

The causes of mood disorders are not well understood. Imbalances in brain chemicals play a role. Environmental factors, such as unexpected life events and/or chronic stress, can also contribute to a mood disorder.

Mood disorders often run in families, so there is a genetic component, too. Children who have relatives with depression are at increased risk for depression. In addition, a family history of bipolar disorder may predispose a child to have bipolar disorder or other mood disorder.

Sometimes, extreme stress or a life event can "turn on" a gene, causing the disorder to develop. This can happen especially with depression.

Children show symptoms differently, according to their age and biological makeup. Symptoms also vary according to the type of mood disorder. Overall signs of a mood disorder may include:

Sad, depressed, irritable, angry, or elevated mood that appears more intense than the child usually feels, lasts for a longer period of time, or occurs more frequently

Trouble with family, including difficult behavior

Lack of motivation or pleasure in previously enjoyed activities

Changes in sleep or eating patterns or weight

Frequent physical complaints, such as headaches, stomachaches, or fatigue

Loss of energy or fatigue

Difficulty achieving in school

Worthlessness, guilt, or low self-esteem

Severe recurrent temper outbursts

Increased energy or bursts of energy with racing thoughts or fast speech

Rebellious or high risk behavior

Running away or threats of running away from home

Difficulty with friends and peers

Expressions of suicidal thoughts, which should be evaluated immediately

If you believe your child is struggling with a mood disorder, you can ask your pediatrician for a referral to a therapist or child psychiatrist. An accurate diagnosis of the mood disorder, as well as any other conditions, is a crucial first step in managing the disorder effectively. At The Children's Hospital of Philadelphia, a specialist will perform a comprehensive evaluation. The evaluation may assess:

Your child's overall health and medical history

Your child's symptoms

Your child's behavior at home, at school, and with peers

Environmental factors that might be stressors in your child's life

Input from teachers or guidance counselor about issues at school

Your child's past experiences with specific medications or therapies

Your opinion or preference for treatment options

Mood disorders can be treated with evidence-based treatments, especially with early recognition of the problem. Treatment can help manage the episode, reduce the severity of symptoms, and help to prevent future episodes. It can also enhance your child's normal growth and development and improve his or her quality of life and relationships.

A CHOP specialist will design a personalized treatment plan based on your child's symptoms and other factors unique to her situation. The plan may include:
Individual therapy

The specialist will identify key problems in your child's life and help your child learn how to manage these stressors. The specialist may also use a variety of techniques to help your child manage the symptoms of the mood disorder, including

Cognitive-behavioral. This approach involves changing problematic thoughts, feelings, and behaviors that your child may be experiencing.

Interpersonal therapy. This technique focuses on building social skills and helping children with difficult relationships in their lives.

Family therapy
Families play a vital supportive role in any mood disorder. Families, including parents or guardians, can learn methods to help their child manage mood and behavior problems. The specialist may also explore potential stressors in a child's life and patterns of interaction within the family. A consultation with your child's teachers or guidance counselor may also be advised.
Medications
A variety of medications are very effective in treating mood disorders by altering the brain chemicals involved. Depending on the mood disorder and your child's symptoms, medications may reduce the severity or frequency of symptoms, decrease problematic behaviors, improve functioning, and prevent future episodes.

Many children who receive early and adequate treatment for their mood disorder may improve significantly and keep their condition managed with ongoing intervention or support . If the episodes recur, they can usually be managed with therapeutic support, including medications, therapy, and additional resources. Despite the mood disorder, children and adolescents are able to grow, develop, and have meaningful life experiences, especially when their mood disorder is managed appropriately and adequately.

Depending on your child's personalized treatment plan, your child and family may continue to meet with the specialist for a number of weeks or months. The focus of individual and family therapy may change over time, depending on your child's age, progress, and needs. Medication needs may also change over time depending on a number of factors. At CHOP, a specialist will monitor and manage your child's condition closely.

Children with mood disorders have a complexity to their condition that includes biology, genetics, factors like stress and physical health, family and peer dynamics, behavior and thought patterns, and sometimes other conditions operating alongside the mood disorder. This complexity means the accuracy of the diagnosis and assessment of your child is crucial and shapes the treatment approach. The right treatment then determines how effectively the mood disorder is managed-and how well your child flourishes in every domain: home, school, and among peers. The team at CHOP is specially trained to recognize, diagnose, and treat the full range of mood disorders in children. They design a personalized plan for your child based on the latest thinking and approaches to care. Their skill set leads your child to long-term success.

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Mood Disorders in Children and Adolescents

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Mood disorders in teens remain one of the most under-diagnosed mental health problems. These disorders also put teens at risk for other conditions that may persist long after the initial episodes of depression are resolved.

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Strategies for ADHD: How Counselors Help Today's Students Succeed

More than 6 million children between the ages of 4 and 17 had been diagnosed with attention deficit hyperactivity disorder (ADHD) as of 2011, according to the Centers for Disease Control and Prevention External link . It's a complicated disorder with a long history. In order to cope with the symptoms, children with ADHD need continuous support from parents, teachers, and school counselors. School counselors are especially poised to serve as a key intermediary between parents and teachers and can be essential in helping students with ADHD thrive.
The Difference Between ADD and ADHD

The term "attention deficit disorder" was first coined in 1980 when the Diagnostic and Statistical Manual (DSM) - the industry standard publication for psychiatric diagnoses - published its third edition. Since then, "ADD" and "ADHD" have become relatively ubiquitous in American vocabularies, yet they do not exist simultaneously. In fact, they are mutually exclusive terms.

As research poured in in the 1980s and 1990s, the DSM adjusted the nomenclature to reflect new findings. Specifically, "attention deficit hyperactivity disorder" was introduced in the 1987 edition and appeared again in 1994, this time with three subtypes: predominantly inattentive subtype, predominantly hyperactive/impulsive subtype, and combined subtype. With the DSM 5, these have been re-termed as "presentations" (i.e., predominantly inattentive presentation, predominantly hyperactive/impulsive presentation, and combined presentation) owing to the research suggesting that children can have different presentations over time. The Attention Deficit Disorder Association External link has a helpful fact sheet with more details on the evolution of ADHD's nomenclature and its subtypes on its website.

Ultimately, while many use the terms "ADD" and "ADHD" interchangeably, the latter is technically the correct, up-to-date term External link .

Symptoms of ADHD

According to the Mayo Clinic External link , symptoms of ADHD often appear in early childhood, with diagnoses typically occurring before age 12. Typical symptoms of ADHD include fidgeting, excessive daydreaming, continual forgetfulness or losing things, taking needless risks, talking too much, limited self-control, misreading social cues and struggles with social interactions such as taking turns or getting along with others

Some may think, "Don't most children experience these 'symptoms' at one point or another during childhood?" - and they'd be right. The difference for children with ADHD is that these behaviors never subside and often worsen over time, and must result in impairment in key domains of functioning (e.g., social, familial, and academic), and often co-occur in two or more settings. Ultimately, ADHD is chronic for many affected children, impeding their social and academic lives well beyond their childhood and adolescence. According to the nonprofit Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) External link , "more than 75% of children with ADHD continue to experience significant symptoms in adulthood." As such, school counselors and educators have an opportunity to support children and teens with ADHD to develop effective techniques to manage their symptoms in school, and maintain them into adulthood.

More than 75% of children with ADHD continue to experience significant symptoms in adulthood.

Helping Students with ADHD

Children with ADHD can have a particularly hard time managing their symptoms in school environments. For example, experiencing difficulty sitting still during class, having trouble waiting for a turn during an activity or conversation, or being unable to play quietly and independently are not only disruptive behaviors, they also interfere with a student's social, emotional, and academic development and functioning.

With up to roughly 11 percent of children External link ages 4 to 17 diagnosed with ADHD, school counselors serve as an important support system for children with ADHD and their families, as well as an essential resource for teachers and other professionals who work with students in and outside of the classroom. Because ADHD manifests itself in many different ways (most children are diagnosed with a combined form of ADHD External link ), counselors should be equipped with several strategies to address the many ways symptoms may occur in students.

With up to roughly 11 percent of children External link ages 4 to 17 diagnosed with ADHD, school counselors serve as an important support system

Before jumping into strategies and suggestions, it's critical to understand what skills, specifically, students coping with ADHD need help developing. "Children need to learn to develop impulse control and time management skills, as well as the ability to focus or concentrate on an undesired task," said Rebecca Newman, an early childhood mental health consultant for the Child Center of NY External link . If the development of these skills is ignored, "they may experience continual frustration, fatigue, poor self-esteem, or embarrassment," she said.

A big part of successfully managing ADHD symptoms is providing structure. The National Institute for Mental Health says External link that keeping the same routine every day and addressing any changes (such as school assemblies or field trips) as far in advance as possible is imperative. Helping students stay organized is another way to provide structure while keeping them on track with demands and expectations from homework, clubs, and sports.

Strategies for School Counselors

Evidence-based interventions (EBIs) are a primary way school counselors can provide support to students coping with ADHD. EBIs are an important part of managing ADHD symptoms, and usually occur outside of where a change in behavior is needed, such as a classroom.

Anil Chacko External link , a professor for Counseling@NYU's online master's in school counseling program, said there are specific strategies that school counselors can implement when working with students who have ADHD.

"School counselors should utilize methods that support students' time management, planning, and organization," Chacko said, citing the work of Joshua Langberg External link at VCU and Howard Abikoff External link at NYU's School of Medicine - both leaders in ADHD research for children and adolescents. "I would also encourage school counselors to work directly with parents to create a school-home note system to support cross-setting changes."

Research as recent as 2016 found that with early intervention for behavioral therapy External link , children who received behavioral therapy first before other interventions (such as medication) received "four fewer rules violations an hour at school than the medication-first group." This is not to say medical treatments should be dismissed, as they have proven benefits for helping children as well, but rather demonstrates the importance of a school counselor's role in encouraging behavior modification. This form of therapy is also cost-effective, as the reports found behavior-first therapy cost roughly $700 less per year compared to medication-first treatment. The CDC agrees both behavioral therapy and medication External link are important for treatment moving forward.

These intervention techniques can be implemented at any point in a student's academic career; it's equally applicable for elementary students as it is for high schoolers. What's more, social and emotional learning is increasingly appearing External link in schoolwide curricula, which can further support a student coping with ADHD in a formal classroom setting, as well.

Strategies for Teachers

In addition to EBIs, school counselors can train teachers to support children coping with ADHD in the classroom. It can be as simple as suggesting that teachers implement point- or token-based systems in class to reward good behavior, or as robust as dedicating a day of in-service training to identify symptoms and provide additional intervention strategies.

As for some immediate tips, for students who are easily distracted (predominantly inattentive), the National Resource Center (NRC) on ADHD External link suggests:

Seating the student near the teacher's desk or away from distractions like windows or the corridor.

Splitting longer assignments into smaller segments, and providing more breaks during class time.

For students who squirm and fidget often (predominantly hyperactive/impulsive), the NRC recommends:

Seating students in an area where there will be the least disruption, such as along the side of the classroom.

Creating opportunities for movement throughout the day, such as completing assignments sitting on the floor or helping with class activities (e.g., handing out activity sheets).

Newman adds that using "first/then" statements - such as "First push your chair in, then come sit for story time" - with children, and directing them to assist during class time will help them both refocus their energy and also feel valuable. A general best practice is for school counselors, teachers, and parents to offer praise and reward when children coping with ADHD exhibit good behavior.

The NRC has additional resources for teachers on supporting students with ADHD for reading External link , writing External link , and math External link accommodations, and general classroom instruction External link .

Strategies for Parents

ADHD is a relatively well-known mental disorder and is subsequently stigmatized - discussions of ADHD as a "fake" disorder on mainstream news sites External link don't help, either. As such, ADHD is oversimplified or even appropriated with things like "AD/HD" T-shirts and an endless meme stream across the internet. Beyond the web, stigmas of ADHD are found in television. Season 2 of Netflix's wildly successful Unbreakable Kimmy Schmidt references an ADHD medication, Dyziplen, that transforms rambunctious kids into slow-moving, deadpan pseudo-robots.

A big part of empowering children to manage their ADHD is providing them with interventions, therapies, medications, and lots of support from adults in all aspects of their life. But when it comes to stigma, speaking up in defense of your child is a great way to fight it, just as this parent did External link in reaction to the Kimmy Schmidt episode last year.

When it comes to stigma, speaking up in defense of your child is a great way to fight it.

While misconceptions of ADHD are seemingly omnipresent, there are many strategies parents can use for helping their child with ADHD at home:

Additionally, Chacko encourages parents to learn more about available behavior parent training programs - arguably the most well-studied and effective "therapy" for children with ADHD and related oppositional problems.

"It's important to remember that many students with ADHD also have a learning disability or learning issues," Chacko said. "School counselors, teachers and parents should appreciate that the challenges these children face may be more than just 'ADHD.' "

As with many misunderstood mental disorders, the best way to change the conversation is through an amplified voice. In terms of supporting parents, school counselors can educate them on support groups External link , online forums External link , and through websites like CHADD External link .
Republished with permission: Counseling@NYU, the online masters in school counseling program from NYU Steinhardt.

Fine Print

ADD and ADHD are used interchangeably for Attention-Deficit/Hyperactivity Disorder.

Any information or suggestions in this article are solely the opinion of the author(s) and should not replace the advice of appropriate medical, legal, therapeutic, financial or other professionals. We do not test or endorse any product, link, author, individual or service listed within.

© 2006 - 2017, by The ADD Resource Center. All Rights Reserved.

To view HUNDREDS of articles and videos on ADD/ADHD, go to addrc.org

Posted on Category:Tagged with:
Categories School Issues
Tags ADD, ADHD, counseling, Education, school, Students

More than 6 million children between the ages of 4 and 17 had been diagnosed with attention deficit hyperactivity disorder (ADHD) as of 2011, according to the Centers for Disease Control and Prevention External link . It's a complicated disorder with a long history. In order to cope with the symptoms, children with ADHD need continuous support from parents, teachers, and school counselors. School counselors are especially poised to serve as a key intermediary between parents and teachers and can be essential in helping students with ADHD thrive.
More than 75% of children with ADHD continue to experience significant symptoms in adulthood.

With up to roughly 11 percent of children External link ages 4 to 17 diagnosed with ADHD, school counselors serve as an important support system

Seating the student near the teacher's desk or away from distractions like windows or the corridor.

Splitting longer assignments into smaller segments, and providing more breaks during class time.

Seating students in an area where there will be the least disruption, such as along the side of the classroom.

Creating opportunities for movement throughout the day, such as completing assignments sitting on the floor or helping with class activities (e.g., handing out activity sheets).

When it comes to stigma, speaking up in defense of your child is a great way to fight it.

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Strategies for ADHD: How Counselors Help Today's Students Succeed

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Strategies for ADHD: How Counselors Help Today's Students Succeed More than 6 million children between the ages of 4 and 17 had been diagnosed with attention deficit hyperactivity disorder (ADHD) as of 2011, according to the Centers for Disease Control and Prevention External link . It's a complicated disorder with a long history.

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We all feel anxious sometimes, but some children experience anxiety that is so serious that it can be diagnosed as a disorder. A child may have an anxiety disorder if their anxiety is:

Unrealistic

Doesn't go away

Makes them start avoiding everyday things

Here are some different kinds of anxiety that children may be diagnosed with.

Separation anxiety disorder

Children with separation anxiety become extremely upset when they are separated from their caregivers. The distress that they feel is unusual for their age.

Some signs include:

Worrying about parents getting sick or dying

Worrying about getting lost or kidnapped

Not wanting to go to school

Social anxiety disorder

Children with social anxiety disorder are very self-conscious. They can find it difficult to hang out with peers or participate in class.

Some signs include:

Avoiding social situations

Feeling panicky during social situations. Older kids may shake, sweat, or be short of breath. Younger kids may have tantrums or cry.

Worrying people will judge them for being anxious

Selective mutism

Children with selective mutism have a hard time speaking in some places, like at school. Their anxiety goes beyond typical shyness. Kids with SM can't speak even when they badly want to.

Some signs include:

Feeling "frozen" with anxiety and unable to speak

Being able to speak in some places but not others (like school or around certain people)

Generalized anxiety disorder

Children with generalized anxiety disorder (GAD) worry about lots of everyday things. Kids with GAD are often particularly worried about how they are doing in school.

Some signs include:

Being a perfectionist

Feeling "out of control" anxiety about many different things

Having trouble sleeping

Panic disorder

Children with panic disorder have a history of panic attacks. Panic attacks are a scary and very sudden surge of symptoms that can make kids worry they are dying or "going crazy."

Some signs include:

Specific phobia

Children with specific phobia have extreme fears about a particular thing. These things aren't typically considered dangerous but seem very scary to the child.

There are five common kinds:

The animal type, or avoiding animals and bugs

The natural environment type, or avoiding things like storms, heights or water

The blood-injection-injury type, or avoiding things like seeing blood or getting a shot

The situational type, or avoiding things like flying, tunnels and bridges

The other type, or avoiding things like loud sounds, choking, vomiting and costumed characters

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What Are the Different Kinds of Anxiety? | Child Mind Institute

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We all feel anxious sometimes, but some children experience anxiety that is so serious that it can be diagnosed as a disorder. A child may have an anxiety disorder if their anxiety is: Unrealistic Doesn't go away Makes them start avoiding everyday things Here are some different kinds of anxiety that children may be diagnosed with.

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KidsHealth in the Classroom offers educators free health-related lesson plans for PreK through 12th grade. Each Teacher's Guide includes discussion questions, classroom activities and extensions, printable handouts, and quizzes and answer keys - all aligned to National Health Education Standards.

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KidsHealth in the Classroom offers educators free health-related lesson plans for PreK through 12th grade. Each Teacher's Guide includes discussion questions, classroom activities and extensions, printable handouts, and quizzes and answer keys - all aligned to National Health Education Standards.

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Oppositional defiant disorder (ODD) - Diagnosis and treatment - Mayo Clinic

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This childhood mental health condition includes frequent and persistent anger, irritability, arguing, defiance or vindictiveness toward authority.

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To address students' mental health needs, school counselors and other school-based student support staff can connect youth and their families to resources in the community. You can also take steps to help increase the likelihood referrals will be successful.

Developing Referral Lists
In developing a referral list of community-based mental health professionals, include a provider's capacity to treat clients with particular presenting problems, ability to work with multicultural populations and comfort with languages other than English. Note logistical factors, such as a provider's hours, location and accessibility by public transportation, affordability and accepted insurance plans.

Ideally, such lists are updated fairly often. You may want to visit agencies or speak with providers by phone to gain a sense of their approaches or take a field trip during a professional development day.

Serving as a Bridge
Even with a referral list of qualified and well-matched community practitioners, making a successful referral can still be challenging. To increase ties among students, families and community-based providers, invite local mental health providers to parent workshops, school-based family events and select classroom lessons focusing on mental-health-related topics.

For example, as part of a school's focus on wellness, community-based professionals could offer strategies to de-stress and discuss warning signs of when students may need more support. These more informal introductions help the school-based staff become a bridge connecting families and students to outside agencies. Community providers are often invested in such activities if it can increase their referrals and decrease their no-show rates.

School counselors can also help to connect students and families to services by addressing common barriers and concerns. Try to create an open dialogue that allows families to feel heard and engages them in a process of mutual problem solving, recognizing their strengths. Authors McKay and Gopalan and colleagues have written about many of the barriers and strategies highlighted here.

Provide students a developmentally appropriate explanation of the reasons a student might be referred to outside mental health services. Understanding the student's and family's feelings and concerns about accessing mental health services is important, as is assessing whether outside mental health services (as opposed to other supports) are the best match for the family.

Address common concerns and questions: Does the student have fears about being labeled "crazy" or being singled out? Does the family feel blamed by the school or a previous provider? What are the family's opinions about medication? What are the family and student hoping for in an outside practitioner? How does the parent or guardian view the child's functioning? Are there concerns about privacy? By listening to and addressing the family's unique needs, concerns and questions, you'll be more likely to provide a successful referral.

If parents want help addressing practical barriers, include the family and student, when appropriate, as much as possible in the process so they can more independently access resources in the future. For example, with the parents' permission, you might make the initial phone contact to an outside provider while the parents are in the room.

Following Up
Once you've made a referral, particularly with more severe cases, be sure to follow up. To share information with an outside provider, you'll need consent to exchange information. You can also connect directly with families or students to check on progress of referrals. If you have significant concerns about a student even after an outside referral, consider the nature of the outside services and whether other supports might be warranted. When students are transitioning back from an out-of-school mental health setting, it is particularly important that school counselors and/or related school staff connect with the student, family and outside providers to make a transition plan for the student's return to school. When students are receiving regular counseling both inside and outside of school, it is important that school staff and the provider connect.

Systems such as checklists and standardized approaches can assist the referral and follow-up processes. A school checklist of steps for referral processes, required documents (such as releases of information), strategies for record-keeping of contacts and most frequently asked questions can make the process more efficient for all involved. Checklists can also help teachers and school counselors efficiently share information about student progress with outside providers. Schools can invite outside mental health practitioners to key meetings (when permissions are in place) to maintain meaningful connections between providers. Other school staff may be able to help in the referral process: perhaps a student support team member can take the role of managing outside partnerships and connecting with providers about students' progress.

Connecting with the School-Based Team
When assisting families and students who have greater mental health needs, remember to work as a team with other school staff in connecting students and families to resources. School psychologists, school social workers, other school counselors and student support team members can help identify potential referral sources, connect students and families to resources, support follow-up and support one another's work with students. Nurturing your school-based connections with school-based colleagues is important for supporting both students and staff.

Jacqueline Zeller, Ph.D., is with the Harvard Graduate School of Education's Prevention Science and Practice/CAS in Counseling Program. She can be reached at zellerja@gse.harvard.edu. Contact the author for references for this article.

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To address students' mental health needs, school counselors and other school-based student support staff can connect youth and their families to resources in the community. You can also take steps to help increase the likelihood referrals will be successful.

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School Guidance and Counseling - Counseling Resources | Texas Education Agency

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The following links provide information for counselors to assist students in preparation for high school and life after high school:

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The School Counselor and the Identification, Prevention and Intervention of Behaviors That Are Harmf - American School Counselor Association (ASCA)

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All schools and communities have students who could potentially drop out of school and/or engage in destructive behaviors such as absenteeism, performing below their potential academically, substance abuse, bullying, cyberbullying, suicidal ideation, physical violence or engaging in self-harm and other destructive or dangerous behaviors.

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National Institute of Mental Health (NIMH)

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Does your child go through extreme changes in mood and behavior? Does your child get much more excited or much more irritable than other kids? Do you notice that your child goes through cycles of extreme highs and lows in mood and energy levels more often than other children? Do these mood changes affect how your child acts at school or home?

Some children and teens with these symptoms may have bipolar disorder, a mental illness that causes unusual shifts in mood, energy, activity levels, and day-to-day functioning. With treatment, children and teens with bipolar disorder can improve over time.

What is bipolar disorder?

Bipolar disorder (formerly called manic-depressive illness or manic depression) is a mental illness that causes people to experience noticeable, sometimes extreme, changes in mood and behavior. It is a common misperception that children cannot have bipolar disorder. Although most people are diagnosed with bipolar disorder in adolescence or adulthood, the symptoms can appear earlier in childhood.

Bipolar disorder is not the same as the typical ups and downs every child goes through. The mood changes in bipolar disorder are more extreme, often unprovoked, and accompanied by changes in sleep, energy level, and the ability to think clearly.

Children with bipolar disorder sometimes feel very happy or "up" and are much more energetic and active than usual. This is called a manic episode. Children with bipolar disorder sometimes feel very sad or "down" and are much less active than usual. This is called a depressive episode. Bipolar disorder is often episodic, but it usually lasts a lifetime.

Bipolar disorder symptoms can make it hard to perform well in school or get along with friends and family members. Some children and teens with bipolar disorder may try to hurt themselves or attempt suicide. Early diagnosis and treatment can lead to better functioning and well-being over the long term.

Signs and symptoms of bipolar disorder may overlap with symptoms of other disorders that are common in young people, such as attention-deficit/hyperactivity disorder (ADHD), conduct problems, major depression, and anxiety disorders.

Diagnosing bipolar disorder can be complicated and requires a careful and thorough evaluation by a trained, experienced mental health professional.

With treatment, children and teens with bipolar disorder can manage their symptoms and lead full, active lives.

What causes bipolar disorder?

The exact causes of bipolar disorder are unknown, but several factors may contribute to the illness.

For example, researchers are beginning to uncover genetic factors linked to bipolar disorder and other mental illnesses. Research shows that a person's chances of having bipolar disorder are higher if they have a close family member with the illness, which may be because they have the same genetic variations. However, just because one family member has bipolar disorder does not mean other family members will have it. Many genes are involved in the disorder, and no single gene causes it.

Research also suggests that people with a genetic risk of having bipolar disorder may be more likely to develop the disorder after experiencing trauma or other stressful life events.

Some research studies have found differences in brain structure and function between people with bipolar disorder and people without it. Researchers are examining these differences to learn more about possible causes and effective treatments.

What are the symptoms of bipolar disorder?

Mood episodes in bipolar disorder include intense emotions and significant changes in sleep habits, activity levels, thoughts, or behaviors. Children and teens with bipolar disorder may have manic episodes, depressive episodes, or "mixed" episodes. A mixed episode has both manic and depressive symptoms. These mood episodes cause symptoms that often last for several days or weeks. During an episode, symptoms occur every day and last for most of the day.

These mood and activity changes are very different from the child's usual behavior and the behavior of healthy children and teens.

Children and teens having a manic episode may:

Show intense happiness or silliness for long periods of time.

Have a very short temper or seem extremely irritable.

Talk fast about a lot of different things.

Have trouble sleeping but do not feel tired.

Have trouble staying focused and experience racing thoughts.

Seem overly interested or involved in pleasurable but risky activities.

Do risky or reckless things that show poor judgment.

Have an inflated sense of ability, knowledge, and power.

Children and teens having a depressive episode may:

Feel frequent and unprovoked sadness.

Show increased irritability, anger, or hostility.

Complain a lot about physical pain, such as stomachaches and headaches.

Start sleeping a lot more.

Have difficulty concentrating.

Feel hopeless and worthless.

Have difficulty communicating or maintaining relationships.

Eat too much or too little.

Have low energy and no interest in activities they usually enjoy.

Think about death or have thoughts of suicide.

Can children and teens with bipolar disorder have other problems?

Young people with bipolar disorder can have several problems at the same time. For example, they may also be at risk of misusing alcohol or drugs. Sometimes extreme behaviors go along with mood episodes. During manic episodes, young people with bipolar disorder may take extreme risks that they wouldn't usually take or that could cause them harm or injury. During depressive episodes, some young people with bipolar disorder may think about running away from home or have thoughts of suicide.

If your child shows signs of suicidal thinking, take these signs seriously and call your child's health care provider.
If your child is struggling or having thoughts of suicide, call or text the 988 Suicide & Crisis Lifeline at 988 or chat at 988lifeline.org . This service is confidential, free, and available 24 hours a day, 7 days a week.

How is bipolar disorder diagnosed?

A health care provider will ask questions about your child's mood, sleeping patterns, energy levels, and behavior. There are no blood tests or brain scans that can diagnose bipolar disorder. However, the health care provider may use tests to determine if something other than bipolar disorder is causing your child's symptoms. Health care providers may need to know about medical conditions in the family, such as depression or substance use.

Other disorders-such as ADHD, disruptive mood dysregulation disorder, oppositional defiant disorder, conduct disorder, and anxiety disorders-have symptoms like those of bipolar disorder. It can be challenging to distinguish bipolar disorder from depression that occurs without mania, referred to as "major depression." A health care provider who specializes in working with children and teens can carefully evaluate your child's symptoms to provide an accurate diagnosis.

How is bipolar disorder treated?

Children and teens can work with their health care provider to develop a treatment plan to help them manage their symptoms and improve their quality of life. It is important to follow the treatment plan, even when your child is not currently experiencing a mood episode. Steady, dependable treatment works better than treatment that starts and stops.

Several types of medication can help treat symptoms of bipolar disorder. Children respond to medications in different ways. They may need to try different types of medication to find the one that works best for them. Some children may need more than one type of medication because their symptoms are complex. Health care providers usually try to prescribe the fewest number of medications and the smallest doses possible to help treat a child's symptoms. Always tell your child's health care provider about any medication side effects. Do not stop giving your child a prescribed medication without speaking to a health care provider. Stopping medication suddenly can be dangerous and can make symptoms worse.

Different kinds of psychosocial therapy can also help children and their families manage the symptoms of bipolar disorder. Therapies based on scientific research-including cognitive behavioral approaches and family-focused therapy-can provide support, education, and guidance to youth and their families. These therapies teach skills that can help people manage bipolar disorder, including skills for maintaining routines, enhancing emotion regulation, and improving social interactions.

What can children and teens expect from treatment?

With treatment, daily functioning and well-being can improve over time. Treatment is more effective when health care providers, caregivers, and young people work together.

Sometimes a child's symptoms may change or disappear and then come back. When this happens, your child's health care provider may recommend changes to the treatment plan. Treatment can take time but sticking with the treatment plan can help young people manage their symptoms and reduce the likelihood of future episodes.

Your child's health care provider may recommend keeping a daily life chart or mood chart to track your child's moods, behaviors, and sleep patterns. This may make it easier to track the illness and see whether treatment is working.

How can I help my child or teen?

Help begins with an accurate diagnosis and treatment. Talk to your child's health care provider about any symptoms you notice.

If your child has bipolar disorder, here are some basic things you can do:

Be patient.

Encourage your child to talk, and listen to your child carefully.

Pay attention to your child's moods, and be alert to any major changes.

Understand triggers and learn strategies for managing intense emotions and irritability.

Help your child have fun.

Remember that treatment takes time: Sticking with the treatment plan can help your child get better and stay better.

Help your child understand that treatment can make life better.

How does bipolar disorder affect caregivers and families?

Caring for a child or teenager with bipolar disorder can be stressful for parents and families. Coping with a child's mood episodes and other symptoms-such as short tempers and risky behaviors-can challenge any caregiver.

It is important that caregivers take care of themselves, too. Find someone you can talk to or consult your health care provider about support groups. Finding support and strategies for managing stress can help you and your child.

Where do I go for help?

If you're unsure of where to get help, your doctor, pediatrician, or other family health care provider is a good place to start. A health care provider can refer you to a qualified mental health professional, such as a psychiatrist or psychologist, who has experience treating bipolar disorder and can evaluate your child's symptoms.

Learn more about getting help on the NIMH website. The Substance Abuse and Mental Health Services Administration has an online treatment locator to help you find mental health services in your area.

What should I know about clinical trials?

NIMH supports a wide range of research, including clinical trials that look at new ways to prevent, detect, or treat diseases and conditions-including bipolar disorder. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct clinical trials with patients and healthy volunteers. Talk to a health care provider about clinical trials, their benefits and risks, and whether one is right for you. Learn more about  participating in clinical trials.

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For More Information

MedlinePlus (National Library of Medicine) ( En español )

ClinicalTrials.gov ( En español )

NIH Publication No. 23-MH-8081
Revised 2023

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Information about bipolar disorder in children and teens including causes, signs and symptoms, diagnosis, treatment options, and how to help a child or teen who has bipolar disorder.

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What is major depression?

Major depression, also known as clinical depression, is classified as a type of affective disorder (also called mood disorder) that goes beyond the day's ordinary ups and downs. It has become a serious medical condition and important health concern in this country.

Who is affected by major depression?

The National Institute of Mental Health, part of the National Institutes of Health, reports the following:

Research indicates that depression onset is occurring earlier in life today than in past decades.

Early-onset depression often persists, recurs, and continues into adulthood. Depression in youth may also predict more severe illness in adulthood.

There is an increased incidence of depression in children whose parents experience depression.

What are the risk factors for major depression?

The following are the most common risk factors for major depression:

Family history of depression (especially if a parent experienced depression as a child or adolescent)

Excessive stress

Abuse or neglect

Trauma (physical and/or emotional)

Other psychiatric disorders

Loss of a parent, caregiver, or other loved one

Cigarette smoking

Loss of a relationship (for example, moving away, loss of boyfriend or girlfriend)

Other chronic illnesses (for example, diabetes)

Other developmental, learning, or conduct disorders

What are the symptoms of major depression?

The following are the most common symptoms of major depression. However, each child may experience symptoms differently. Symptoms may include:

Persistent feelings of sadness

Feeling hopeless or helpless

Having low self-esteem

Feeling inadequate

Excessive guilt

Feelings of wanting to die

Loss of interest in usual activities or activities once enjoyed

Difficulty with relationships

Sleep disturbances (for example, insomnia, hypersomnia)

Changes in appetite or weight

Decreased energy

Difficulty concentrating

A decrease in the ability to make decisions

Suicidal thoughts or attempts

Frequent physical complaints (for example, headache, stomachache, fatigue)

Running away or threats of running away from home

Hypersensitivity to failure or rejection

Irritability, hostility, aggression

For a diagnosis of major depression to be made, a child often needs to exhibit a "cluster" (several) of the above symptoms during the same 2-week period. The symptoms of major depression may resemble other problems or psychiatric conditions. Always consult your child's health care provider for a diagnosis.

How is major depression diagnosed?

Because depression has shown to often coexist with other psychiatric disorders, such as substance abuse or anxiety disorders, seeking early diagnosis and treatment is crucial to the recovery of your child.

A child psychiatrist or other mental health professional usually diagnoses major depression following a comprehensive psychiatric evaluation. An evaluation of the child's family, when possible, in addition to information provided by teachers and care providers may also be helpful in making a diagnosis.

Treatment for major depression

Specific treatment for major depression will be determined by your child's health care provider based on:

Your child's age, overall health, and medical history

Extent of your child's symptoms

Your child's tolerance for specific medications or therapies

Expectations for the course of the condition

Your opinion or preference

Mood disorders, including major depression, can often be effectively treated. Treatment should always be based on a comprehensive evaluation of the child and family. Treatment may include 1, or more, of the following:

Antidepressant medications (especially when combined with psychotherapy has shown to be very effective in the treatment of depression in children and teens)

Psychotherapy (most often cognitive-behavioral and/or interpersonal therapy) for the child (focused on changing the child's distorted views of him- or herself and the surrounding environment; working through difficult relationships; identifying stressors in the child's environment and learning how to avoid them)

Family therapy

Consultation with the child's school

Parents play a vital supportive role in any treatment process.

For several reasons, many parents of children or adolescents with depression never seek the appropriate treatment for their child, although many people with major depression who seek treatment improve - usually within weeks. Continued treatment may help to prevent reoccurrence of the depressive symptoms.

Without appropriate treatment, symptoms of depression can persist for weeks, months, or years. In addition to causing interpersonal and psychosocial problems, depression in children and adolescents is also associated with an increased risk for suicide. Further, this risk rises, particularly among adolescent boys, when the depression is accompanied by other mental health disorders (for example, conduct disorder, substance abuse). It is crucial for parents and care providers of children and adolescents to take all depressive and suicidal symptoms very seriously and seek treatment immediately. Suicide is a medical emergency. Consult your child's health care provider for more information.

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Major depression, also known as clinical depression, is classified as a type of affective disorder (also called mood disorder) that goes beyond the day's ordinary ups and downs. It has become a serious medical condition and important health concern in this country.

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How to Help a Child with ODD

Step one to treating oppositional defiant disorder (ODD) is detecting and controlling the symptoms of attention deficit disorder (ADHD or ADD) if they are present. Treatment for ADHD symptoms may include taking a daily stimulant or non-stimulant medication which can sometimes help with oppositional defiant symptoms as well.

Step two is receiving a formal evaluation for other related psychological conditions that can cause oppositional behavior.

Step three is devising a strategy to treat ODD. The preferred ODD treatment is a combination of individual and family behavioral therapy. When therapy alone does not resolve symptoms, medication for ODD can sometimes help. In addition, lifestyle changes can help some people with mild symptoms to control their explosions.

Oppositional Defiant Disorder Treatment Options

Oppositional Defiant Disorder treatment may include:

Cognitive-behavioral therapy

Parent-child interaction therapy

Collaborative problem solving

Medication in the form of a low dose, atypical neuroleptic

Lifestyle changes

Oppositional Defiant Disorder Treatment: Therapy

Counseling for ODD should include both the patient and his or her family members, and it should emphasize strategies that the family can use to cope with defiant behaviors.

Remember, people with ODD are neurologically hard-wired to defeat and thwart people in roles of authority. They have no intention of cooperating in any therapeutic process.

[Self-Test: Oppositional Defiant Disorder in Adults]
[Self-Test: Oppositional Defiant Disorder in Children]
Individual Cognitive-Behavioral Therapy for ODD
Individual therapy teaches people with ODD a series of techniques for managing anger, controlling emotions, and solving problems. It can provide positive alternative behaviors to replace defiant ones. This type of therapy works best when it begins early in life, when family and social interactions aren't ingrained and difficult to change.
Family and Parent Training Programs for ODD
Parent- and family-training programs are built on the premise that children behave badly when they realize that doing so gets them what they want. Say your child throws a fit when you ask him to turn off a video game; if you give in even once, he learns that he will sometimes succeed. Parent training teaches caregivers what to do in these stressful, exhausting moments to avoid setting a precedent that will encourage more bad behavior.

Parents learn to change their reactions to a child's behavior - good and bad. They learn to demonstrate and define their expectations, and then give well-defined rewards and praise when their child behaves accordingly - or consistent consequences when the child doesn't. Most effective parenting programs are built around these four core principles:

1. Reinforce good behavior with a reward system - like stars on a chart, or extending a special privilege.

2. Discourage negative behavior by ignoring it. Kids often use bad behavior to get attention.

3. Take away a privilege if negative behavior is too serious to ignore.

4. Remove common triggers of bad behavior.
[Free Download: 4 Parent-Child Therapies for Better Behavior]
A therapist will also work with a parent and child together to solve specific challenges. The plan should start with a key, narrow behavior - like no swearing. Parents learn how to give instructions in an authoritative way, use time-outs effectively, praise children, and create rewards systems.

The goal is to incrementally teach a child new ways of behaving and to break the cycle of defiance. By focusing on and rewarding desired behaviors, a parent can help their child experience success, which encourages the child to behave that way again.

The three most common types of parent- and family-training programs are:

1. Parent-Child Interaction Therapy (PCIT) - PCIT is a program that looks beyond bad behavior to examine troubled relationships - and how changing them can improve daily life. It helps parents become better at managing their child's behavior with real-time coaching. It is most effective for children ages two to seven, and is offered in university-based centers and by individual therapists.

Participating family members interact while listening to advice from therapists behind a one-way mirror, so the child associates the parenting skills with her parent, not the therapist.

2. Collaborative Problem Solving (CPS) - CPS is a program created by Ross W. Green, Ph.D., for defiant teens who have outgrown time-outs. The program focuses on giving kids the problem-solving skills they lack rather than using a reward-and-punishment system.

The first step in CPS is to identify and understand the child's concern about a problem (completion of homework or chores), and reassure him that the problem will be resolved by the child and the adult together. The second step is to identify the adult's concerns about the same problem. The third step invites the child to brainstorm solutions with the adult, and to find a plan that is mutually satisfactory.

3. Vive - This is an intensive family therapy program for parents of older kids with behavioral problems. It uses the principles of parent management training, but involves two separate therapists: a "mentor" for the struggling teen, and a "coach" for the parents. The program can help kids become more reflective about problems, and help families recognize patterns in the ways they react to each other. This technique is geared toward families in crisis who can devote a substantial amount of time and money. Fees can be up to $3,000 a month.

Oppositional Defiant Disorder Treatment: Medication

If therapies prove ineffective, medication can sometimes help to "re-wire" oppositional behaviors. No medications are FDA-approved for the treatment of ODD in the U.S. Nonetheless, clinical experience has shown that the majority of children and adolescents with ODD do show signs of improvement with a low dose of atypical neuroleptics - arippirazole (Abilify) and risperidone (Risperidal), for example.

Oppositional Defiant Disorder Treatment: Lifestyle Changes

Families can use many of the techniques taught in behavioral therapy to improve everyday life with defiant behavior while working to diminish it. These techniques include the following:

Always build on positives: Praise your child and offer positive reinforcement when he shows flexibility or cooperation. Recognize the "little victories" with enthusiasm.

Learn to control yourself: Take a time-out or break if you suspect you are about to make the conflict with your child worse, not better.

Pick your battles: Since a child with ODD has trouble avoiding power struggles, prioritize the demands you put on your child.

Provide structure: Bad behavior tends to escalate when a child has unsupervised free time and unclear expectations. A daily routine, on the other hand, lets a child know what to expect.

Position behavioral issues as problems she can solve: Explain to your child that ignoring an alarm clock doesn't help her get to school on time, and ask what she can do to avoid being tardy again.

Set up reasonable, age-appropriate limits and enforce consequences consistently: Resist the temptation to rescue the child from naturally occurring consequences.

Don't go it alone: Work with and get support from the other adults (teachers, coaches, and spouse) who interact with your child. Look for local support groups and/or parenting classes for parents of difficult children.

Avoid burnout: Maintain interests other than your child so that managing her behavior doesn't sap all of your time and energy. Manage your own stress with exercise and relaxation. Use respite care as needed.

Additionally, supplements may improve certain symptoms of ODD. Be sure to consult with a physician before trying any of the alternative therapies below.

Omega-3 Fatty Acids to regulate mood and emotions

Vitamin E to help absorb Omega-3s

Melatonin to help normalize sleep patterns

Zinc to help neutralize brain chemicals that can lead to hyperactivity and impulsivity

For adults, reading about ODD can be an asset. Taking Charge of Anger, a book by W. Robert Nay, Ph.D., gives practical advice that may benefit an adult with the condition.
[Back From the Brink: Two Families' Stories of Oppositional Defiant Disorder]

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Step one to treating oppositional defiant disorder (ODD) is detecting and controlling the symptoms of attention deficit disorder (ADHD or ADD) if they are present. Treatment for ADHD symptoms may include taking a daily stimulant or non-stimulant medication which can sometimes help with oppositional defiant symptoms as well.

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Psychosis (Schizophrenia) in Children and Youth

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Psychosis (Schizophrenia) Schizophrenia and other psychotic disorders are medical illnesses that result in strange or bizarre thinking, perceptions (sight, sound), behaviors, and emotions. Psychosis is a brain-based condition that is made better or worse by environmental factors - like drug use and…

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Child Abuse Prevention, Treatment & Welfare Services | Children's Bureau

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Is Your Child Displaying Behavioral or Emotional Distress?

Children's Bureau can help.

COVID-19 UPDATE: To accommodate social distancing measures, m ental health therapy services are now being delivered to children and their parents via phone and/or video conferencing (telemental health). We're also making it easy for families to review and sign paperwork electronically. As always, our services are delivered with care and privacy.

Children's Bureau is here to help young children, adolescents, and youth (ages 0 to 21) and their families find ways to decrease potential outbursts and violence in the home as well as aid in the development of appropriate social skills. We hope to meet every child's mental health treatment needs with the care of a mental health professional.

Children's Bureau provides a wide range of counseling for kids and mental health services for children including a comprehensive assessment of your child's behavior, child abuse therapy, family-focused therapy, individual counseling, cognitive behavioral therapy and group therapy sessions. Additionally, our mental health counseling center offers intensive day treatment for young children to monitor their daily activities, medication management, case management assistance, therapeutic behavioral health services, as well as assistance to the significant caretakers and support person(s) in the child's life.

By extending our child counseling services and mental health resources, Children's Bureau hopes to give families and children the tools they need to begin children's therapy services.

Our counseling for children is culturally sensitive with a substantial focus on the Latino community. Counseling services are provided in the home, school, office or community.

Our Approach

Customizing Treatment

Children's Bureau youth therapists utilize a family therapy system for the health and well-being of the child. When counseling children, our patient therapists make sure to engage with the child's caregiver as a partner in problem-solving. Additionally, all child therapy treatments are customized to meet the specific needs of the child and family to ensure that they are receiving the best care from the respective child therapist or counselor.

Child mental health services make a difference in helping young adults and children that are struggling with a mental health issue, mental illness, or disorder. With treatment programs such as cognitive behavioral therapy, our professional counselors hope to guide younger children through the extremely emotional time of childhood and adolescence. We customize the care & treatment plan for your child by providing a variety of services to suit their mental health needs, ranging from early intervention services to in-home services. From individual counseling to art therapy sessions, our professional counselors are committed to providing the proper care and treatment that works for your child.

Know the Signs

Connect with a counselor or therapist that specializes in providing child counseling services. Sign up for services or check out our mental health flyer for child behaviors to observe.

Get Help

COVID-19 UPDATE:

We're here for you...just in a different way. While our offices are closed, mental health services are being delivered through telehealth. For more information or to sign up call 1.800.520.2445 , email mhreferrals@all4kids.org or complete this form.

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Los Angeles, CA 90007

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Children's Bureau partners with a variety of service providers. To learn more about what we offer, call one of our sites listed above or click the Learn More link below. We look forward to hearing from you.
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Magnolia Place Parents

"My son was experiencing sad, fearful behavior due to violence in my previous marriage. Thanks to Children's Bureau's family support specialist, he has participated in counseling and is doing better. I received help in many ways and now feel empowered and more confident in how to protect all of my children."

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National Suicide Prevention Lifeline

Help is available. Call 1-800-273- TALK (8255) to speak with a counselor today.

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Counseling for Kids & Child Mental Health Services | Children's Bureau

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Children's Bureau can help. COVID-19 UPDATE: To accommodate social distancing measures, m ental health therapy services are now being delivered to children and their parents via phone and/or video conferencing (telemental health). We're also making it easy for families to review and sign paperwork electronically. As always, our services are delivered with care and privacy.

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Michael J. Labellarte, MD

Mark A. Riddle, MD

Abstract

The diagnosis of childhood psychosis raises a host of unresolved problems, despite the Diagnostic and Statistical Manual Of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) giving identical symptoms and definitions for children, adolescents, and adults. The fantasy lives of children, and issues of developing language and cognition (including retardation), all impair diagnostic accuracy, particularly when differentiating between childhood-onset schizophrenia (COS) (≤12 years), bipolar affective disorder, major depressive disorder, and even obsessive-compulsive disorder and attention-deficit/hyperactivity disorder: the catch-all classification, psychosis not otherwise specified (PNOS), is always available for conundra that prove unsolvable. Typical if nonpathognomonic features include neurocognitive difficulties. Multiple screening instruments and specialized versions of semistructured diagnostic interviews are available. Although smooth-pursuit eye-tracking movements may prove a genetic marker for COS, etiologies are likely to be oligogenetic rather than related to a single gene. No specific biological markers or neuroimages have been identified. As such, psychoses may be indicative of a more general pattern of brain dysfunction. Drug treatments are largely based on the adult literature because of a dearth of controlled data below age 18. There are still no rigorous studies of psychosocial treatments and psychotherapy specific to childhood psychosis.

Keywords: childhood-onset schizophrenia, diagnosis, psychosis in children, psychopharrnacological treatment, psychosocial treatment

Abstract

El diagnóstico de la psicosis infantil da origen a un sinnúmero de problemas no resueltos, a pesar del Texto Revisado del Manual Estadístico de Trastornos Mentales en su cuarta versión (DSM-IV-TR) que entrega síntomas y definiciones idénticas para niños, adolescentes y adultos. Tanto la vida imaginaría de los niños como los temas del desarrollo del lenguaje y la cognición (incluido el retardo) dificultan la precisión diagnóstica, particularmente para diferenciar entre la esquizofrenia de inicio infantil (Eli) (≤12 años), el trastorno afectivo bipolar, el trastorno depresivo mayor, e incluso el trastorno obsesivo compulsivo y el trastorno por déficit de atención con híperactívídad. La amplía clasificación que incluye las psicosis no especificadas en otro lugar está siempre disponible para resolver dificultades que parecen insolubles. Especialmente en las Eli, las características típicas, aunque no patognomónicas incluyen las dificultades neurocognitivas, las que están presentes a menudo en los probandos desde una edad precoz y también en el 30% de los padres no psicóticos. Se dispone de diversos instrumentos de evaluación y de versiones especializadas de entrevistas semies-tructuradas principalmente para adultos. Aunque los movimientos de seguimiento ocular pueden representar un marcador genético de la Eli, las etiologías parecen ser más bien olígogenétícas que debidas a un gen único. Se han identificado marcadores biológicos y neuroimágenes no específicos. Estas psicosis pueden traducir, por lo tanto, un patrón más general de dísfunción cerebral. Los tratamientos con fármacos se utilizan ampliamente, al igual que en los adultos, a pesar de una escasez de estudios controlados en menores de 18 años. Tampoco se cuenta con investigaciones rigurosas de tratamientos psícosocíales o psicoterapias específicas para las psicosis infantiles.

Résumé

Le diagnostic des psychoses de l'enfant soulève une multitude de problèmes non résolus bien que le Diagnostic and Statistical Manual Of Disorders, 4 e édition. Textes Révisés (DSM-IV-TR) en donne des symptômes et des définitions identiques pour les enfants, les adolescents et les adultes. La vie imaginative des enfants d'une part et les problèmes de développement du langage et de la cognition (y compris le retard) d'autre part perturbent l'exactitude du diagnostic, en particulier lorsqu'il s'agit de différencier la schizophrénie survenant dans l'enfance (Childhood-onset schizophrenia, COS) (≤12 ans), les troubles affectifs bipolaires, les dépressions sévères, voire les troubles obsessionnels compulsifs et les troubles à type de déficit de l'attention/hyperactivité ; la classification fourre-tout, représentée par la psychose non autrement spécifiée (PNAS), est toujours disponible pour les cas énigmatiques qui se révèlent insolubles. Les tableaux typiques ou non pathognomoniques, en particulier dans les COS, incluent les difficultés neurocognitives souvent présentes chez ces patients à partir du plus jeune âge mais également chez 30% des parents non psychotiques. De nombreux examens de dépistage et des versions spécialisées d'interviews diagnostiques semi-structurées pour adultes sont disponibles. Bien que les mouvements oculaires sans à-coups au cours du test de poursuite oculaire puissent constituer un marqueur génétique de COS, les etiologies semblent être plutôt polygénétiques que provenant d'un seul gène. Aucun marqueur biologique ou de neuro-imagerie spécifique de COS n'a été identifié. De telles psychoses pourraient être un indicateur d'un tableau plus global de dysfonctionnement cérébral. Les traitements médicamenteux sont globalement les mêmes que chez l'adulte malgré un manque de données contrôlées en dessous de 18 ans, et nous ne disposons toujours pas d'études rigoureuses sur les traitements psychosociaux et la psychothérapie spécifique dans les psychoses de l'enfant.

Psychosis presenting in childhood and adolescence has been a controversial topic throughout the history of the field of child psychiatry because of the conundrum of diagnostic clarity. As the necessity of diagnostic accuracy informs treatment as well as prognosis, an important question is whether the various psychoses of childhood are contiguous with the adult forms, or whether the symptoms labeled as psychotic in youth, particularly in prepubertal children, are exactly the same as those seen in adults. Historically, the definition of psychosis in children and adolescents has been particularly vague because of confusion regarding the developmentally appropriate role of imagination and fantasy in children and adolescents with and without psychiatric disorders. Formulations of "childhood psychosis" and psychosis were originally conceptualized as part of the spectrum of the pervasive developmental disorders, but currently, symptoms of psychosis and definitions of psychotic disorders do not differ for children, adolescents, or adults in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR)

The word "psychosis" applies to a state of being (ie, a psychotic state) as well as distinct diagnostic entities. The psychotic symptoms described in DSM-IV-TR include disorganization or gross disturbance of thought form or speech, thought content, or behavior, or extreme negativism. A psychotic symptom, or symptom cluster, is associated with a specific disorder as defined by a certain number of symptoms occurring over a circumscribed duration of time with demonstrated impairment. Hallucinations and delusions are usually thought to establish the diagnosis of psychosis. However, neither of these symptoms are pathonomonic of psychosis, as they can occur in other organic medical or neurological conditions, such as dementias or complications of seizure disorders. Normal children with active fantasy lives can often misperceive their thoughts as actual events and can insist in a firm way that a thought or a dream actually occurred, which would seem to meet the definition of hallucination and delusion.

Schizophrenia is perhaps the best studied of the adult psychiatric disorders. Its symptoms and phenomenology are well established, and there is a comparative wealth of neuroimaging, genetic, and neurocognitive research that informs the understanding of this illness. When the criteria are applied to older adolescents, an age group when first episodes often occur, the diagnosis is often reliable. However, in the younger age group, the issues of developing language and cognition interfere with the dependability of diagnostic accuracy. The adult form of schizophrenia is not a monadic entity, but rather appears to be a collection of etiologically distinct disorders with similar clinical presentations. No consistent or gross neuropathology that identifies the illness.

These issues also apply to bipolar affective disorder (BPAD). The template of symptoms and presentation can apply easily to older adolescents as well as adults, but the situation is less clear in younger children.

Because of variability of symptom presentation, psychotic symptoms that can occur within the spectrum comprising childhood-onset schizophrenia (COS, age of onset (≤12 years), eg, schizophreniform disorder, schizotypal disorder, and schizoaffective disorder, are difficult to distinguish from psychotic and nonpsychotic symptoms related to BPAD and major depressive disorder (MDD). Psychotic symptoms in children and adolescents need to be differentiated from other, intense, repetitive, but nonpsychotic phenomena, such as obsessions related to obsessive-compulsive disorder (OCD), anticipatory anxiety related to non-OCD anxiety disorders, rumination related to depression, perseverative thoughts related to developmental disorders, simple disorganization related to attention-deficit/hyperactivity disorder (ADHD), and overvalued ideas. In addition, language deficits and cognitive deficits related to mental retardation may suggest psychosis in nonpsychotic children. Furthermore, nonspecific symptoms, such as anxiety, distractibility, and irritability, may precede a psychotic break and confuse diagnosis based on course of illness. Psychosis not otherwise specified (PNOS) is intended to classify psychotic symptoms not associated with COS, BPAD, or MDD. Accurate and reliable diagnosis of psychosis during childhood remains elusive, and is indicative of the necessity for more thoughtful study.

Prevalence

Sparse epidemiological data suggest that psychosis is rare in children. Schizophrenia with onset during middle to late adolescence is fairly common, with 1% prevalence, compared with the extremely rare COS with a prevalence of 0.2 to 0.4/10 000. The largest study of COS to date, involving 1400 national referrals to the National Institute of Mental Health (NIMH) over 10 years, identified 260 children with psychosis. Only 71 patients met criteria for COS at study entry, whereas only 54 children retained the diagnosis of COS (Rapoport JL, personal communication, 2000). In contrast, MDD may occur in 1% of children and 5% of adolescents, whereas BPAD occurs in 1% to 2% of adolescents. Mood disorders with psychosis arc considerably rarer in children and adolescents. The prevalence of psychosis NOS and BPAD in children is hard to ascertain because of controversy about validity.

Phenomenology

Childhood-onset schizophrenia

As with schizophrenia diagnosed at any age, COS presents with two types of symptom clusters, positive psychotic symptoms and negative psychotic symptoms. Positive symptoms (phenomena that are present and should not be) in children include gross disturbance of thought process or thought content, whereas delusions likely appear with increasing developmental age. Negative symptoms (phenomena that are not present and should be) include flat affect, ancrgy, and paucity of speech and thought. Prepubertal children with psychosis seem to have less systematic delusions and lower incidence of catatonic symptoms, but are capable of exhibiting hallucinations, disordered thought process, and flattened affect. Insidious course of COS and onset prior to age 12 years are predictors of a more serious outcome. Other features of COS that contribute to poor outcome include severity of positive and negative symptoms in acute episodes, lower cognitive functioning, and premorbid dysfunction in language, motor development, and social relatedness.

Bipolar disorder

The clinical picture of pediatric BPAD ranges from symptoms resembling severe ADHD to symptoms resembling paranoid schizophrenia. Children with BPAD often initially present with either rapid cycling or mixed state symptoms rather than an insidious onset as described with COS. Children and adolescents with mania present with pressured speech, racing thoughts, elation, and increased risk-taking activities, which may include developmentally inappropriate or situationally inappropriate sexuality. When BPAD has first onset during adolescence, psychosis is typically the presenting symptom and an adult-like cycling pattern follows. Grandiosity, a hallmark symptom of BPAD at any age, may be disguised by developmental age, as prepubertal children with BPAD appear severely oppositional instead of obviously grandiose. Unfortunately, the clinical distinction between the grandiosity of BPAD and the paranoia of schizophrenia is often too hard to distinguish. Mood symptoms, such as euphoria or irritability, may also be disguised by developmental age. One researcher described poorly formed euphoria in manic adolescents that resembles a carefree, "spacey," or "delirious-like" quality that may present as disordered thought process (Popper C, personal communication, 2001). Interpersonal difficulties may exist secondary to symptoms associated with BPAD; however, children with BPAD do not seem to have the social withdrawal or the impoverished social relatedness seen in COS. While these children may present with language disorders or learning disabilities, they do not appear to have the extent of deficits seen in children with schizophrenia. Children and adolescents with BPAD involving severe mood instability have a more chronic and treatmentrefractory course then adults. Over half of all bipolar adolescent patients with prolonged episodes show significant functional impairment in the long term compared with their premorbid state. When children with premorbid social withdrawal and poor interpersonal relationships were compared in terms of diagnosis, children with BPAD had lower rates of positive and negative symptoms at 1-year follow-up than children diagnosed with schizophrenia or schizoaffective disorder.

Major depression

Flat affect related to psychosis is often difficult to distinguish from severely depressed or restricted affect at any age; similarly, anergy of psychosis may be hard to distinguish from psychomotor retardation of depression. Children who present with a psychotic depression may also appear to have impoverished thoughts and social withdrawal; however, the mood symptoms are expected to improve with resolution of the episode. In contrast, the negative symptoms of schizophrenia may not improve with resolution of the episode. In children presenting with psychosis in the context of depression, 50% to 60% will develop BPAD, and their risk for suicide is markedly increased.

Schizoaffective disorder

As the name implies, schizoaffective disorder shares many symptoms with the affective disorders, which can complicate the diagnosis. In the initial phases of psychotic illness in children and adolescents, affective symptoms related to adjustment and demoralization may overshadow the presence of psychotic symptoms. According to DSM-IV-TR, delusions or hallucinations of 2 weeks' duration must occur in the absence of mood symptoms to distinguish schizoaffective disorder from a mood disorder with psychotic features. Traditionally, the diagnosis of schizophrenia has relied on the presence of bizarre hallucinations or delusions instead of mood-congruent hallucinations or delusions related to BPAD or MDD. However, the determination of "mood congruent" at times appears too subjective. For instance, youngsters who initially present with mood-incongruent hallucinations, marked thought disorder, and paranoia have later been diagnosed with BPAD as prominent mood cycling appeared. In contrast, some children initially diagnosed with schizoaffective disorder on the basis of prominent mood symptoms later develop significant symptoms of thought disorder, while the mood symptoms only accompany the psychotic episodes. Schizoaffective disorder is associated with the poorest outcome and chronic impairment in children.

Psychosis not otherwise specified

The diagnostic category of PNOS may be used by default when full criteria are lacking for psychotic disorders in the schizophrenic or mood disorders spectrum. There are divergent opinions about the validity of PNOS. The diagnosis is sometimes given to children who present with self-reports of hallucinations and/or delusions in the absence of a formal thought disorder, severe mood disturbance, or other clinical context suggesting a state of psychosis. The validity of self-reported hallucinations and delusions was questioned in a study of children diagnosed with PNOS with brief psychotic episodes and hallucinations, but without formal thought disorder or psychotic behaviors. One group of researchers found high incidence of physical/sexual abuse in children diagnosed with PNOS, and suggested a scenario of dissociative symptoms accounting for the self-report symptoms. The NIMH study group decided that children who did not meet criteria for COS were better served with a diagnosis of PNOS, and described a subgroup called multidimensionally impaired disorder (MDI), which has also been called multiplex developmental disorder, for a group of children presenting with brief transient psychotic symptoms, emotional lability, normal social interest with poor interpersonal skills, and multiple deficits in information processing. Preliminary follow-up suggests that this cohort does not progress to a more severe psychotic disorder; however, there is a high rate of schizophrenia spectrum disorders in their first-degree relatives. There are also similarities in brain morphologic abnormalities between the MDI group and children with schizophrenia.

Schizotypal disorder

The inclusion of a personality disorder in a discussion of childhood psychosis reflects the controversy of psychosis in children. Researchers and clinicians are generally uncomfortable diagnosing personality disorders in the pediatric population, and the distinction of state versus trait symptoms remains controversial at all ages. Poor social relations, odd thinking, and perceptual problems, such as illusions and ideas of reference without actual psychosis, are the characteristics of schizotypal disorder as defined in adults. In one study of adolescents with schizophrenia, the social skills of the adolescents mirrored those reported in adults with schizotypal personality disorder. These adolescents had more difficulty in labeling positive emotions than other emotions and performed worse than a control group on social roleplaying tasks. Neuropsychological deficits correlated with the presence of negative signs in adolescents with schizotypal personality disorder. Subjects who exhibited more negative signs had a high association with dysmorphia and lower cognitive ability, suggesting early developmental instability.

Features associated with psychosis in children

Neurodevelopmental delays

Children with COS have been described as having developmental differences as early as infancy. These children show abnormal or delayed development including gross and fine motor delays, hypotonia, poor coordination, sensory integration difficulties, and language delays. These children also exhibit stereotypies, such as hand flapping, perseverative smelling, and touching, ie, symptoms typically seen in children with pervasive developmental disorders. These children also have attcntional problems, distractibility, and other disinhibitions of executive functioning, which meet criteria for ADHD, possibly an indicator of poor prognosis. Children who have other schizophrenia spectrum disorders also have a history of developmental delays and cognitive deficits.

Children with COS have a high incidence of language disorders, not only expressive and receptive, but also with specific impairments and deficits that directly contribute to thought disorder and disorganization. Children with delayed expressive and receptive language development were able to catch up with their peers, although they continued to have deficits in their linguistic capacities. Children with schizophrenia use fewer linguistic or cohesive devices to connect ideas expressed within and across sentences compared with a sample of children without schizophrenia. They also exhibit decreased use of conjunctions, referential cohesions such as pronouns, lexical cohesions illustrated by the use of antonyms and synonyms, and increased use of ellipses (eg, deletion of words or phrases whose referent is located in the previous utterance). Such difficulties in conveying language lead to three components of thought disorder: exophora, which is the diversion of speech from the context of a conversation to the immediate environment; loose associations or topic maintenance; and cohesion. In a larger study of schizophrenic children who were compared with a control group, children with COS are distinctly impaired in their ability to organize their thinking, present adequate reasoning, and prepare the listener for a change in the topic of conversation above and beyond differences in mental age. Children with COS make more references in their conversation to the immediate situation rather than to the context of the conversation. They are also unable to use clarifying references on a consistent basis so that the listener can understand the context. These deficits may be related to the freedom from distractibility factor of the Wechsler Intelligence Scale for Children-Revised (WISC-R) rather than global intellectual deficits. Subjects with COS and premorbid speech and language impairments had a higher familial loading for schizophrenia spectrum disorders as well as more obstetrical complications, and the relatives of these children had worse smooth-pursuit eye-tracking movements. These data suggest that the pathophysiology of schizophrenia involves abnormal development of language-related functions.

There is little in the literature about developmental difficulties in children with psychotic mood disorders. Children with early onset BPAD show evidence of delayed language, social, and motor development.

Neurocognition

Children with COS as a group appear to have lower IQ scores than the normal population. It has been speculated on the basis of neurocognitive studies that these lower IQ scores reflect prodromal neurocognitive deficits, rather than exposure to environmental factors. Cognitive functioning, such as attention, memory, and motor functioning, has been found to be abnormal in many schizophrenic subjects. Since the above cognitive findings are similar to findings in children with ADHD, researchers compared these two groups with each other and with normal controls. Adolescents with schizophrenia showed more deficits in visual memory than ADHD or normal controls. In addition, they had lower scores in abstraction-flexibility, spatial organization, and motor function. Subjects with ADHD had significantly worse auditory processing and distractibility which may indicate selective impairments in visual memory specifically related to schizophrenia. In addition, the subjects with COS had more difficulty on tests requiring shifting of sets, which is seen as a function of working memory. Furthermore, it has been reported that subjects can show impairments on the span of apprehension task when they are acutely psychotic, as well as intcrepisode. This neurocognitive test is a measure of thought disorder. Deficits in both verbal and spatial working memory lead to limited information-processing capacity in children with COS.

The IQ of adolescent subjects with COS was studied to determine whether the postpsychotic decline in full-scale IQ is secondary to a dementing process or whether it reflects a failure to acquire new information and skills. Those areas in which scores declined significantly postpsychosis were picture arrangements, information, and block design. This research group also used magnetic resonance imaging (MRI) to detect changes in the brain anatomy and found a significant correlation between decrease in hippocampal volume with a smaller increase in the raw score on the information subtest. The authors concluded that the IQ decline during adolescence of subjects with COS is secondary to an inability to acquire new information and skills.

Studies of the families of children with COS indicate first-degree relatives and other relatives have similar neurocognitive difficulties. Nearly 30% of nonpsychotic parents of COS probands showed neurocognitive impairments. Children of schizophrenic parents, affectively ill parents, and psychiatrically normal parents have been studied to search for predictors of future illness. Measures of attention deviance, verbal memory, and gross motor skills were utilized based on studies of relatives of adult psychiatric probands. This report suggests that these may be phenotypic indicators, as the deficits were present before clinical symptoms, independent of the illness date, more prevalent in relatives of schizophrenic patients than in comparison subjects, and comparatively specific to the risk for schizophrenia versus the risk for affective disorders. Verbal memory and attention were tested over several evaluations and found to have longitudinal stability and persistence of impairment. These neurobehavioral deficits may represent a prodromal indicator of risk if they are sustained.

Children with COS and children with PNOS shared a similar pattern of generalized cognitive deficits including deficits in attention, learning, and abstraction, which are also observed in adult patients with schizophrenia. Learning disabilities and language disorders occurred in children with BPAD during the illness and between episodes. There was a significant discrepancy between the verbal IQs of children of bipolar parents and normal controls.

These studies viewed as a whole would suggest that the syndromes of the psychoses, and in particular that of COS, are indicative of a more general pattern of brain dysfunction. If these findings can be replicated, then they would contribute to a theory of neurodevelopmental pathogenesis that investigators in adult psychiatry are debating.

Diagnostic assessments

In general, the psychiatric assessment of psychosis in children follows the model for comprehensive psychiatric assessment of children and adolescents, which includes a medical and psychiatric history, mental status examination, physical examination, and standardized psychiatric assessment instruments. The psychiatric history focusing on psychotic symptoms must carefully delineate family history, course of illness, and comprehensive review of symptoms. Particularly, the extent, nuance, and context of the psychotic phenomena must be clarified to identify mood congruence, mood incongruence, bizarre content, and stability of symptoms. Most importantly, psychosis must be ruled out when the phenomenology does not hold under close diagnostic scrutiny. While no medical assessment procedure is diagnostic of COS or any other psychiatric condition associated with psychosis, use of imaging studies, electroencephalography, and laboratory tests may help detect medical conditions associated with psychosis in children and adolescents.

Screening instruments

Before a formal diagnosis is established, and in addition to using a reliable and valid structured or semistructured interview, screening instruments may help identify psychiatric disorders associated with psychotic symptoms. Screening instruments for depression in children and adolescents include the Children's Depression Inventory, which has normative data for children and adolescents. The Young Mania Rating Scale (Y-MRS) has normative data for adolescents with BPAD. There is no screen with normative data for children with schizophrenia or other psychotic disorders.

Semistructured diagnostic interviews

The stringent use of adult criteria to delineate psychotic symptoms in children and adolescents, and the development of reliable and valid rating instruments to clarify the presence and severity of these symptoms suggest that some children with psychotic illness are exhibiting an early manifestation of the adult form of the illness. Homogeneous diagnostic criteria have demonstrated that COS can be diagnosed using adult standards, and studies using DSM-III and DSM-III-R criteria confirmed these findings. Rigorous application of DSM-III criteria can accurately diagnose childhood BPAD. Standardized interviews, such as the Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime Version (K-S ADS-PL), the Diagnostic Interview for Children and Adolescents (DICA), and the Diagnostic Interview Schedule for Children (DISC) are reliable and valid measures for diagnosing MDD, BPAD, COS, and other psychiatricdisorders in childhood that present with psychosis. The K-SADS is the probably the gold standard. Currently, specialized versions of the K-SADS, such as the Washington University at Saint Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS), offer the advantage of focused diagnosis in prepubertal and early adolescent manifestations of mania with and without rapid cycling.

The real importance of the standardized diagnostic instruments is establishing diagnostic stability, symptom dimensions, clinical characteristics, and predictive validity. Long-term studies utilizing the same diagnostic tests over time indicate that there is stability of symptoms with the differentiation of features of the various illnesses and establishment of the clinical characteristics of the individual illnesses. A more recent example of symptom predictability involved a prospective study of a birth cohort (n=761), who were given structured diagnostic interviews at age 11 years and then again at 26 years. The group was divided into those who had weak symptoms and strong symptoms based on the reports of hallucinations or delusions, their severity, and the presence of other symptoms meeting criteria for a psychotic disorder. No children were diagnosed with COS. Those children who reported strong symptoms were 16 times more likely to have a schizophreniform diagnosis by age 26 years. Furthermore, 90% of the strong symptom children had occupational and social dysfunction as adults. Even those children who reported weak symptoms were significantly more likely to meet diagnostic criteria for adult schizophreniform disorder. Forty-two percent of diagnosed schizophreniform cases at age 26 interviews were associated with the presence of either weak or strong symptoms at age 11 years. The authors suggest that children experiencing hallucinations or delusions in the absence of a thought disorder may be experiencing prodromal changes, which could lead to the onset of frank psychotic symptoms.

Rating scales

Once a diagnosis has been established, rating scales are useful for monitoring symptoms of psychotic disorders during treatment and over time. Useful pediatric rating scales include the Child Depression Rating Scale (CDRS) and the Kiddie Version of the Positive and Negative Symptoms of Schizophrenia (K-PANSS) for COS. Rating scales such as the Clinical Global Impressions-Severity and Improvement (CGI-S and CGI-I) and the Clinical Global Assessment of Function (CGAF) are also useful to measure severity of impairment both at diagnosis and over time for any psychiatric disorder.

Research that may inform diagnostic testing in the future

Genetics

Evidence from twin, family, and adoption studies indicate genetic factors play an etiological role in schizophrenia. A possible susceptibility gene for schizophrenia is localized in the region 8p22-8p21. Studies of children with velocardiofacial syndrome (VCFS) suggest that chromosomal region 22qll.2 may have a role in development of schizophrenia because the autoso mal dominant syndrome sometimes leads to chronic paranoid schizophrenia. An ongoing study at the NIMH in 47 subjects with COS demonstrated that 5 patients (10.6%) had cytogenetic abnormalities: 3 patients had VCFS, 1 had Turner's syndrome (involving a deletion of part of the long arm of one X chromosome 46,X,i[Xq24]), and 1 had a balanced translocation of chromosomes 1 and 7.

Smooth-pursuit eye-tracking movements have been proposed as a possible genetic marker for schizophrenia due to the association of eye -tracking pursuit abnormalities in adult-onset schizophrenia before and after treatment, in family members of schizophrenic probands, and in children of schizophrenic parents. Unique eye-tracking findings in schizophrenia include specific difficulties in the high rates of catch-up saccades and the failure to suppress saccadic anticipation of target motion. In a study of children with COS compared with patients with adult-onset schizophrenia and their family members, smooth-pursuit eye-tracking movements and P50 eventrelated potential predicted bilineal genetic loading. On the basis of results of family studies and early genetic studies, oncogenetics rather than genes of major effect may better explain complex psychiatric disorders such as MDD, BPAD, and schizophrenia.

Biological markers

Adolescents with schizotypal disorder had an increase in minor physical anomalies including abnormal hair whorls, larger or small head circumference, epicanthal folds, hypertelorism, asymmetrical or low-seated ears, curved fifth finger, webbed toes, and other dysmorphic features, dermatoglyphic asymmetries, and higher mean Cortisol values. Children and adolescents with COS had higher rates of skin conductance responses and heart rate compared with controls; however, their skin conductance level was marginally lower and declined more slowly over time than the controls. Impaired skin conductance rates, more erratic habituation, and smaller anticipatory heart rate responses to stimuli were also described. Cerebrospinal fluid monoamine metabolite concentrations in COS subjects 6 weeks after clinically effective haloperidol or clozapine treatment did not differ from drug-free levels. An increase in homovanillic acid during week 2 of treatment and a decline around week 6 were also apparent. The haloperidol treatment group also exhibited a substantial increase in serum prolactin levels. All of the above findings are consistent with findings with schizophrenia of later onset.

Neuroimaging

Magnetic resonance imaging

The NIMH study group on COS has reported sequential MRI results suggesting brain anatomy changes consistent with adult studies. On the initial scan, children with COS have larger lateral ventricular volumes as well as smaller cerebral volumes, whereas the temporal lobe volumes appear relatively spared. A strong association between smaller cerebral volumes and negative symptoms was reported.

Adolescents with COS also had larger globus pallidus, caudate, and putamen volumes at the initial scan. When the subjects were scanned 1 to 4 years later, subjects with COS exhibited decreases in total cerebral volume, and globus pallidus, caudate, and midsagittal thalamic volumes associated with significant increases in ventricular volume as compared with the control group, which had similar findings, but no changes in ventricular volumes or thalamic anatomy. Subjects with COS who were treated with atypical neuroleptics had even greater decreases in the globus pallidus and caudate volumes on rescan. The progressive changes in ventricular volumes and thalamic area correlated significantly with each other, and the increases in ventricular volume were significantly related to prepsychotic adjustment problems rated on the premorbid adjustments scale and Brief Psychiatric Rating Scale (BPRS). A 2-year follow-up study of subjects with COS showed significant decreases in the volumes of the right temporal lobe, bilateral superior temporal gyrus, posterior superior temporal gyrus, right anterior superior temporal gyrus, and left hippocampus compared with controls. The decline in the right posterior superior temporal gyrus volume was associated with high scores for positive symptoms.

Of subjects with COS, 12.5% had enlarged cavum septi pellucidi consistent with a rate found in adult-onset schizophrenia. The researchers posited that dysgenesis of the hippocampus or the corpus callosum could lead to larger than normal cavum septi pellucidi. In a 2 year follow-up study of adolescents with COS, healthy controls showed decrease in cortical gray matter in the frontal and parietal regions, but patients with very earlyonset schizophrenia had a fourfold greater decrease in cortical gray matter volume, not only in the frontal and parietal areas, but also in the temporal lobe volume. The decreases in frontal and temporal gray matter are consistent with MRI findings in adult-onset schizophrenia. Using whole-brain voxel-based morphometric analyses in both children and adolescents with COS, the volume of the posterior lateral ventricles was significantly increased rather than the anterior regions. In a controlled comparison of children with COS and children diagnosed with PNOS, the two groups were shown to have similar brain volumes. However, children with COS had a smaller midsagittal thalamic area compared with controls and PNOS. Neither group showed a decrease in the volume of the temporal lobe.

Magnetic resonance spectroscopy

Magnetic resonance spectroscopy ( ¹H-MRS) performed on subjects with COS showed significantly lower N-acetylaspartate to creatine ratios bilaterally in the hippocampal area and the dorsolateral prefrontal cortex compared with normal controls, suggesting malfunction or neuronal damage. Findings of reduced N-acctylaspartate in the frontal areas were replicated. Elevated glutamate/glutamine levels in both frontal lobes and basal ganglia were detected in 10 children with BPAD. These children also had elevated lipid levels in the frontal lobes, but not in the temporal areas. The significance of the elevated lipids is yet to be determined, but an increase in excitatory amino acids could be associated with manic behaviors.

Ultrasound

In examining the ventricular size of fetuses of mothers with schizophrenia, mild ventriculomegaly was apparent and associated with older mothers and a shorter gestation.

Psychopharmacological treatment

This section presents pharmacological approaches to treating psychosis in children, which can be divided into three categories: (i) COS; (ii) psychosis related to depression; and (iii) psychosis related to bipolar disorder. Neuroleptics may be needed for acute management of substance-induced psychosis or psychosis related to a general medical condition or delirium, but the details are beyond the scope of this manuscript. PNOS that cannot be better conceptualized in children and adolescents as part of the schizophrenia spectrum or a mood disorder may be better managed with observation and psychosocial interventions, unless severe aggression or agitation warrants acute use of a neuroleptic.

Treatment of childhood-onset schizophrenia

The majority of data on neuroleptic treatment of schizophrenia is from adult studies of typical and atypical neuroleptics. Several neuroleptics are Food and Drug Administration (FDA)-indicated for psychotic disorders in children and adolescents, but none of the indications is based on adequate controlled treatment data in individuals below age 18 years : chlorpromazine (Thorazine®) for ages ≥6 months; thioridazine (Mellaril®) for ages ≥2 years; and haloperidol (Haldol®) for ages ≥3 years. Only two published controlled studies of typical neuroleptics demonstrated efficacy (both included haloperidol; one also included loxitane) in the treatment of COS. Only one published controlled study of an atypical neuroleptic (clozapine) demonstrated efficacy in the treatment of COS. Despite the presence of efficacy data, haloperidol, loxitane, and Clozaril are not considered to be first-line treatments of COS or any psychosis in children and adolescents because of their adverse effect (AE) profiles. Atypical agents, such as risperidone and olanzapine, are more likely first choices because of easier tolerability, although weight gain has emerged as a problematic AE.

Typical, neuroleptics

Both haloperidol (2-16 mg/day) and loxitane (10-200 mg/day) proved superior to placebo in a 4-week treatment study of 75 adolescents (aged 13-18 years) with acute schizophrenia. All treatment groups showed noticeable improvement based on ratings on the BPRS; subjects rated as severe or very severe tended to show more improvement on active medication. Sedation occurred in more than half the subjects on active drug: about 50% on haloperidol and about 80% on loxitane experienced sedation. Extrapyramidal symptoms (EPSs) occurred in about 70% of treated subjects. Haloperidol later proved superior to placebo based on Clinical Global Judgment and BPRS ratings in a 10-weck, double -blind, crossover study of 16 children (aged 5-11 years) with schizophrenia. The dosage of haloperidol ranged from 0.02 to 0.12 mg/kg/day, or 0.5 to 3.5 mg/day. As expected, EPSs and sedation were the most problematic AEs.

Atypical neuroleptics

Clozapine proved superior to haloperidol for treating positive and negative psychotic symptoms in a doubleblind, 6-week study of 21 adolescents with schizophrenia. As with prior adult studies of clozapine, AEls of concern included seizures and neutropenia. Several open studies of clozapine in COS also demonstrated neutropenia, as well as other AEs, such as sedation and drooling.

A review of 15 studies of clozapine in COS, including controlled and open data, suggested that clozapine had a greater antipsychotic effect than typical antipsychotics during acute episodes, more improvement in chronic forms of the illness with prominent negative symptoms, and "good tolerability" with fewer reports of EPS. In another review of atypical neuroleptics (including clozapine, risperidone, olanzapine, sulpiride, tiapride, amisulpride, remoxipride, and clothiapine) for COS, clozapine seemed to have the most robust effect on the symptoms of COS, and risperidone and olanzapine also had utility in the treatment of COS. Overall, clozapine remains a tertiary treatment option for COS due to its association with potentially dangerous AEs, including agranulocytosis, seizures, tachycardia, and arrhythmia.

Risperidone has proven useful in the treatment of a number of pediatric disorders, but no controlled treatment study of risperidone has been performed for COS. Open studies of risperidone (up to 10 mg/day) have been promising for adolescents and children and adolescents with COS based on the CGI-I, BPRS, and KPANSS. In both studies, the AEs included sedation and EPS. In a controlled study of risperidone for adults with first-onset schizophrenia, doses of 2 to 4 mg/day were superior to 5 to 8 mg/day. By extrapolation, the open studies of pediatric patients described above likely utilized too high a dose of risperidone. The only published controlled data on risperidone use in pediatric subjects is a treatment study of adolescents with conduct disorder. Weight gain has been the most problematic AE in two open-label studies of risperidone treatment of children and adolescents with aggression and other psychiatric problems.

There have been no published controlled studies of olanzapine in COS. Open-label studies of olanzapine for COS indicate a positive impact on psychotic symptoms, and report primary AEs including weight gain, sedation, and akathisia, ie, a profile similar to that reported in adults. A pharmacokinetic study suggested similar olanzapine exposure (defined as area under the concentration-time curve) in children and adolescents with COS compared with adults. The authors suggested that 10 mg/day olanzapine is the target dose for treating psychosis in pediatric patients, consistent with dosing in adults.

There have been no published controlled studies of quetiapine in COS. A pharmacokinetic study of quetiapine in adolescents with psychotic disorders demonstrated slightly higher quetiapine exposure in adolescents than in adults. Quetiapine had a beneficial effect on positive and negative symptoms and was well tolerated; the most common AEs were insomnia and postural tachycardia. Ziprasidone was released on the US market in March 2001. No controlled data on ziprasidone treatment for COS have been published. However, a placebo-controlled study of ziprasidone (5-40 mg/day) was carried out in 28 children and adolescents (aged 7-17 years) with Tourette's syndrome. Somnolence and EPSs were rare and resolved with dose decrease: 1 subject had brief but severe somnolence on 40 mg/day, and 1 subject experienced akathisia on 40 mg/day. No significant weight gain was noted in subjects.

Adverse effects

The relative impact of neuroleptics at various receptor types determines the AEs. Depending on which dopamine receptor D ₂ tracts are blocked, AEs of neuroleptics include EPS (nigrostriatal pathway), increased negative symptoms (mesocortical pathway), and hyper prolactinemia (tuberoinfundibular pathway). Prolactin levels were studied in 35 children and adolescents with COS treated with haloperidol, olanzapine, and/or clozapine. After 6 weeks of treatment, all subjects on haloperidol and 70% of subjects on olanzapine showed increased prolactin above the upper limits of normal, whereas no subjects on clozapine showed increased prolactin level. In addition to an impact on D ₂, typical neuroleptics have an anticholinergic effect (muscarinic acetylcholine receptor, M ₁) including sedation, dry mouth, blurry vision, and constipation; an antihistaminergic effect (histamine receptor, H ₁) including sedation and weight gain; and antiadrenergic effects (adrenergic receptor, α ₁ including dizziness and hypotension.

Atypical neuroleptics also have capacity to impact M ₁, H ₁₍ and α ₁ receptors, and may additionally block D ₁, D ₂, and D ₄, as well as the serotonin (5-hydroxytryptamine) receptors 5-HT ₃,5-HT ₂C, and 5-HT ₃. In vitro data suggest that the atypical agents have unique receptor blockade selectivity. For instance, clozapine blocks all of the above receptors, whereas risperidone blocks only 5-HT 2A, 5-HT 2C, α ₁, and D ₂ receptors. Serotonergic blockade by atypical neuroleptics appears to modify antipsychotic effect and AEs related to dopamine blockade, and it may have a mood-stabilizing effect. Significant prolongation of QT C duration (Q-T interval adjusted for rate) is associated with butyrophenoncs, phenothiazines, and pimozide, and does not appear to be clearly associated with any of the atypical neuroleptics. However, electrocardiographic monitoring of QT C intervals is recommended with ziprasidone. lthough atypicals contribute to less EPS, cardiac toxicity, and hyperprolactinemia than typical neuroleptics, atypical neuroleptics are more likely contribute to prominent weight gain and have higher risk for agranulocytosis than typical neuroleptics. Neuroleptic malignant syndrome (NMS) is possible with both typical and atypical neuroleptics.

Treatment of psychosis related to pediatric bipolar disorder

No controlled study of pharmacological treatment for pediatric BPAD with psychosis has been published. The only controlled medication treatment study to date for pediatric BPAD included 25 subjects with concomitant substance-abuse problems. In this study of lithium monotherapy, bipolar symptoms and substance use decreased significantly in subjects treated with lithium. Divalproex, lithium, and carbamazepine each showed a large effect size (Cohen's d>1.00) in an open study 42 children and adolescents (aged 8-18 years) with BPAD based on outcome measures of CGI and Y-M'RS.

A retrospective chart review of risperidone in juvenile BPAD indicated improvement in manic and psychotic symptoms. Open studies of olanzapine in acutely manic children are promising. Because of the robust antimanic effect demonstrated with atypical neuroleptics in adults with BPAD, future controlled pediatric studies of neuroleptics for BPAD are likely.

Treatment of pediatric major depression with psychotic features

No controlled studies of pharmacological treatment of psychosis associated with pediatric MDD exist. To date, only two controlled studies of antidepressants have shown efficacy in treatment of pediatric MDD. Fluoxetine (5-20 mg) proved superior to placebo in a study of 96 children and adolescents with MDD based on CGI and Hamilton Depression Rating Scale (HAM-D). Paroxetine proved superior to placebo in a study of 275 adolescents with MDD, according to HAM-D and CGI rating. An open study of chlorpromazine plus nortriptyline for psychotically depressed adolescents showed some benefit from the combination, however, neither nortriptyline nor chlorpromazine now appear desirable as treatment in pediatric mood disorders or pediatric psychosis because of their side effect profiles.

Psychosocial treatment

To date, there have been no published rigorous studies of psychosocial or psychotherapy treatments specific to the psychoses of childhood. Clinical practice standards include detailed education of the patient and parents about the illness, the provision of supportive psychotherapy during the recovery phase of the acute illness, and practical guidance regarding behavior. Continued supportive work interepisode appears to help patients with social and developmental crises. Clinicians also act as advocates with the parents for their patients with schools and other social agencies to ensure that these children and adolescents can continue with their education and that their specials needs are recognized. Families should be given information about the various patient advocacy groups, such as the National Alliance for the Mentally III.

These groups not only aid on a national and state level to address the mental health needs of family members, but also act as a resource for support as these families struggle with these serious illnesses.

Discussion

COS is the best studied of the psychotic disorders of childhood. The neurobiological studies include neuroimaging, family studies (which point to phenotypic markers), and neurocognitive findings, and strongly support continuity with the adult form of schizophrenia. Further work is needed in describing the neurocognition of children with affective disorders. The affective psychotic disorders including BPAD, while indicating continuity with adult forms, would clearly benefit from a comprehensive study, as has been seen in COS. Hopefully, the controversy over the identification of psychosis and the diagnosis of these valid disorders will narrow the focus. Long-term follow-up studies including genetic and other vulnerabilities, neuroimaging, and neurometabolic studies will inform researchers and clinicians as to the care and treatment of these very ill children. 'there are clearly too few studies of atypical neuroleptics in the pediatric population. The long-term effects of chronic treatment in the developing child are unknown. Careful, well-designed studies of available medications in the various psychotic disorders in order to guide appropriate treatment should be a priority. Novel medications with potential antipsychotic applications, such as dopamine partial agonists, also require pediatric study. The current trend in treatment research of COS involves large controlled treatment studies of atypical neuroleptics for COS. There is also need for studies in the psychotherapi.es and psychosocial treatments to help the patients and their families to manage their illness.

Selected abbreviations and acronyms

ADHD

attention-deficit/hyperactivity disorder

BPAD

bipolar affective disorder

BPRS

Brief Psychiatric Rating Scale

CDRS

Child Depression Rating Scale

CGAF

Clinical Global Assessment of Function

CGI-I

Clinical Global Impressions-Improvement

CGI-S

Clinical Global Impressions-Severity

COS

childhood-onset schizophrenia

DICA

Diagnostic Interview for Children and Adolescents

DISC

Diagnostic Interview Schedule for Children

EPS

extrapyramidal symptom

K-PANSS

Kiddie Version of the Positive and Negative Symptoms of Schizophrenia

K-SADS

Schedule for Affective Disorders and Schizophrenia for School- Aged. Children

MDD

major depressive disorder

MRI

magnetic resonance, imaging

magnetic resonance spectroscopy

OCD

obsessive-compulsive disorder

PNOS

psychosis not otherwise specified

Y-MRS

Young Mania Rating Scale

REFERENCES

32. Done DJ., Crowe TJ., Johnstone EC., Sacker A. Childhood antecedents of schizophrenia and affective illness: social adjustment at ages 7 and 11. [[ PMC free article] [ PubMed] Google Scholar]

50. Hooper S., Courvoisie H., Fine C., Kruck S. Neuropsychological functioning in children with bipolar disorder Presented at the International Neuropsychological Society Meeting. Denver, Co, February 18. 2000 [ Google Scholar]

67. National Institute of Mental Health. CGI (Clinical Global Impression Scale). [ Google Scholar]

69. Kendler KS. Schizophrenia: genetics. In: Sadock BJ, Sadock VA, eds. [ Google Scholar]

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Psychosis in children: diagnosis and treatment

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Michael J. Labellarte, MD Mark A. Riddle, MD The diagnosis of childhood psychosis raises a host of unresolved problems, despite the Diagnostic and Statistical Manual Of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) giving identical symptoms and definitions for children, adolescents, and adults.

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What is obsessive-compulsive disorder?

Obsessive-compulsive disorder (OCD) is an anxiety disorder that can affect children and teenagers. Kids with OCD experience unwanted thoughts, worries or impulses called obsessions. Obsessions are very upsetting and hard to control. Children with OCD develop repetitive actions - called compulsions- to calm the anxiety caused by their obsessions.

Often, compulsions are not connected to obsessions in a realistic way. For example, a child might have an obsessive fear that their parents will be in a car accident. To deal with that fear, they might turn a light on and off five times. Even if they know it doesn't make sense, they feel that the ritual will keep their parents from getting hurt. Professionals call that feeling "magical thinking."

Children as young as five can develop OCD. At that age, they may not even realize that their thoughts and fears are exaggerated or unrealistic.

A child with OCD may hide their rituals until they get to be too overwhelming. They may be able to suppress their rituals at school and then act out when they get home.

Some children suddenly develop OCD symptoms, along with other disturbing symptoms, after they have had an infection, such as a staph infection. This is a disorder called PANDAS or PANS.

What are the symptoms of obsessive-compulsive disorder?

Kids with OCD usually experience both obsessions and compulsions. They use compulsions to control the anxiety that obsessions cause.

Common obsessions that kids experience include:

Fear of contamination (germs, waste, vomit, chemicals, etc.)

Needing everything to be even or symmetrical

Extreme worry about safety, like thinking that the house will burn down or a parent will get hurt

Fear that they might do something violent or terrible

Common compulsions include:

Washing their hands repeatedly

Locking and relocking doors a certain number of times

Lining up objects or touching parts of their bodies symmetrically, like scratching both ears

Counting a certain number of times or repeating something mentally

Repeatedly asking parents for reassurance that something bad isn't going to happen

Compulsions can be thoughts instead of behaviors, so they can be hard to spot. For example, a child's compulsion might be counting to 20 in their head.

How is obsessive-compulsive disorder diagnosed?

To be diagnosed with OCD a child has to have obsessions, compulsions or both. They must get in the way of the child's normal life.

The severity of the symptoms can be measured using a rating scale called Y-BOCS, or the Yale-Brown Obsessive-Compulsive Scale.

How is obsessive-compulsive disorder treated?

The most effective treatment for OCD is a form of cognitive behavior therapy (CBT) called exposure and response prevention.

In this therapy, the therapist exposes the child to small amounts of the thing that usually triggers their obsession. That way, the child gets practice dealing with their anxiety in a safe environment. The therapist helps the child avoid using their compulsion. Over time, the child feels less anxious, and they don't need the compulsion anymore. The therapist can also train the child's family to practice at home.

More severe cases of OCD are often treated with a combination of CBT and medication. The most effective medication for anxiety is SSRIs, or selective serotonin reuptake inhibitors. The medication can reduce anxiety and help the child get more out of therapy. Once kids learn skills in therapy, they can take less medication or stop altogether.

Kids with OCD will often return to their clinician in the years after their treatment for "booster sessions" to freshen up the skills they learned to control their anxiety.

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Quick Guide to Obsessive-Compulsive Disorder (OCD) - Child Mind Institute

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Lo sentimos, la página que usted busca no se ha podido encontrar. Puede intentar su búsqueda de nuevo o visitar la lista de temas populares. Obsessive-compulsive disorder (OCD) is an anxiety disorder that can affect children and teenagers. Kids with OCD experience unwanted thoughts, worries or impulses called obsessions.

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In popular culture, obsessive-compulsive disorder (OCD) is often portrayed through characters who can't bring themselves to step on cracks in the sidewalk, who are germaphobes, or who are obsessed with cleanliness and organization. These "hang-ups" are often played for comic effect.

"There's a huge misconception that OCD is cute and quirky," says Shala Nicely, a licensed professional counselor (LPC) with a practice in Marietta, Georgia, who specializes in treating OCD and related disorders. "There's nothing further from the truth. That [stereotype] keeps people from seeking help. They think they just need to 'get it together' and deal with it."

In reality, OCD can be debilitating, says Nicely, who has lived with the disorder since she was a child. Individuals with OCD are haunted by unwanted and invasive thoughts that are often self-critical, fear-inducing or disturbing. One of the classic portraits of OCD is the person who won't touch a doorknob without a sleeve pulled over their hand out of fear of contracting germs. But that is only the tip of the iceberg when it comes to the different types of compulsions - whether external, such as repeated hand-washing, or internal, such as rumination - that individuals with OCD feel subjected to in order to keep themselves safe.

OCD can be "hell on Earth," Nicely asserts.

"It puts people in absolute misery. It makes people's lives smaller and smaller and smaller," she says. "Having OCD is like living with an abuser 24/7. It's incredibly mean, it's very critical, and [it] can be violent. It is being yelled at by your own brain and you can't get away from it."
The tipping point
Justin Hughes, an LPC who owns a private practice in Dallas, specializes in treating clients with OCD, anxiety and other mental health issues. He says many of his clients seek treatment because they are overwhelmed by intrusive thoughts or because their compulsions and routines are interfering with their daily life - taking up enormous amounts of time and causing them stress or even physical pain. Other clients come to treatment because a parent, spouse or loved one noticed the toll that OCD was taking on the person and expressed concern.

Karina Dach, who specializes in treating OCD and anxiety at her private practice in Denver, says clients sometimes come to counseling knowing that "something doesn't feel right" but without realizing that they have OCD. "They may say things like, 'I feel stuck,' 'My brain won't let me move on,' or 'I can't stop thinking about this or imagining this.' They might feel like something is wrong with them or worry that these thoughts and fears mean something bad about their character or them," explains Dach, an LPC and licensed mental health counselor.

Clients who come to counseling with OCD may be struggling with self-criticism and intense feelings of shame, guilt, anger, worry and fear, Nicely adds. Intrusive thoughts are common with OCD, and for some people, these thoughts can involve the idea that they might somehow end up killing, injuring or sexually molesting someone, including their loved ones. As these thoughts repeat themselves over and over, the individual may begin to believe the content of these thoughts and feel a deep sense of shame or embarrassment.

In fact, clients struggling with OCD may be hesitant to share the worst of their intrusive thoughts because they can involve things that are criminal or dangerous. "Some [individuals with OCD] really do think they might be a closet murderer. They're afraid to share that, [thinking that] they might get in trouble," Nicely says.

Given that insight, Nicely says, counselors should not hesitate to follow up conversations about intrusive thoughts and worries in session by asking clients if there is anything else they have been too scared to share. These clients should be reassured that counseling is a safe and confidential place to share whatever they are going through, Nicely adds.
Obsessions + compulsions
The National Institute of Mental Health reports that an estimated 1.2% of U.S. adults experience OCD each year. This prevalence is higher for females (1.8%) than for males (0.5%). The lifetime prevalence of OCD in the U.S. is 2.3%.

Jeff Szymanski, a clinical psychologist and executive director of the International OCD Foundation, notes that even though the prevalence of OCD is not increasing, mental health practitioners may see more people who struggle with the disorder in their caseloads in the future because of a gradual, general increase in awareness and a reduction of stigma regarding
the disorder.

OCD is characterized by two components: 1) recurring and intrusive thoughts (obsessions) and 2) excessive urges to perform certain actions over and over again (compulsions) to prevent or counteract the recurring thoughts. The types of obsessions and compulsions that individuals with OCD can experience are wide-ranging.

Not all recurring thoughts can be categorized as OCD obsessions, Szymanski stresses. "Obsessions in OCD are also ego-dystonic, meaning that the individual doesn't like or want them. ... Some recurring thoughts people like to have," he says. "In lay language, people say things like 'I'm obsessed with baseball.' This means they like baseball. They may even spend a lot of time 'compulsively' following baseball. But this doesn't interfere with their life, and it is something that is invited, not something they are trying to get away from."

OCD-related obsessions can include unwanted sexual thoughts, religious obsessions, fear of contamination (by dirt, germs, chemicals or other substances), fear of losing control of yourself, fear of being responsible for harm to oneself or others, fear of illness, and myriad other concerns. Compulsions can involve:

Washing and cleaning tasks (including personal hygiene)

Checking behaviors (such as checking news headlines over and over to ensure that nothing terrible has happened, or checking multiple times that a door is locked)

Repeated actions such as blinking or tapping

Performing certain actions multiple times (e.g., opening and closing doors, going up and down stairs)

Asking questions (possibly to include the same or similar questions over and over) to seek reassurance

Internal actions such as repeated prayers, counting rituals, and repeated mental review or replaying of past scenarios and interactions

(Get an in-depth explanation of OCD from the International OCD Foundation at iocdf.org/about-ocd.)

"If a counselor begins hearing the exact same things [from a client in session], worded or behaved in similar ways, this is a good indicator [of OCD] to watch out for," Hughes says. "Many of my clients are good at exactly quoting themselves on what they've said before. Obsessions are repetitions on a theme; if you get good at catching the theme, you can usually spot an obsession miles away."

Compulsions can also involve avoidance behaviors. For example, Dach once had a client, a new mother, who was experiencing intense thoughts and fears about harming her baby. She would avoid interacting with her child - particularly being in the bathroom with the child while he was being bathed - because she felt it was safer to be away from him.

OCD-related avoidance can spill over into the life choices that clients make, such as where they work or live, what their hobbies are or even the words they use, Dach says. Individuals with OCD sometimes exercise another form of avoidance - breaking up with a partner because they fear the doubt, uncertainty and risks involved in having a relationship. However, they soon find that ending the relationship doesn't quell their rumination, Dach notes.

Individuals with OCD "operate on a risk-adverse level," explains Dach, a member of the American Counseling Association. "You find them checking a lot, asking for reassurance, accommodating their fears and compulsions. ... It's terrifying and it takes over people's lives. We see OCD as this mental bully. You are a complete prisoner to your fears. People with OCD just want to protect themselves and their loved ones."

Obsessions are often a reflection of a person's deeply held values, such as being a good parent, keeping their family safe, or being a good person, Dach notes. Focusing on these values can be a source of leverage when counseling clients with OCD. When working with the new mother who had intrusive thoughts about harming her child, Dach talked with the client about how her fears were based in the values she possessed of wanting to connect with her child, be a good mother and keep him safe.

"If you can find what the client's values are, that can be very powerful," Dach says. "Maybe you fear rejection and failure but value excelling in a career. Finding those values can make a really clear [therapeutic] path to work on and find motivation."

Several of the counselors interviewed for this article recommend that practitioners use the Yale-Brown Obsessive Compulsive Scale to assess clients for OCD and to get a full evaluation of clients' obsessive thoughts and compulsive behaviors. If clients identify numerous behaviors and thoughts that they experience from the assessment's detailed checklist, counselors should work with them to "triage," creating a plan of care to address their most pressing or concerning issues first, Nicely says. Seeing the fearful thoughts and tortuous behaviors that they've been experiencing included on the checklist can serve to normalize clients' experiences and demonstrate that they aren't alone in their struggles, she adds.
Distinguishing OCD
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders categorizes OCD under a cluster of diagnoses that also includes body dysmorphic disorder, hoarding disorder, trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder.

OCD can be complicated to identify because the disorder often co-occurs with other issues such as bipolar disorder, anxiety-related disorders, depression, eating disorders and substance abuse, notes Nicole Hill, an LPC who co-authored an ACA practice brief on OCD. Because clients with OCD often struggle with multiple presenting concerns, the disorder can be hard to pinpoint. In addition to delving into these clients' distress, counselors should complete full biosocial assessments to get a clearer picture of their life and family history, social landscape, early childhood experiences and other contextual factors, says Hill, a professor and dean of the College of Education and Human Services at Shippensburg University in Pennsylvania.

Although there is no one particular cause of OCD, research indicates that there may be a number of contributing or correlating factors, including genetics and family-based factors, autoimmune issues, and the brain structure involved in transmission of serotonin. Being aware of the client's full context - especially whether other family members have OCD - can provide counselors a better understanding of the person's experience and risk factors, says Hill, an ACA member who co-authored a chapter on OCD and related disorders in the 2016 book Diagnosing and Treating Children and Adolescents: A Guide for Mental Health Professionals.

OCD is easier to pinpoint in clients who describe overt compulsive behaviors, such as checking the weather forecast repeatedly. Asking questions to probe the depth and root of clients' fears can help uncover mental compulsions that aren't as immediately noticeable, such as mentally reviewing the activities of their day over and over again, repeating a conversation or a word to themselves a certain number of times, or saying a certain prayer repeatedly, Dach says.

To probe clients' experiences, Dach suggests counselors begin by asking how they deal with stress and anxiety. It is certainly normal for people to experience anxiety from time to time, and it is true that individuals with anxiety disorders may be confronted by intrusive thoughts, ruminate, and perform certain coping behaviors. With OCD, however, the worry, fear and compulsive behaviors become so all-encompassing that they impair the individual's ability to function. For example, most people wash their hands to keep from getting sick, but individuals with OCD may wash their hands a certain number of times, for a certain length of time, or until it feels "right" to them, Dach says.

"We all have this inner voice that's telling us what's safe and not safe. But someone with OCD has a faulty alarm system. They're more vigilant. A whole battle can be happening internally on what's safe and what it takes to be safe," Dach explains.

To uncover compulsions that are internal (and, thus, less apparent to others), Dach suggests asking clients questions along the following lines:

Are there words or statements that make you feel better or that you say to yourself? Do you do something a certain number of times in your mind until it feels right?

When you're lying in bed, is that when your mind wanders the most? What are you thinking about? Is it about your day and what you could have done differently? What you
did wrong?

When you enter a room, what's the first thing you do? Do you beeline straight to where you need to go, or do you scan the area first to feel safe?

From there, Dach suggests asking clients what would happen if they weren't able to complete whatever action they felt compelled to perform. "If there is clear distress in their answer, that may indicate OCD," she says.

Another indicator that OCD may be present is if the client doesn't respond to methods that counselors typically use to help individuals with their negative thoughts, says Hughes, the Dallas-Fort Worth advocate for OCD Texas, a regional affiliate of the International OCD Foundation. "If a client isn't improving from certain methods - especially things like cognitive restructuring in cognitive behavioral therapy - this is 'Getting Stuck 101' and needs further assessment," Hughes says. "Most of my clients have had prior experience with a counselor who had no idea how to treat OCD from an evidence-based way and approached it the same as regular old automatic negative thoughts. This is not typically helpful."

OCD is disruptive, not only to the individual's ability to function but also to their family life, says Hill, whose past clinical work included treating juvenile clients with OCD via play therapy. Parents and families often restructure their routines or make accommodations to work around a loved one's compulsive behaviors, especially if the individual with OCD is a young child. OCD behaviors can be very concerning to parents and, in some cases, embarrassing in public situations. In making accommodations, the family typically feels like they are doing what they can to help the person, but that approach is actually counterproductive, Hill says. In reality, accommodating or yielding to OCD behaviors can exacerbate the issue.

Counselors shouldn't hesitate to involve a client's family in OCD treatment (if applicable and with the client's consent) or to reach out to collaborate with social workers, family counselors or other professionals who may be working with the family, Hill says. Counselors can play a vital role in educating parents and family members about what an OCD diagnosis entails and clarifying the therapy goals for their loved one. They can also offer helpful, nonaccommodating ways to intervene when the person's OCD spikes. Hill says that in her past work with juvenile clients, she often saw the severity of OCD decrease when she used filial play therapy with children and parents. This approach served to bolster their relationship, problem-solving skills and communication patterns. It also instilled a focus on positive behavior and empowering the child, she says.
Working with other treatment providers
Research has shown that a combination of therapy and psychiatric drugs, especially exposure and response prevention (ERP) therapy and serotonin reuptake inhibitors, can be particularly helpful to people with OCD.

"Attending to clients' socioemotional and cognitive issues [in counseling] will be helpful, in addition to medicine," Hill says. "Research consistently shows that the both/and approach is best, with medication and therapy."

Medicine can "turn down the volume" on clients' OCD so that therapy can help them manage their rituals and compulsions, says Nicely, who estimates that three-quarters of her clients take medication. Eventually, if clients and their prescribers agree it is the best course of action, their medications can be tapered back as their coping skills are strengthened in counseling.

Although professional counselors cannot prescribe medications, they must always consider their clients' use of medications - and be proactive in working with clients' medication prescribers - when looking at the whole picture of treating OCD. With clients' consent, counselors can check in with these other treatment providers about clients' symptoms and progress in counseling.

"I always worked on a team with other professionals," says Szymanski, who was previously the director of psychological services at McLean Hospital's OCD Institute in Massachusetts. "It is important to ensure that some time is spent coordinating care and that everyone's work is complementary and not getting in the way of each other. It is equally important to inquire from the client how the team format is working for them and to ask them for specific feedback and encourage them to give direct feedback to each of their team members."

Coordinating care among multiple treatment providers can be challenging, but it is worth it to work toward the best outcome for the client, Hughes asserts. Even imperfect, one-way communication stands to benefit the client.

"Although seamless communication and record exchange between providers is likely ideal, it just rarely happens in real life," Hughes says. "In complex cases, it is almost unheard of for me to not [reach out to] another provider that is connected somehow to shared treatment concerns. I think we need to be realistic about other providers' schedules and to communicate what we can, how we can. This often looks like me leaving a psychiatrist a voicemail after release is given and not hearing back, but at least they have the information."

In addition to professionals who prescribe them medications, clients may be seeing other practitioners for treatment of issues such as depression and substance abuse that often co-present with OCD. This offers opportunities not only to coordinate care but also to make other health care professionals who do not specialize in OCD treatment aware of the disorder's nuances. These professionals can also be alerted to the pitfalls of inadvertently undermining the client's work in counseling by feeding their compulsions through accommodation or reassurance, Hughes says.

Many other comorbidities in clients will often improve by treating their OCD first, Hughes adds.
Exposure and response prevention
Research has identified ERP, a type of cognitive behavior therapy, as the most helpful and effective therapeutic method for treating OCD. All of the counselors interviewed for this article recommend its use with clients who have OCD. The International OCD Foundation refers to ERP as the "gold standard" for treating OCD and more helpful than traditional talk therapy methods.

In ERP, clinicians use gradual exposure to desensitize clients to the OCD-related thoughts, compulsions, situations or objects that are invoking fear and worry in them. With each exercise, the client works to overcome a triggering thought or scenario without responding with a compulsive action. This is the "response prevention" part of ERP. Exposure work is done both in session with a counselor and outside of session as homework for clients to complete on their own.

Counselors should be aware that clients' OCD is likely to spike as they begin ERP treatment, Nicely says, because it removes the compulsions that have given them reassurance in
the past.

Over time, ERP empowers clients to confront thoughts and situations that they often would have tried to avoid previously, Dach says. "When someone has intrusive thoughts, they tend to [try and] push them away, and it effectively boomerangs. Pushing things away and trying to avoid them only empowers [the OCD] and gives it too much value," she explains. "This [ERP]
puts them in the driver's seat. They are the driver, instead of the fear deciding their choices."

With the new mother mentioned earlier in this article, Dach used incremental exposure exercises to help her overcome her fear of harming her baby. At first, the baby was left outside of the counseling room with a caretaker while the client met with Dach. They started small, exposing the client to words that were triggering, such as "baby" or "bathing." As the client progressed, Dach asked her to bring the baby into sessions. Even taking the baby out of his car seat and putting him on her knee was triggering to the client at first, Dach recalls. Dach would talk the client through each exercise, asking her throughout to monitor her level of distress on a scale of 1 to 10.

Eventually, the client graduated to exercises that included changing the baby's diaper in session. In time, the client was able to work toward bathing her child at home, which had been one of her most fear-inducing obsessions.

Giving clients exposure assignments to work on between sessions is a critical part of ERP, Dach says. This can include creating a "worry script" in which clients write out imagined worst-case scenarios for themselves. For example, for one client, the scenario might involve going to the mall or another public place and losing control of themselves so that they vomit or yell and cause a scene, Dach says. The client imagines everyone staring at them, the client dying of embarrassment and then being banned from the mall. The client writes out all of the details of what they are feeling, seeing and experiencing in this imagined scenario. Next, the client reads or rewrites the story script repeatedly or records themselves reading it and listens to the recording over and over, Dach explains.

"It's like watching a scary movie 1,000 times. It might be scary when you watch it the 1,000th time, but [it's] not as terrorizing as the first time," she says.

Dach uses the metaphor of working at a garbage facility to explain the effectiveness of ERP: On your first day, you notice the smell of the garbage and it's so disgusting to you that you can't even eat your lunch. But the smell bothers you less and less as you return to work each day and, eventually, you barely notice the smell at all.

ERP is granting permission "to open the doors to your dungeon and hang out with all these skeletons that you've got hiding in there," Dach says. "If you grab your sleeping bag and pillow and hang out in there, eventually you'll be more comfortable being around them."

Hughes recalls one client with OCD who was struggling with severely distressing thoughts about harming her children. The client had no history of harm or abuse. Over time, the client found it difficult to differentiate between reality - that she would never intentionally hurt her children - and her intrusive thoughts about having impulses to stab her children, Hughes says.

"She knew [these fears] were irrational, yet it felt so real to her," Hughes says. "As can be very typical, the stress also took a toll on most every area of her life, [including] making work difficult."

ERP work began with small exercises the client learned to conquer while staying present with her distress and without turning to compulsions, Hughes says. The client was able to integrate ERP assignments into her daily life with the support of her loved ones, church community and her own desire to be able to engage with her family without fear of harming them.

She soon graduated to script writing and larger exposures that involved holding knives and stating her feared thoughts aloud (appropriately and not in front of her young children), Hughes says. For example, the client would work outside in the family garden and repeat to herself the worst-case scenario she had written in her scripts: "I'm wanting to use these yard tools to kill my daughters." Later, she added more distressing content: "I want to stab them, and I'll get arrested and divorced and be hated by my kids."

Other exposures involved holding a butcher knife firmly for 15 seconds at a time (and eventually longer) while repeating her scripts. Over time, the client worked toward being home alone with her children, bathing her children, and ultimately cooking for her children (including using knives) while her husband was out of town.

Now the client's OCD symptoms score so low on the Yale-Brown Obsessive Compulsive Scale that she would be considered subclinical, Hughes says. "In relapse prevention planning, [this client] understands the chronic nature of OCD and the necessity of staying on top of her good progress, with the plan to follow up at occasional intervals for 'booster sessions,'" Hughes says. "I gain so much joy from stories like these."
Tolerating uncertainty
ERP is effective because it empowers clients to tolerate the uncertainty that is at the core of their fear and worry, Nicely explains. The crux of the problem is not a client's worry over contracting HIV or stabbing their husband, she says, but tolerating the uncertainty of whether or not those fears might happen.

"The hallmark question of OCD is 'what if' and having doubts," says Nicely, the author of the 2018 book Is Fred in the Refrigerator? Taming OCD and Reclaiming My Life. Treating only the content of a client's worries without teaching the client to tolerate uncertainty will simply lead the OCD to surge (or resurge) in another area of the client's life, Nicely notes.

For ERP to be effective, it requires commitment and trust between the client and practitioner. Nicely explains to each client that the work requires a cognitive shift - that trying to avoid anxiety and OCD triggers actually makes them worse.

In working with clients with OCD, Nicely uses the acronym JOY: Jump into anxiety, opt for greater good, and yield to the anxiety. Nicely goes into detail about this method in the 2017 book she co-authored with Jon Hershfield, Everyday Mindfulness for OCD.

She asks clients, "What if we didn't push the anxiety away? What if we brought it toward us? Can you handle it?" Then she points out an example of how the clients are already handling uncertainty by taking the first step of coming to counseling. Bringing anxiety toward them is equal to taking away OCD's power, she explains.

Nicely books a double session with clients for their first exposure treatment. After the exposure work, they process what happened together. Nicely asks questions such as: Was it as hard as you thought? What did you learn? Did you learn that this is something that you can do to get your life back?

"If you do [triggering things] over and over again, then the brain begins to learn that these things aren't the problem," Nicely says. "The reason that our brain is putting these thoughts up front is because we're reacting to them. The brain is learning when you're allowing it to stay at a high level of anxiety."

"OCD is a biological issue," she says. "Our brains [in those with OCD] are structurally and functionally different than those without OCD. You can't think your way out of this. It's a brain disorder, and ERP changes the way our brain functions."

Nicely uses a concept she calls "shoulders back" with both herself and her clients. She says that squaring one's shoulders can serve as a physical reminder that whatever a person's OCD is telling them, it doesn't matter, and they can act as if it's irrelevant.

"Ultimately, we want people to hear all of this [OCD triggers] in their heads and go on and have it bother them less and less," Nicely says. "We want them to live in a world of uncertainty and not have it bother them and act as if their intrusive thoughts don't matter."

It can also be helpful for clients to imagine what their OCD "monster" looks like or even to give it a name. Nicely does that herself, even speaking to her OCD when it begins to surge. Nicely thinks of her OCD as something that will always be a part of her. It's something that, at its core, wants her to feel safe.

"It's exceptionally important [for clients] to realize that OCD is part of them, but it is not them," she says. "That will help them to conceptualize the process. Think of it as something that has been torturing you. Talk back to it and tell it where you want it to go."
Reassurance
The compulsions associated with OCD often arise out of a person's urge to find reassurance and feelings of safety, Dach says. As helping professionals, counselors' natural reaction may be to try to comfort these clients by telling them that their worst fears will not come true. But in the case of clients with OCD, offering reassurance is actually doing harm and reinforcing behavior, Dach stresses.

"No one knows whether or not the fear will happen - not the therapist [and not] the client. But the client will search and search and search for reassurance, an illusion of security and control," Dach says. "If a practitioner gives them reassurance, they're making the condition worse."

When Dach finds clients asking questions as a means of seeking reassurance in sessions, she explains that she will answer questions to provide education or information but not for the purposes of offering reassurance. "It may be a hard pill to swallow, but we [counselors] need to sit with their uncertainty together and model what it looks like to sit with distress," Dach says.

When clients express anxiety over the possibility of vomiting in a public place or some other OCD-related fear coming true, counselors shouldn't reassure them that it won't happen, Dach says, because there is no way to ensure that it won't. Instead, she says, counselors can respond with questions such as, "If you did vomit, what's the worst thing that could happen? What would it feel like? How do you know it's going to happen?"

"The possibility is there, but the probability is low," Dach says. "I can't tell [the client] whether or not something is going to happen. The best we can do is put ourselves in a situation [via exposure] to learn what's going to happen. Then I offer to lean into that discomfort [with the client]."
On the same team
There is sometimes a misconception among mental health professionals that exposure work can traumatize clients, but that simply isn't true, Dach stresses. Therapy with a practitioner specially trained in ERP is hard work - it's asking a client "to walk into their worst nightmare and have a party" - but it's also incredibly effective and rewarding, she says.

"This is an extremely collaborative intervention. We're on the same team. It's not forcing [clients] to do things. It is asking them to get close to the thing they're afraid of the most. You [the counselor] are there to offer gentle pushing, but it's all choice-based," Dach says.

Nicely and Hughes say that clients with OCD tend to be incredibly brave and also deeply caring. It is inspiring, Nicely says, to watch clients tackle such hard things in therapy and become more resilient.

"For many reasons, I love work with clients who have OCD," Hughes adds. "I have found that they are some of the kindest, hardest-working and most conscientious individuals on this planet. This is where I believe many of their personality strengths arise once [they move] through pathology. It is a joy every day to see recovery, growth and maturity bloom out of suffering."

The International OCD Foundation offers a wealth of resources and information on its website, iocdf.org, as well as training programs, an annual conference, and local affiliates around the country.

Contact the counselors interviewed for this article:

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It's not uncommon for people to describe themselves in casual conversation as "obsessed" with a television series or "OCD" about the way they organize their closet.

Professional counselors can be agents of change when it comes to casual use of the language related to obsessive-compulsive disorder (OCD), says Shala Nicely, a licensed professional counselor in Georgia who specializes in treating the disorder. She encourages counselors to be mindful of their own language and to gently correct those who misuse OCD-related terms.

One place to begin: Stop using OCD as an adjective, she says. Someone might be meticulous or detail-oriented or neat, but he or she is not "OCD." To say "I'm so OCD" about something can discourage people who really do have OCD from seeking treatment, especially if that offhand pronouncement comes from a mental health professional, Nicely says.

****

Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

Letters to the editor: ct@counseling.org

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

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Living with - and beyond - OCD - Counseling Today

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In popular culture, obsessive-compulsive disorder (OCD) is often portrayed through characters who can't bring themselves to step on cracks in the sidewalk, who are germaphobes, or who are obsessed with cleanliness and organization. These "hang-ups" are often played for comic effect.

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The American Counseling Association recognizes that the work counselors do, while very important and rewarding, can also be stressful. Self-care is an essential tool that can help in dealing with stress. The following ACA resources focus on self-care for counselors.

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Gerald Corey, Michelle Muratori, Jude T. Austin II and Julius A. Austin

This inspirational book for students, clinicians, educators and supervisors offers practical perspectives on the lifelong quest for personal wellness. Through conversational, diverse and deeply personal narratives, the authors reveal their self-care journeys at various stages of their careers, and 39 guest contributors-ranging from graduate students to counseling veterans-share how they overcome setbacks and prioritize self-care to maintain competent, ethical practice.

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The American Counseling Association recognizes that the work counselors do, while very important and rewarding, can also be stressful. Self-care is an essential tool that can help in dealing with stress. The following ACA resources focus on self-care for counselors. Counselor Self-Care 2nd Edition Gerald Corey, Michelle Muratori, Jude T.