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Obsessive Compulsive Disorder and the School Counselor

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Obsessive Compulsive Disorder and the School Counselor

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Obsessive Compulsive Behaviors in the School Setting

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Obsessive Compulsive Behaviors in the School Setting

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OCD in the Classroom- Child Mind Institute

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OCD in the Classroom- Child Mind Institute

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

Obsessions Common in Kids With OCD

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

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

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

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

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

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

Behaviors You Might See in Students With OCD

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

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

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

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

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

Behaviors Often Confused With Another Disorder

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

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

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

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

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

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

How to Help Students With OCD

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

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

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

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

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

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

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

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

How to Minimize Behavioral Problems

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

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

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

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

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

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

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

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Paul H. Wender, & David A. Tomb. (2017). ADHD : A Guide to Understanding Symptoms, Causes, Diagnosis, Treatment, and Changes Over Time in Children, Adolescents, and Adults: Vol. Fifth edition. Oxford University Press.

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George J. DuPaul, & Gary Stoner. (2014). ADHD in the Schools, Third Edition : Assessment and Intervention Strategies: Vol. Third edition. The Guilford Press.

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Cecilia A. Essau. (2003). Conduct and Oppositional Defiant Disorders : Epidemiology, Risk Factors, and Treatment. Routledge.

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Teaching Strategies for Behavioral Disorders

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Teaching Strategies for Behavioral Disorders

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

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

1. Emotional and Behavior Disorders (EBD)

2. Emotional Conflict (EC)

3. Serious Emotional Disturbance (SED)

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

General Strategies

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

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

Teacher Presentation

Laboratory

Group Interaction and Discussion

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

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

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

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

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

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

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

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

Reading

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

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

2. Reading in group or with others.

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

4. Demonstrating appropriate reading

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

Research

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

2. Use appropriate laboratory and field strategies.

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

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

Field Experiences

1. Use appropriate general strategies.

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

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

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

5. Use a buddy system.

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

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

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

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

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

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

Testing

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

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

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

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

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

Organizations

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

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

Resources

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

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

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

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A Closer Examination of Bipolar Disorder in School-Age Children

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A Closer Examination of Bipolar Disorder in School-Age Children

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a closer examination of bipolar disorder in school-age children

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Ian H. Gotlib, & Constance L. Hammen. (2014). Handbook of Depression, Third Edition: Vol. Third edition. The Guilford Press.

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Accommodations for Students with Bipolar Disorder

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Accommodations for Students with Bipolar Disorder

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

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

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

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

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

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

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

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

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

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

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

Shortened assignments.

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

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

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

Preferential seating in the classroom.

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

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

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

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

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

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

Students on some medications may need:

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

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

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

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

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

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

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

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

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Individuals with Disabilities Education Act

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Individuals with Disabilities Education Act (IDEA)

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

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

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

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

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

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

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

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

* The child's parent or caregiver

* General and special education teachers

* The school principal

* The child's parent or caregiver

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

* At least one special education teacher

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

* A district representative with authority over special education services

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

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

* Specific accommodations, supports, or services for the child

* Names of who will provide each service

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

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

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

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

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

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

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

* How the child will participate in standardized tests

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

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

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

How to resolve disputes

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

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

* Mediation

* Alternative dispute resolution

* Impartial hearing

* Complaint to the Office for Civil Rights (OCR)

* Lawsuit

* Mediation

* Due process complaint

* Resolution session

* Civil lawsuit

* State complaint

* Lawsuit

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

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

About the author

About the author

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

Reviewed by

Reviewed by

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

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

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

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Rates of childhood depression have been rising in the last several years. Yet, information and awareness about childhood depression has not caught on at the same rate. Millions of people across the world wonder and doubt if children can get depressed. Many well-intentioned adults still believe that children 'can't get depressed. They are so young- what do they have to be depressed about? When we were that age, we were just happy'. Alongside misunderstanding is stigma and the idea that mental illness is a taboo subject.
What we now know:

Childhood depression is a real, distinct clinical entity.

It is a serious health condition, which if left untreated, increases risk of future, prolonged and more severe depressive episodes. Untreated depression in childhood and adolescence can pose risk of suicide.

Depression often has biological, psychological and social underpinnings. An individualized treatment plan that explores and addresses each of these aspects, works best.

Effective treatment options for childhood and teen depression have been widely tested, proven and established, through several scientific studies over the years.

Childhood depression can be hidden and therefore, easily missed. Timely recognition and treatment can be life-changing and life-saving.

The barriers surrounding mental health stigma are beginning to give way due to powerful social movements and discussions that address realities of mental health.

Who is Affected by Depression in Childhood or Teenage?
Depression can affect anyone. However, children or teens who have immediate family members with a history of depression or other mood disorders (such as bipolar disorder) are more likely to suffer from depression, often due to a genetic predisposition. Predisposition implies greater likelihood; it does not mean that the child or teen will necessarily experience depression.

Children with chronic or severe medical conditions are at a greater risk of suffering from depression.
Common Signs of Depression in Childhood or Adolescence
Depression in childhood/adolescence can manifest somewhat differently than it does in adults. Irritability and/or anger are more common signs of depression in children and teens.

When depressed, younger children are more likely to have physical or bodily symptoms, such as aches or pains, restlessness, distress during separation from parents, as they may not have the emotional attunement and/or expressive abilities to talk about their emotions.

Other signs of depression in children and teens, can be:

Loss of interest in usual fun activities

Withdrawal from social or usual pleasurable activities

Difficulties with concentration

Running away from home or talking about running away from home

Talking about death or dying, giving away (or talking about giving away) favorite possessions, writing goodbye letters

Sleep increase (or decrease)

Appetite/weight changes (more likely an increase, in depressed teens)

Occasionally, new or recent onset agitation or aggression

Comments indicating hopelessness or low self-worth

Not all of the above-mentioned symptoms have to be present for a diagnosis of depression. Symptoms usually occur on most days, for at least 2 weeks, in order to meet criteria for depression. When seeing a professional to explore a diagnosis, you can utilize online health resources to prepare meaningful questions to ask a doctor in order to facilitate productive conversation for treatment.
Ruling Out Medical Conditions First
Psychiatric disorders are diagnosis of exclusion, which means that only if the symptoms are unexplained by medical conditions, or effect of substances or other non-psychiatric causes, would the cause of symptoms be deemed to be due to a primary psychiatric disorder.

Before arriving to the diagnosis of depression, a child or teen who is suspected to be depressed, must undergo a comprehensive medical evaluation to rule out any underlying medical condition which could be manifesting as or resulting in depression. For example, hypothyroidism (depressive symptoms, weight gain, low energy, cognitive difficulties, constipation). Even conditions such as undiagnosed anemia can mimic depression, due to accompanying fatigue/low energy. Vitamin D deficiency, common in cold climates, increases risk of depressive symptoms and fatigue. The good news is that these conditions have effective treatments, and treatment of the underlying medical condition in a timely manner should resolve depressive symptoms.
Ruling Out Other Psychiatric Conditions
Rule out undiagnosed/untreated ADHD (attention Deficit Hyperactivity Disorder), anxiety disorders or other psychiatric conditions, which when left untreated, can result in depressive symptoms due to the impairment in functioning from ADHD or anxiety disorder itself.
Treatment
Why Treat?

Depression is associated with visible brain changes seen on functional brain MRI studies of depressed individuals. Treatment, for example, psychotherapy has been shown to confer long term benefit and neural changes in the brain.
How Do I know My Child Needs Treatment?
In addition to an overall assessment, your child's pediatrician may administer rating scales and other forms of assessment to determine the degree of depression and may refer you to a psychiatrist or a psychotherapist.

We know a child/teen needs treatment for depression when their school, social, and/or home functioning is significantly affected by depressive symptoms, on a frequent basis.

If your child/teen is feeling suicidal and/or having thoughts/urges to hurt themselves, call 911 or take your child/teen to the nearest ER.
What Kind of Treatment?
For mild to moderate depression, CBT (Cognitive Behavioral Therapy) is the typical first-line treatment of choice for children and teens. There can be exceptions to this, depending on the specific clinical condition, age and circumstance of the child. For children younger than 10, other modalities of psychotherapy such as play therapy, psychodynamic psychotherapy, and behavior therapy may be utilized.

For moderate to severe depression, evidence-based guidelines recommend a combination of CBT and antidepressant medications (typically SSRI medications, also known as Selective Serotonin Re-Uptake Inhibitors).
SSRI Use for Depression in Children

SSRIs and other antidepressants have a black box warning from FDA about risk of increase in suicidal thoughts and behavior with use, particularly in the early phase of treatment. Studies did not show completed suicides.

After this warning came out in 2004, antidepressant prescription rates dropped, and suicide rates climbed up.

Close monitoring during dose initiation, titration and dose changes helps to reduce this risk

Antidepressant medication use in children and adolescents is preceded by a weighing of benefits and risks of use versus risks of untreated depression.

Fluoxetine and Escitalopram are FDA approved for treatment of depression in children and teens.

Studies involving paroxetine (another SSRI) have shown a higher profile of side effects with its use in children, and therefore, may not be recommended for children and teens.

Studies show a higher likelihood of an individual responding to an SSRI that an immediate family member benefitted from (however, this is a likelihood, not necessary that it will happen in each situation)

If depressive symptoms are secondary to other conditions, such as untreated ADHD or anxiety disorders, adequate treatment of those disorders is essential and will usually resolve the depressive symptoms. However, in certain situations, specific antidepressant medications and/or psychotherapy targeted towards depression may be needed in addition. One might note that if trials of two or more antidepressants are not effective, or if a child/teen is sensitive to medications in general, there are additional avenues that can be explored. One plausible route for consideration is genetic testing that combines personal genetic data with medication information to achieve the desired remedy.

Your child's pediatrician/psychiatrist, therapist, together with you, may also explore for any bullying, trauma, and will try to understand your child/teen's inner life and look further for any school, social, family or other stressors that may be contributing to, or exacerbating/perpetuating the depressive condition. If family stressors are significantly contributing to your child's depression, your doctor may recommend family therapy in addition. With your permission, the doctor/therapist may coordinate with your child's school to share recommendations to optimize your child's school functioning and emotional well-being at school.
Overcoming Mental Health Stigma
In 1999 the United States Surgeon General labeled stigma as quite possibly the biggest barrier to mental health care. Stigma manifests as misguided stereotypes and negative attitudes or beliefs towards those with mental illness. Research shows that stigma and embarrassment were the top reasons why people with mental illness did not engage in medication adherence, such as self-care, therapy and medication compliance. As of late, there has been an increase in available resources and tools to overcome stigma for children and teens, as well as their caregivers. Allies such as Bring Change to Mind, an organization focused on encouraging dialogue about mental health, as well as raising awareness through education, offers high-school and college programs that foster a culture of peer support within schools.
A Word About Substance Use and Depression
Sadly, substance use among teens is becoming rampant across the country, even in reputed school districts, and thus, needs to be addressed when exploring and treating depression.

Marijuana use is particularly common among teens. Marijuana is considered to be a 'gateway drug' and can lead to 'amotivational syndrome'. This syndrome manifests as low motivation to do things, and in conjunction with marijuana related 'munchies' can mimic a primary depressive disorder. In many cases, a teen may be 'self-medicating' for untreated or undiagnosed depressive or anxiety symptoms through substance use. Use or withdrawal from other substances can cause depressive, mood symptoms as well.

Proper and timely treatment can be very effective in resolving depressive symptoms and in reducing risk of relapse. Please consult your child's pediatrician or health care provider if you suspect your child/teen may be suffering from a medical or a psychiatric condition.

Note: This article is for informational purposes only and is not intended to provide medical or psychiatric advice or recommendations, or diagnostic or treatment opinion. This is not a complete review or description of this subject. If you suspect a medical or psychiatric condition, please consult a health care provider. All decisions regarding an individual's care must be made in consultation with your healthcare provider, considering the individuals' unique condition. If you or someone you know is struggling, please contact the 24x7, confidential National Hotline at 1-800-273-8255 or use the crisis text line by texting HOME to 741741 in the US, or go to http://www.suicide.org/international-suicide-hotlines.html for the suicide hotline number for your country.
About the author:
Richa Bhatia, MD, FAPA is a Child, Adolescent and Adult psychiatrist, dual Board certified in Child, Adolescent and General Psychiatry. She is the author of 2 books: 'Demystifying Psychiatric Conditions and Treatments' and '65 Answers about Psychiatric Conditions'. Previously, she served as a faculty member in the departments of psychiatry at Harvard Medical School and Geisel School of Medicine at Dartmouth. She serves as an Associate Editor for Current Psychiatry, Section Editor for Current Opinion in Psychiatry and is on the editorial board of several other psychiatry journals. She is an expert contributor for Psychology Today and Thrive Global. Some of her interests are childhood depressive and anxiety disorders, the interface between medical and psychiatric conditions, differential diagnosis, compassion and bullying prevention. She is an active member of the Child and Adolescent Psychiatry Section of the World Psychiatric Association (WPA), the American Psychiatric Association and the Anxiety and Depression Association of America.

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Rates of childhood depression have been rising in the last several years. Yet, information and awareness about childhood depression has not caught on at the same rate. Millions of people across the world wonder and doubt if children can get depressed.

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What is schizophrenia in children?

Schizophrenia is a serious mental illness. It is a long-lasting and disabling problem of the brain. A child with this disorder has unusual behavior and strange feelings. He or she may suddenly start to have psychotic symptoms. Psychotic means having strange ideas, thoughts, or feelings that are not based in reality.

Schizophrenia is not often found in children younger than age 12. It's also hard to spot in the early stages. Often, the psychotic symptoms start in the middle to late teen years. Slightly more boys develop it in childhood. But by the teen years it affects both boys and girls equally.

What causes schizophrenia in a child?

Schizophrenia has no single cause. A combination of genes from both parents plays a role. So do unknown environmental factors. Experts believe that a child has to inherit a chemical imbalance in the brain to develop it.

Which children are at risk for schizophrenia?

Schizophrenia tends to run in families. A child who has a family member with the disorder has a greater chance of developing it.

What are the symptoms of schizophrenia in a child?

Behavior changes may occur slowly, over time. Or they may start suddenly. The child may slowly become more shy and withdrawn. He or she may start to talk about odd ideas or fears and start to cling more to parents.

Each child's symptoms may vary. Early warning signs are:

Trouble telling dreams from reality (distorted view of reality)

Confused thinking, such as confusing TV with reality

Detailed and bizarre thoughts and ideas

Fear or belief that someone or something is going to harm him or her

Seeing, hearing, or feeling things that are not real, such as hearing voices (hallucinations)

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

Extreme moodiness

Lots of anxiety or fear

Lack of emotional expression when speaking

Trouble doing schoolwork or a drop in levels of school success

Social withdrawal, such as having problems making and keeping friends

Sudden agitation and confusion

Disorganized behavior, such as doing private things in public. Or catatonic behavior, such as sitting and staring, as if the child can't move.

Odd behaviors, such as an older child acting like he or she is much younger

Children with schizophrenia have the same symptoms as adults with the condition. But more children hear voices. Children also don't tend to have delusions or formal thought problems until they are in their teens or older.

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

How is schizophrenia diagnosed in a child?

A child with symptoms of schizophrenia needs a thorough medical and mental health evaluation. Talk with your child's healthcare provider if you are concerned about symptoms your child is having. A child psychiatrist or other qualified mental health expert can diagnose schizophrenia in children and teens. He or she does a mental health evaluation to figure out how best to treat the child.

How is schizophrenia treated in a child?

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

Schizophrenia is a major mental illness. Treatment is complex. A child often needs a combination of therapies to meet the specific needs. Treatment is aimed at easing symptoms. It may include the following.

Medicines

The doses and types of medicines may need to be adjusted from time to time so they can keep working well. Your child may be given:

Medicines to help reduce delusions and hallucinations (antipsychotics). This special class of medicines can reduce symptoms or reduce how severe the symptoms are. But they don't cure schizophrenia.

Mood stabilizing medicines. Examples are lithium and valproic acid, especially in the early stages of the illness.

Other treatment

Individual and family therapy. This may include supportive, thinking, and behavioral therapy.

Specialized educational or structured activity programs. These may include social skills training, vocational training, and speech and language therapy.

Self-help and support groups. These can help the child learn ways to cope with the disorder and also work on social skills.

How can I help prevent schizophrenia in my child?

Experts don't know how to prevent schizophrenia. But early diagnosis and treatment can improve a child's quality of life. Treatment works best when early symptoms are dealt with quickly.

How can I help my child live with schizophrenia?

Schizophrenia is a serious mental illness that will require your support, patience, and attention. You are your child's best advocate. Here are things you can do to help:

When should I call my child's healthcare provider?

Call your healthcare provider right away if your child:

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

Feels out of control

Hears voices that others don't hear

Sees things that others don't see

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

Has new symptoms or if current symptoms get worse

Shows side effects of medicines

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

Schizophrenia may increase a child's risk for suicidal thinking.

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

Key points about schizophrenia in children

Schizophrenia is a serious mental illness.

A child with this disorder has unusual behavior and strange feelings. He or she may have delusions or hallucinations.

Symptoms can develop slowly over time or start quickly.

A mental health expert can diagnose schizophrenia. Ask for a referral to a psychiatrist with experience evaluating and treating children with schizophrenia.

Treatment can include a combination of medicine, therapy, and special programs.

The American with Disabilities Act (ADA) and Section 504 of the Civil Rights Act provide legal protections for your child in a public school setting.

Schizophrenia is a difficult disease. Talk with your child's healthcare provider about a support group for caregivers of children with schizophrenia or seek counseling.

Next steps

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

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

Before your visit, write down questions you want answered.

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

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

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

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

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

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

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

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Schizophrenia is a serious mental illness. It is a long-lasting and disabling problem of the brain. A child with this disorder has unusual behavior and strange feelings. He or she may suddenly start to have psychotic symptoms. Psychotic means having strange ideas, thoughts, or feelings that are not based in reality.

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Learning your child has schizophrenia-or suspecting your child may have it-can feel overwhelming and scary. But early identification and treatment are important in managing the symptoms and improving your child's long-term prognosis.

Schizophrenia is a mental illness that causes people to interpret reality abnormally. It involves a range of cognitive, emotional, and behavioral problems that impair a child's ability to function.

Prevalence

Onset usually occurs between the late teens and the mid-thirties. The peak age of onset for males is the early twenties and for females the late twenties, but it may occur at any age. According to the Institute of Mental Health, about .25 to .64% of Americans have schizophrenia.﻿﻿

Childhood schizophrenia, characterized by onset before age 13, is only found in 1 in 40,000 children. Childhood schizophrenia presents special challenges in terms of diagnosis and treatment.﻿﻿

Scientists haven't found a single set of causes for schizophrenia. It's suspected that there are multiple genetic and environmental factors that play a role:﻿﻿

Genetic Factors - Family, twin, and adoption studies support a strong genetic component in schizophrenia. Parents of children with schizophrenia are ten times as likely to also develop schizophrenia.﻿﻿ If an identical twin has the illness, the likelihood that the other twin will develop schizophrenia is over 40 percent.﻿﻿

Environmental Factors - There may be some environmental factors that contribute to schizophrenia in children, especially if there are already genetic components at play. Prenatal infections, obstetric complications, and maternal famine may play a role.﻿﻿

Childhood schizophrenia is often associated with cognitive delays. Cognitive decline typically occurs at the time of onset of schizophrenia. Intellectual deficits appear to be stable over time without continued deterioration.﻿﻿

Hallucinations - Seeing or hearing things that aren't actually there

Delusions - False ideas that are believed by the individual but not by others

Disorganized thinking - Evidenced by derailed or incoherent speech

Flat affect - Monotone, diminished facial expressions, and appear apathetic

Paucity of speech or thought - Only speaking when prompted and replying with short answers

Bizarre behavior - Inappropriate, disorganized, or odd behavior inappropriate for a child's age

The course of schizophrenia varies from person to person. But, there are hallmark phases that individuals tend to experience.

Prodrome phase - Most individuals with schizophrenia experience some functional deterioration before the onset of psychotic symptoms.﻿﻿ Social withdrawal, bizarre preoccupations, unusual behavior, academic failure, or a decline in hygiene and self-care may begin before any signs of psychosis.

Acute phase - This phase is marked by prominent symptoms, such as hallucinations, delusions, disorganized speech and behavior, and a serious deterioration in functioning. This phase may last several months depending on the response to treatment.﻿﻿

Recuperative/Recovery phase - After the acute psychosis subsides, there is generally a several-month period when the individual continues to experience a significant impairment. Flat affect and social withdrawal are often present.﻿﻿

Residual phase - Children with schizophrenia may have several months or more between acute phases. However, most individuals will continue to be at least somewhat impaired. Some individuals never progress to residual symptoms and continue to have symptoms despite treatment.﻿﻿

When to See a Doctor

It's hard to identify schizophrenia in children. Young children have excellent imaginations so it's common for them to have imaginary friends with whom they carry on conversations. That type of pretend play doesn't mean your child is having hallucinations.

Kids also aren't good at telling adults about their symptoms. When young children are asked questions about hallucinations or delusions, many of them say yes. But, that doesn't mean they have psychosis.

Instead, in a paper published in 2013, researchers believe kids may report having those symptoms because they have overactive imaginations, cognitive limitations, or they simply misunderstand the question. So asking your child questions like, "Do you ever see things that no one else sees?" isn't likely to give you much insight into whether your child should see a doctor.﻿﻿

Symptoms also tend to begin gradually. Over time, however, a child may develop psychosis and the symptoms become much more obvious. If you notice developmental delays, strange eating rituals, bizarre behavior or ideas, change in academic performance, or social isolation, consult your child's doctor.

Since schizophrenia in children is rare, there's a good chance the symptoms may stem from something else. But it's important to find out the reasons for the changes that you're seeing.

There isn't a lab test that identifies schizophrenia. Mental health professionals make the diagnosis based on several factors, after gathering a full history, observing the child, and interviews with the parent and child. Other conditions must also be ruled out.

Schizophrenia Discussion Guide

Get our printable guide to help you ask the right questions at your next doctor's appointment.

Many of the symptoms of schizophrenia in children are also found in other disorders, such as autism spectrum disorders, mood disorders with psychotic features, or obsessive compulsive disorder.﻿﻿

Medical conditions may also result in psychosis. Central nervous system infections, endocrine disorders, genetic syndromes, autoimmune disorders, and toxic exposures may cause children to exhibit symptoms similar to those found in schizophrenia.﻿﻿

Drug use may also cause psychosis. Hallucinogenic mushrooms, stimulants, inhalants, and cannabis are just a few of the drugs that may lead to psychotic symptoms. Prescription drug misuse may also lead to acute psychosis. Symptoms resolve within a few days to weeks after the drug is discontinued.﻿﻿

All of those other conditions must be ruled out before a diagnosis of schizophrenia can be made.

Treatments

Antipsychotic medication is the primary treatment for schizophrenia in children as well as adults. Individuals with schizophrenia are at significant risk of relapse if antipsychotic medication is discontinued. It's essential for parents to maintain contact with physicians to monitor symptoms, side effects, and adherence.﻿﻿

Talk therapy may also be helpful to children with schizophrenia. Children and their parents may benefit from psychoeducation and problem-solving sessions. It may be important for siblings to get involved in therapy so they can understand their brother or sister's behavior.﻿﻿

Social skills training, relapse prevention, and basic life skills training may be helpful. Some children with schizophrenia may need specialized education programs or vocational training programs.

If a child becomes a danger to herself or others, a psychiatric hospitalization may be necessary. Inpatient treatment can be helpful in getting symptoms under control.

Childhood-onset schizophrenia is associated with low intellectual functioning and higher rates of negative symptoms across the lifespan. According to a 2011 study published in Pediatric Clinics of North America, childhood-onset schizophrenia is associated with greater social deficits in adulthood compared to those with other mental illnesses.﻿﻿

It's also been linked to lower level of employment and a lesser likelihood of living independently, compared to other psychiatric disorders.﻿﻿

Adolescents are at a higher risk of suicidal behavior during their first episode of psychosis. At least 5 percent of people who exhibited symptoms of schizophrenia before age 18 die by suicide or accidental death directly related to behaviors caused by their psychotic thinking.﻿﻿

If your child is having suicidal thoughts, contact the National Suicide Prevention Lifeline at 1-800-273-8255 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.

Individuals with schizophrenia also are at a higher risk of physical health conditions such as heart disease, obesity, hepatitis, diabetes, and HIV. There isn't a cure for schizophrenia, but symptoms can be managed with treatment. Early intervention is key to improving the outcome for children with schizophrenia.﻿﻿

Coping and Support

Learning your child has schizophrenia-or suspecting that he or she may have it-can feel scary and overwhelming. It's important to learn as much as you can about schizophrenia in children, however, so you can best support and advocate for your child.

Ask your child's doctor for resources on schizophrenia. Attending support groups for people who have a family member diagnosed with schizophrenia could serve as a wealth of information.

The National Alliance on Mental Illness, NAMI, may also be a valuable resource. NAMI is a mental health organization who has local affiliates who provide support, education, and services in communities throughout the United States. NAMI may be able to help you locate the resources, tools, and information you need to help your child.

It's important to take care of yourself as well. Attend a support group or seek therapy for yourself. Managing your stress level will be key to helping you be best equipped to support your child.

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Here Are the Warning Signs of Schizophrenia in Children

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Learning your child has schizophrenia-or suspecting your child may have it-can feel overwhelming and scary. But early identification and treatment are important in managing the symptoms and improving your child's long-term prognosis. Schizophrenia is a mental illness that causes people to interpret reality abnormally.

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Sophia F. Dziegielewski. (2015). DSM-5 in Action. Wiley.

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Sophia F. Dziegielewski. (2015). DSM-5 in Action. Wiley.

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Renée M. Tobin, & Alvin E. House. (2016). DSM-5® Diagnosis in the Schools. The Guilford Press.

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Renée M. Tobin, & Alvin E. House. (2016). DSM-5® Diagnosis in the Schools. The Guilford Press.

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Suzanne Abraham. (2016). Eating Disorders: The Facts: Vol. Seventh edition. OUP Oxford.

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Suzanne Abraham. (2016). Eating Disorders: The Facts: Vol. Seventh edition. OUP Oxford.

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How to Help a Child With an Anxiety Disorder

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How to Help a Child With an Anxiety Disorder

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When worrying gets in the way of a child's functioning, parents need to get help rather than arranging the child's life to avoid the occasions of anxiety.

Credit... Getty Images

By

Anxiety disorders, the most common mental health problems in children and adolescents, often go untreated while children suffer, even though there are effective treatments available, according to a new report on anxiety in children and adolescents from the Child Mind Institute in New York. Anxiety may be missed because it doesn't necessarily declare itself with attention-getting disruptive behaviors; in fact, symptoms may keep some children quiet and inhibited, though in other children, alternatively, anxiety may be misunderstood as oppositional behavior.

Adults may also assume that anxiety in a child is just a phase to be outgrown. A certain amount of anxiety is a normal aspect of development for young children - consider separation anxiety, for example - and it can even be protective, since children need to learn to keep themselves safe and anticipate certain kinds of dangers. But when worrying or avoiding possible threats gets in the way of a child's functioning or a child's enjoyment, it should be a signal to parents that help is needed, not just watching and waiting, not arranging the child's life to avoid the occasions of anxiety.

Kathleen Merikangas, the senior investigator and chief of the Genetic Epidemiology Research Branch at the National Institute of Mental Health, said, "To me, anxiety is one of the most underrecognized or under-treated conditions of childhood and adolescence." These children can get missed, she said, because they may seem to be functioning well; many don't have the kinds of developmental problems or attention issues that draw attention in school, though they may be suffering.

Consider the child whose anxiety about speaking in public gets in the way of participating in class. The child may be silent out of a fear of being laughed at or otherwise rejected, Dr. Merikangas said, but to the teacher, it may look like the child is just not interested. Environmental modifications can really help these children thrive in school, she said; for example, working in small groups with children they know.

The new report, released in September, summarizes the evidence that early temperament in children predicts their later behavior patterns around anxiety; toddlers who show what are called "behaviorally inhibited" behaviors, which parents are likely to perceive as extreme shyness, or anxiety around new people, are more likely to develop social anxiety later on. That doesn't mean that shyness is pathological (as with all varieties of temperament, there's a wide range of function), but it does suggest how important it is to help a child with this temperament who develops difficulties.

The tendency toward anxiety - and toward some specific forms of anxiety, like phobias - may persist throughout childhood and adolescence and into adulthood. And anxiety is closely tied to depression, Dr. Merikangas said. Although there have been reports that anxiety rates among American teenagers have soared, she cited evidence that the international rates of the underlying disorders had stayed consistent from 1998 to 2013; there is no global "epidemic" of clinical anxiety disorders, she said.

But with rates of suicide and suicidal ideation on the rise, it's particularly important to provide information to schools and to parents about recognizing anxiety and getting children help.

Dr. Harold Koplewicz, the president of the Child Mind Institute, said that when anxiety disorders in children are left untreated, anxiety can inhibit their lives, making standard daily activities difficult, from attending school to sleeping in their own beds, and lead to many extra visits to the school nurse or the pediatrician.

But beyond that, he said, "people underestimate that this is a gateway disorder." If children don't get help with these disorders, they may be at risk to develop other mental health problems; the child with severe separation anxiety may develop panic disorder, he said; the child with untreated general anxiety may be at greater risk for depression.

Dr. Merikangas was a co-investigator on a national study of mental disorders in adolescents, which has shown both that anxiety disorders were the most common mental health problems in adolescents in the United States, and also the problems that showed up earliest in those children's lives - the mean age of onset for anxiety disorders was 6. But many adolescents had never received treatment. That makes it essential to get the word out, Dr. Merikangas said, that anxiety is "one of the most treatable symptoms and syndromes, we can really change their lives with minimal intervention."

"All these disorders are remarkably treatable," Dr. Koplewicz said. There are highly effective behavioral and psychosocial therapies, including cognitive behavioral therapies, to help children cope with the demands of daily life. For children who don't respond to psychosocial therapies, he said, medications can be added.

But perhaps because anxiety is a normal response, parents often believe that even severe and disabling anxiety symptoms are just a phase, and on average, there is a two-year lag between the time children develop anxiety and the time they get help. "It's bad for these children's brains," he said. "Having your brain's thermostat miss-set is not good for your brain."

"Anxiety can manifest itself along a continuum," said Rachel Busman, the senior director of the anxiety disorders center at the Child Mind Institute. The report shows that there is some overlap with physical illnesses, such as chronic headaches or stomach aches, often coordinated with school. "That could be a kid's way of saying, 'I'm anxious,'" she said.

And when a child who is having a lot of difficulty with separation gets into the classroom, Dr. Busman said, that child may start throwing things, or running and hiding, and that "bad behavior" may represent the fight or flight response of anxiety. "We've also seen kids who have intense social anxiety and their way of managing it is to be class clown," she said.

Treating children with anxiety always means working with their parents. Jerry Bubrick, senior clinical psychologist at the anxiety disorders center of the Child Mind Institute, said that when children are little, it's normal for parents to operate in "fix-it mode," blocking the staircase so a toddler doesn't tumble down, averting problems before they happen.

As children get older, parents normally pull back, helping children find solutions of their own. "But anxious parents of anxious children remain in fix-it mode," he said, helping their children avoid the situations that make them anxious. Therapy involves exposing children to those situations and helping them develop strategies to manage them; with treatment, Dr. Bubrick said, parents can "let the child experience the anxiety and learn to tolerate and overcome it on their own."

"If you see things you're not sure about, talk to the preschool, talk to the pediatrician, be open to the idea that maybe there is anxiety," even in a young child, Dr. Busman said. Separation anxiety can be a problem even in children who are able to go to school, she said. Parents should pay attention if a child can't be left with a babysitter, a child can't sleep alone at home."These are the kids, they go into the bathroom, and they're like, are you still there?" she said. "We do see really young anxious children."

"If your child is suffering distress and dysfunction, reach out to your pediatrician," Dr. Koplewicz said. When you get to a mental health professional, "make sure you ask the right questions," he said, including asking whether that person has specific experience with treating anxiety and how long the treatment is expected to take.

"You want a professional who understands what they're doing and can explain to you what they're doing."

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How to Help a Child With an Anxiety Disorder

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When worrying gets in the way of a child's functioning, parents need to get help rather than arranging the child's life to avoid the occasions of anxiety. By Anxiety disorders, the most common mental health problems in children and adolescents, often go untreated while children suffer, even though there are effective treatments available, according to a new report on anxiety in children and adolescents from the Child Mind Institute in New York.

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From Dr. Tamar Chansky Creator of Worrywisekids.org