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

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

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

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

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Angelo State University - Library Online Resources

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Unauthorized use is prohibited; Usage may be subject to security testing and monitoring; Misuse is subject to criminal prosecution; No expectation of privacy except as otherwise provided by applicable privacy laws.

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

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

Listen for ongoing or severe traumatic stress symptoms.

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

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

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

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

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

Steps for making a referral

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

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

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

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

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

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

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

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

Keep the door open.

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

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

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

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

Effective mental health treatment for traumatic stress

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

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

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

Do you have experience working with children after trauma?

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

What is your success rate?

How do you work with parents?

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

Online resources - help in finding a mental health professional

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

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

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

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

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

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

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

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When and How to Refer for Mental Health Care

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

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Home - ADDA - Attention Deficit Disorder Association

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Empowering adults with adhd to live their best lives A Different Brain Requires a Different Approach Whether you're newly diagnosed, wondering if you have ADHD, or simply ready to take charge of your life - we're here to help. Have ...

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Child Mind Institute | Transforming Children’s Lives.

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

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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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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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Causes and Symptoms

Obsessive-compulsive disorder (OCD) is a disorder characterized by persistent intrusive and uncontrollable thoughts and the subsequent need to perform specific behaviors repeatedly. The presence of obsessions or compulsions must be time-consuming, cause distress or impairment, and be recognized as excessive or unreasonable by the person with OCD. The obsessions and compulsions must not be caused by medication, drug abuse, or another medical condition. Obsessive-compulsive behavior is highly distressing because it feels as if one’s behavior or thoughts are no longer voluntarily controlled. The more frequently these uncontrolled alien and perhaps unacceptable thoughts or actions are performed, the more distress is induced. An individual with OCD may at various times have either obsessions (which are thought-related) or compulsions (which are action-related), or both.

Dermatophagia - extreme nail biting/biting of skin to point of self-mutilating behavior is an obsessive compulsive disorder (OCD). By 6th Happiness (Own work) [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

Hoarding is an example of an obsessive compulsive disorder. By Grap (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

OCD affects 1 to 2.5 percent of the population. Onset is bimodal and typically occurs before the age of thirty; most of those afflicted begin suffering from the disorder in late childhood (mean age ten years) or early adulthood (mean age twenty-one years). Onset is often preceded by a stressful event such as pregnancy, childbirth, or family conflict. It may be closely associated with mood disorders such as depression or anxiety, with OCD developing soon after a mood disorder or the mood disorder developing as a result of the OCD. OCD affects men and women in roughly equal numbers.

Individuals with OCD generally recognize and are distressed by the irrational or excessive nature of their obsessions and compulsions. However, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) outlines specifiers for OCD related to the individual's degree of insight about the nature of their obsessions and compulsions, including good or fair insight, poor insight, and absent insight/delusional, which involves an absolute conviction that the OCD beliefs are valid and true. Obsessions generally fall into one of five recognized categories. Obsessive doubts are persistent doubts that a task has been completed; the individual is unwilling to accept and believe that the work is done satisfactorily. Obsessive thinking is an almost infinite chain of thought, targeting future events. Obsessive impulses are very strong urges to perform certain actions, whether they are trivial or serious, that would likely be harmful to the affected person or someone else or that are socially unacceptable. Obsessive fears are thoughts that the person has lost control and will act in some way that will cause public embarrassment. Obsessive images are continued visual pictures of either a real or an imagined event. Common obsessions relate to contamination, safety, the fear of committing a socially unacceptable behavior, the need for order, and sexual or aggressive thoughts.

Four factors are commonly associated with obsessive characteristics, not only in people with OCD but in the general population as well. First, obsessive individuals are unable to control their mental processes completely. Practically, this means the loss of control over thinking processes, such as intrusive thoughts of a loved one dying or worries about hurting someone unintentionally. Second, there may be thoughts and worries over the potential loss of motor control, perhaps causing impulses such as shouting obscenities in public or performing inappropriate sexual acts. Third, many obsessive individuals may be afraid of contamination and suffer irrational fear and worry over exposure to germs, dirt, or diseases. The last factor is checking behavior, or backtracking previous actions to ensure that the behavior was done properly, such as checking that doors and windows are shut, faucets are turned off, and so on.

Compulsions may be either mild or severe and debilitating. Mild compulsions might be superstitions, such as refusing to walk under a ladder, knocking on wood, or throwing salt over one’s shoulder. Severe compulsions become fixed, unvaried ritualized behaviors; if these compulsions are not practiced precisely in a particular manner or a prescribed number of times, then intense anxiety may result. These strange behaviors may be rooted in superstition; many of those suffering from the disorder believe that performing the behavior may ward off danger. Compulsive acts are not ends in themselves but are “necessary” to produce or prevent a future event from occurring. Although the enactment of the ritual may assuage tension, the act does not give the person with OCD pleasure.

Common compulsions include cleaning, checking, counting, arranging, touching objects, hoarding, seeking reassurance, and making lists. For people with repeating compulsions, they must do everything by numbers. Checking is another compulsive act; a compulsive checker believes that it is necessary to check and recheck that everything is in order. Cleaning is a behavior in which the person believes he or she must engage; they may wash and scrub repeatedly, especially if they think that they have touched something dirty. A fourth common compulsive action is avoidance; for certain superstitious or magical reasons, certain objects must be avoided. Some individuals with compulsions experience compelling urges for perfection in even the most trivial of tasks; often the task is repeated to ensure that it has been done correctly. Some determine that objects must be in a particular arrangement; these individuals are considered “meticulous.” A few people with OCD have hoarding compulsions; they are unable to throw away trash or rubbish. Many individuals have a constant need for reassurance; for example, they want to be told repeatedly that they have not been contaminated.

The direct cause of OCD is uncertain, and no single cause for OCD has been isolated. Sigmund Freud (1856–1939) first proposed that obsessive thoughts are a replacement for more disturbing thoughts or actions that induce guilt or anxiety in the sufferer. However, this view has been discredited, and today it is believed that OCD is caused by a complex interaction of genetic, behavioral, cognitive, cultural, and neurobiological factors. OCD tends to run in families; however, genes appear to be only partly responsible for causing OCD. Twin studies have suggested that genetic factors influence 45 to 65 percent of cases of childhood-onset OCD and 27 to 47 percent of adult-onset OCD. Other suspected influences include abnormalities with the neurotransmitter serotonin in the brain.

Treatment and Therapy

Diagnostic techniques evaluating OCD usually involve psychological evaluation. It is important to determine whether an individual is actually suffering from OCD or other potential problems such as schizophrenia or a mood disorder. Additionally, it is important to determine whether more than one disorder is present. OCD may occur in conjunction with other disorders, such as substance use disorders, eating disorders, and mood disorders. When this occurs, treatment must be adjusted. For example, when depression is also noted, both disorders must be addressed in treatment. OCD is related to other disorders characterized by repetitive behaviors and intrusive thoughts, including body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder.

In cases when differentiation is required between OCD and schizophrenia, the concern is to understand the nature of the dysfunctional thoughts and behaviors. For instance, a distinction can be made by determining the motive behind the ritualized behavior. Stereotyped behaviors are symptomatic of both disorders. In the person with schizophrenia, however, the behavior is triggered by delusions rather than by compulsions. People suffering from delusions do not resist the ideas inundating their minds, and ritualized behavior does not necessarily decrease the feelings associated with the intrusive ideas. On the other hand, people with OCD usually experience decreases in anxiety when they perform their rituals and may be absolutely certain of the need to perform their rituals, though other aspects of their thinking and logic are perfectly clear. They generally resist the ideas that enter their minds and realize the absurdity or abnormality of the thoughts to some extent. As thoughts and images intrude into the mind, the person may sometimes appear to have symptoms that mimic schizophrenia.

Other problems having symptoms in common with OCD are stimulant abuse, Tourette syndrome, and other tic disorders. What seems to separate the symptoms of these disorders from those experienced with OCD is that the former are organically induced. Thus, the actions of a sufferer from Tourette syndrome may be mechanical since they are not purposely enacted. In the case of the stimulant user, the acts may bring pleasure and are not resisted, but reinforced by the drug effects.

Most people experience obsessive thoughts on occasion; in fact, the obsessions of individuals without OCD are not significantly different from the obsessions of those with OCD. The major difference is that those with the disorder have longer-lasting, more intense, and less easily dismissed obsessive thoughts. The importance of this overlap is that mere symptoms are not a reliable tool to diagnose OCD, since some of the same symptoms are experienced by the general population.

Assessment of OCD separates the obsessive from the compulsive components so that each can be examined. Obsession assessment should determine the triggering fears of the disorder, both internal and external, including thoughts of unpleasant consequences. The amount of anxiety that these obsessions produce should be monitored. The compulsive behaviors then should be examined in the same light. DSM-5 criteria include the presence of time-consuming (more than one hour per day) obsessions and compulsions that cause significant distress; that interfere with or reduce the quality of the individual's social, academic, or occupational functioning; and that are not better explained by another mental disorder or substance use.

The greatest chance for successful treatment occurs with individuals who experience mild symptoms who seek help soon after the onset of symptoms and who had few problems before the disorder began. Many valuable and successful treatment strategies are available for OCD. The American Psychiatric Association and the US National Institute for Health and Care Excellence (NICE) recommend exposure-and-response-prevention, a form of cognitive-behavioral therapy (CBT), and/or selective serotonin reuptake inhibitors (SSRIs) as first-line treatments, depending on the patient's preference, the level of OCD complexity and severity, and the presence of depressive symptoms. The NICE recommends low-intensity CBT alone for mild cases of OCD.

The most effective treatment for controlling OCD is the behavioral therapy. CBT involves the identification of misperceptions and negative thoughts and repeated attempts to challenge these beliefs and replace them with less distressing thoughts. CBT may include psychoeducation, cognitive training, mapping OCD target symptoms, and exposure-and-response-prevention therapy. Exposure-and-response-prevention therapy (also called exposure-and-ritual-prevention therapy) is a form of CBT specifically designed to treat OCD symptoms. It involves gradual yet prolonged confrontation with the anxiety-producing stimuli in the presence of a supportive therapy. This exposure often begins with imagined stimuli or photographs and eventually progresses to real-life exposure to the anxiety-provoking stimuli. The exposure continues until the person's anxiety decreases, in a process called habituation. Exposure-and-response-prevention therapy also involves active abstinence from rituals and compulsive behaviors, although this approach does not involve active blocking of the person's compulsions. Exposure-and-response-prevention therapy is highly effective in the treatment of OCD, particularly when the client has less severe forms of OCD, does not have a comorbid diagnosis of depression, adheres to exposure homework early in the therapeutic process, has contamination fears or overt ritualistic behaviors, and has undergone no previous treatment.

Therapeutic approaches to the treatment of OCD may be supplemented with medications. Selective serotonin reuptake inhibitors (SSRIs) are considered to be the first-line agents for the treatment of OCD and often have remarkable effects on OCD, helping individuals to experience a change in their thinking and behavior, as well as providing relief. SSRIs appear to improve OCD symptoms compared with tricyclic antidepressants or monoamine oxidase inhibitors. Approximately 40 to 60 percent of persons with OCD will respond to SSRIs.

Some psychiatrists may recommend neurosurgery to relieve a patient’s symptoms in very severe or intractable cases. Cingulotomy and deep brain stimulation are reported to reduce symptom severity in patients with treatment-refractory OCD. Electroconvulsive therapy has also been reported to be effective in the treatment of OCD in case reports; however, no high-quality, placebo-controlled trials have studied the efficacy of this treatment. Alternative treatments for OCD that have demonstrated benefit include kundalini yoga, mindfulness meditation, and progressive muscle relaxation.

Perspective and Prospects

Descriptions of OCD-like behavior go back to medieval times; a young man who could not control his urge to stick out his tongue or blurt out obscenities during prayer was reported in the fifteenth century. Medical accounts of the disorder and the term “obsessive-compulsive” originated in the mid-nineteenth century. At that time, obsessions were believed to occur when mental energy ran low. Later, Freud attributed the characteristics to a regression to early childhood, when there are perhaps strong urges to be violent and/or to dirty and mess one’s surroundings. To avoid acting on these tendencies, he theorized, an avoidance mechanism is employed, and the symptoms of obsession and/or compulsion appear.

Although not totally disabling, OCD behaviors can be strongly incapacitating and cause a significant amount of distress. Most parents will agree that children commonly have rituals to which they must adhere or compulsive actions they carry out. A particular bedtime story may be read every night for months on end, and children’s games involve counting or checking rituals. It is also not atypical for adults without psychiatric disorders to experience some mild obsessive thoughts or compulsive actions, as seen in an overly tidy person or in group rituals performed in some religious sects. Excessively stressful events may trigger obsessions as well. Further research into the biopsychosocial causes of OCD will be important in developing future treatment approaches.

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Working to deliver a better special education service

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Abstract

A substantial proportion of noncommunicable disease originates in habitual overconsumption of calories, which can lead to weight gain and obesity and attendant comorbidities. At the other end of the spectrum, the consequences of undernutrition in early life and at different stages of adult life can also have major impact on wellbeing and quality of life. To help address some of these issues, greater understanding is required of interactions with food and contemporary diets throughout the life course and at a number of different levels: physiological, metabolic, psychological, and emotional. Here we review the current literature on the effects of dietary manipulation on anxiety-like behaviour. This evidence, assembled from study of preclinical models of diet challenge from gestation to adult life, supports a role for diet in the important connections between psychology, physiology, and behaviour. Analogous processes in the human population in our current obesogenic environment are likely to contribute to individual and societal challenges in this area.

1. Introduction

The quality and composition of the food we eat is under constant scrutiny, and there are numerous factors which affect our food selection and preferences. The disparate properties of the food we consume themselves act in a regulatory feedback system to impact on our future choices. One way in which food may influence subsequent choice is by affecting mood and consequently behaviour. Although it is recognised that mood can affect what we eat, here we consider how food affects our mood and, in particular, anxiety levels.

The fat and sugar content of contemporary diets and of processed foods, in particular, is a high profile issue for consumer groups, the media and health professionals. There is also increasing pressure from public health bodies and governments to reduce the amounts of fats and sugars, along with salt, in our diet. However, there may be unexpected consequences of such changes as our bodies may respond not only to the presence of these substances in our diets but also their absence, following a dietary manipulation. Withdrawal of dietary components has the potential to influence future food choices and also our emotional health. Generic, calorie restriction, and weight loss diets usually fail to produce the desired long-term outcomes, but increased awareness of the effects of the composition of our diet over both the short and the long term may increase our ability to adapt our diets successfully to improve both metabolic and emotional wellbeing.

Anxiety is linked to prevalence of disease [ 1]. People with mood disorders often have poor quality diets which are low in fruits and vegetables but high in fat and sugar [ 2]. Increasingly, modified diets are being used to treat behavioural and mood disorders such as attention deficit disorder, where diets low in sugar and high in fatty acids are recommended [ 3]. Children have less control over their food choice than adults as they are highly influenced by their parents [ 4]. However, children do have a reputation for knowing what they want to eat and being "picky" eaters, and high levels of anxiety have been shown to increase selective or fussy behaviour [ 5]. Dietary choice, whether it is quality/composition or quantity, is also affected in overweight adults who report increased calorie intake when they are under stress [ 6]. Stress can interact with eating behaviour in a number of ways regardless of an individual's normal eating habits [ 7].

Nutrition and anxiety can have both independent and interactive negative impacts on health. The life stage at which either of these factors becomes unbalanced impacts on the severity of the outcome. Consequently, insults which occur during critical sensitive stages in development, especially in utero or in early life may have long-lasting consequences. This emphasises the importance of maternal diet and diet during adult life, and their interaction with mental health. The aim of this review is to bring together existing knowledge of how food components affect anxiety at various stages of development, while highlighting some major gaps in our current understanding.

2. Measures of Anxiety

Tests for anxiety focus mainly on an animal's normal response to a novel environment or object(s) and measure changes in locomotion, exploration, and reactive behaviour (e.g., preference for enclosed and dark environments) as well as changes in acute behaviour such as grooming and rearing (see for common tests). Tests for anxiety tend to be less challenging to the animal than those for depression, which often attempt to enforce behaviour such as swimming or an escape response. Detailed information on behavioural tests for anxiety and the differences between anxiety and depression tests can be found elsewhere [ 8]. A wide variety of behavioural tests are used in drug testing but, in studies investigating dietary effects, elevated plus maze (EPM) and open field (OF) are the tests most frequently deployed. By their very nature these tests are affected by subtle variations in setting, manipulation, and indeed the strain or sex of the animal. Detailed evaluations of the more common maze tests are available [ 9, 10], setting out the limitations of the tests and differences between them. It is difficult to compare results between tests since exposure time, habituation, and prior experience of the test are all likely to affect the outcomes.

Table 1

3. Effects of Diet

Concern over obesity and metabolic disease, as well as their potential relationships with mental health disorders, has led to increasing emphasis on strategies to tackle poor eating habits. This has led researchers to investigate the emotional value of food, which may make an important contribution to diet choice [ 11, 12]. Dietary habits at various stages of life from gestation into adulthood have been connected not only to disruption of energy balance but also to attention, mood, behavior, and anxiety disorders.

3.1. Maternal Nutrition

Increased risk of developing numerous conditions including obesity, metabolic disease, mental health issues, and anxiety has been linked to poor early nutrition, particularly during critical stages of in utero development [ 13]. One example of a mental disorder which has been linked to obesity is attention deficit/hyperactivity disorder (ADHD), where mothers of children with the condition are twice as likely to be obese as mothers of children without the condition [ 14, 15], illustrating that maternal nutrition may affect the mental health and behaviour of offspring. However, there are likely to be confounding issues related to the mother's health in these studies, and this supports preclinical work currently being undertaken to identify the association between mental health and maternal nutrition as in animal models health can be closely monitored and food intake and diet closely regulated.

Various maternal diets in rodents have been shown to impact on circulating hormone levels which are likely to contribute to increased susceptibility to disease. Maternal high-fat diets increased circulating leptin and insulin levels [ 16], as well as desensitising the dopamine system [ 17], which affected the offspring's feeding behaviour. Another study using maternal high-fat (saturated or trans fat) feeding from 4 weeks prior to mating through until weaning, showed that while a diet high in saturated fat increased circulating leptin levels in both male and female offspring, anxiety, as assessed on the elevated plus maze (EPM), was increased only in male rats and apparently irrespective of the composition of maternal high-fat feeding [ 18]. This suggests that behavioural effects may have some sex specificity although this requires further investigation. Links between maternal diet and anxiety have also been associated with the mood regulating neurotransmitter, serotonin [ 19]. Peleg-Raibstein et al. showed increased anxiety in the EPM in a model of maternal high fat-feeding (dams fed 60% high-fat diet prior to mating through to weaning) and also suggest that this effect on anxiety is due to elevated serotonin in the ventral hippocampus as a result of the maternal high-fat feeding [ 20]. Again using 60% high-fat diet prior to mating through until weaning, Sasaki et al. showed that males decreased time in centre of OF, females spent less time in open arms of EPM, but no differences were seen in the light dark box [ 21]. In terms of hormonal changes, this study also reported that offspring from dams on a high-fat diet had reduced corticosterone levels while the corticosterone receptors had increased abundance in the amygdala of females only [ 21].

Maternal diets composed of mixed palatable "junk" food or cafeteria feeding have been demonstrated to increase expression of opioid receptors and reduce dopamine transporters in offspring during early life. Although this effect appears to be reversible in later life, it suggests that the maternal diet is responsible for reduced sensitivity of opioid and dopamine signalling [ 22]. Also focusing on the effects of cafeteria diet, Wright et al. showed that dams fed cafeteria diet from weaning to mating produced male offspring that had reduced anxiety, increasing open arm exploration in the EPM and reducing latency to enter the centre of the open field [ 23]. Even providing this diet during the lactation phase only influenced dopamine and serotonin levels of the offspring [ 24]. There are numerous reasons why a cafeteria style diet might have different consequences to the high-fat diets described above. For instance, shows some of the central and peripheral factors which are affected by maternal diet and have been implicated as potential mediators of diet-regulated anxiety. The potentially high-sugar content of a mixed cafeteria style diet may also be responsible for counteracting the effects of the fat content or perhaps the more defining characteristic of a cafeteria diet; namely, the high variability and increased novelty and choice of food types may allow individuals to adapt their diet consciously or subconsciously to best suit their requirements to minimise anxiety.

Perturbations in supply of other macronutrients during early life may also impact on emotional behaviour, with low consumption of key dietary components such as protein affecting anxiety behaviour of offspring. For example, one study showed that protein restriction during pregnancy, but not lactation, increased anxiety as measured by EPM and decreased motivation for sucrose solution in operant system, but without effect on sucrose preference when given free access [ 25]. Likewise, another study of protein restriction from lactation onwards using foster dams found that anxiolytic drugs had little differential effect on anxiety of these animals in the EPM compared to rats on a standard diet, suggesting that any effects of malnutrition, in particular protein restriction, are likely to occur earlier in development [ 26].

3.2. High Fat

Alsiö et al. showed an inverse relationship between high-fat feeding of rats and anxiety in the EPM [ 27], and this was supported by A. Prasad and C. Prasad who found that diets high in fat but not those high in carbohydrates or protein were anxiolytic after just 1 week of dietary intervention [ 28]. In the light dark box paradigm, mice on a high-fat diet showed no response to an enforced stress whereas mice on a low-fat diet reduced the time spent in the light box by approximately 30% [ 29].

By contrast, Buchenauer et al. describe a reduced level of activity with changes in generic behaviour such as rearing (decreased) and grooming (increased) as indicators of increased anxiety in rats following exposure to a 35% high-fat diet for 8 weeks [ 30]. Likewise, mice fed a 58% high-fat diet for 12 weeks in order to promote obesity have shown increased corticosterone prior to and following a stressor as well as anxiogenic responses in OF and EPM [ 31]. This raises the issue of the implications of dietary regime on baseline anxiety and on responses to subsequent exposure to stressful experiences.

As is frequently the case with dietary manipulations, the precise composition of the diet may be an important variable influencing the experimental outcomes. Accordingly, it has been suggested that saturated fatty acids are less anxiogenic than trans fats [ 32], so the source of fat in the diet may be as important as the quantity given. As indicated briefly above, both the quantity and type of fat in the diet vary across current reports on anxiety, along with the duration of feeding, all of which may impact on the anxiolytic or anxiogenic outcomes of high-fat diet feeding.

3.3. High Sugar

Solid chow diet enriched with sucrose appears to increase anxiety in rats as indicated by decreased time spent in the light chamber of a light-dark box although there was no effect on OF exploration [ 33].

Little work has been done on the direct anxiogenic properties of sugar in the diet although there is more information on the effects of subsequent withdrawal of sugar. Withdrawal of a liquid high-sugar chocolate-flavoured diet in rats increased anxiety on the EPM and also increased corticotropin-releasing factor (CRF) expression in the amygdala [ 34]. Interestingly, these rats were also hypophagic on standard chow. This same diet, even if provided for a short period of time (10 minutes) following a period of food deprivation, induced changes in hormonal levels and behaviour, with increased leptin, decreased ghrelin, and increased anxiety as measured in the EPM [ 35] suggesting that the anxiogenic effects of a palatable diet are fast acting and seen almost immediately after presentation of the food. The work of Avena and Hoebel and colleagues on withdrawal from sugar has been widely cited as a model of food addiction. With this model, rats habituated to intermittent feeding on sucrose were less willing to enter the open arms of the EPM after sucrose had been withheld suggesting an increased state of anxiety similar to that seen during withdrawal from addictive drugs [ 36]. It is interesting to note that this work has been done on withdrawal from sweetened liquids, and the form and schedule in which sugar is presented may affect quantities consumed and the extent of effects on anxiety.

Longer-term effects of a high-sugar diet were described by Souza et al. [ 33] who reported that after 4 months rats showed increased anxiety in the light/dark box but no effects in the OF setting. This again raises the question of the comparability of results from different behavioural paradigms and whether experimental examination of a greater range of tests could be revealing.

3.4. Mixed Palatable Diets

High-energy diets with a mixed composition of fat and sugar are known to result in memory deficits [ 37]. However, due to what may be opposing effects of fat and sugar on anxiety, as outlined above, it is difficult to predict their impact on behaviour and anxiety, and limited work has been done in this area.

Exposure to a "comfort" diet enriched with sugar and fat for just 6 days decreased corticosterone levels in rats following a foot shock stressor but did not affect basal levels. Anxiety behaviour was also decreased in an OF arena but no effects were observed either before or after stress in the EPM [ 38]. Likewise, stress responses to neonatal handling and early life isolation can be ameliorated by the anxiolytic effects of palatable diet high in fat and sugar [ 39], with increased locomotion and reduced anxiety in both the EPM and OF paradigms. This was confirmed in other work where stress was induced by isolation (maternal separation) and high-fat diets were reported to ameliorate anxiety in the EPM and light dark box in both dams [ 41] and pups [ 40- 42]. It may be important that the diets were given in a cafeteria style and were also high in sugar.

Withdrawal of palatable (high fat, high sugar) diets has been shown to increase anxiety in obesity-prone animals in the OF paradigm as well as to increase motivation (operant lever pressing) for sucrose pellets compared to animals on the same feeding schedule but classed as being obesity resistant based on relative weight gain [ 43]. This would support the theory that preference for a diet or predisposition to consume a higher intake may interact with the primary diet effect and that effects on anxiety might be influenced by body phenotype rather than being solely diet dependent. Essentially, it appears that anxiety and diet and energy balance are likely to be interrelated. This will complicate attempts to distinguish between cause and effect, particularly with a mixed cafeteria style diet.

3.5. Irregular Eating

It is not only the components of the diet that affect anxiety behaviour. The frequency and regularity of feeding also affect circulating hormones and impact on behaviour due to effects on the circadian rhythms of the regulatory feeding and reward systems [ 44]. Models of irregular feeding can be considered to mimic the sporadic eating habits of dieters. Feeding a mixed high fat, high sugar diet to rats on an intermittent schedule either 2 hours a day or 3 days a week blocked the elevation of corticosterone associated with restraint stress seen in rats fed the palatable diet ad lib [ 45]. Rats given alternating access to a preferred high-sugar chocolate-flavoured diet had decreased activity and decreased time in the open arm of the EPM upon withdrawal from the preferred high sugar diet [ 46], and anxiety behaviour was greatest in those animals with the greatest propensity to binge. This may reinforce a cycle where mood or anxiety determines intake and the availability of certain foods feeds back on mood and behaviour.

4. Mechanisms

There are a number of possible mediators of the effect of diet on anxiety-like behaviour, including both peripheral and central mediators such as corticosteroids, insulin leptin, acetylcholine, serotonin, opioids and dopamine. The potential contribution of these factors is considered here in relation to the various palatable diets discussed previously.

The ability of maternal environment to influence the health status of offspring has been linked to various physiological changes associated with both over- and undernutrition of the mother [ 47]. There is evidence that hormones associated with energy status of the mother such as insulin and leptin as well as expression of neurotransmitters associated with reward such as dopamine can impact on anxiety and other behaviour disorders of offspring [ 48]. Also, the disregulation of serotonin, which also plays an important role in regulating neurogenesis and synaptogenesis and is affected by diet and stress [ 49], has been strongly linked to effects of maternal high-fat diet on anxiety in offspring [ 19, 50]. It has also been suggested that undernutrition of the mother alters the HPA axis of the offspring [ 51] and increases corticosterone [ 52], and these changes have all been associated with mediating the anxiety phenotype of the offspring. All of these factors may contribute to the overall impact that maternal diet can have on the anxiety levels of offspring and associated behaviour. Nutritional insult in early life may also influence the developing brain and behaviour and mental health in later life via epigenetic programming mechanisms [ 53].

In adults there are a number of common components of the stress, reward, and homeostatic pathways that link feeding behaviour, dietary choice, and anxious behaviour. While the hypothalamus is classically known for its role in the regulation of food intake and energy balance, corticosteroid receptors in this part of the brain are also known to be involved in the stress response, and this may provide a link between mood or anxiety levels and macronutrient preference or intake quantities [ 54, 55]. Circulating corticosterone is commonly measured as an indicator of stress and has been reported several times to be influenced by diet. Although it may be difficult to distinguish whether this is a result of rapid weight gain or a particular dietary component, the speed of the response would suggest the latter. A study by Ortolani et al. showed attenuation of corticosterone induction following stress after just 6-day exposure to a palatable diet compos of high fat and high sugar cafeteria style food although no effects of diet were seen on basal corticosterone levels [ 38]. Similarly, exposure to 30% sucrose solution had no effect on basal corticosterone but suppressed the anxiogenic effects of restraint stress [ 56]. By contrast, Buchenauer et al. describe elevated corticosterone levels in diet-induced obese rats following 8 weeks on a high fat-diet [ 30]. In mice there were no effects of HF diet on the HPA axis following a forced swim stress [ 29] although the diet did protect against stress-(social defeat) induced anxiety and depressive behaviour. Overall, this body of data appears to suggest that diet itself does not generically affect corticosterone or stress levels but may mediate the (protective) response to additional anxiogenic environments or stresses.

High-fat diets result in alterations to the circulating levels of insulin, and the resulting resistance to leptin has been associated with cognitive deficits in mice [ 57]. In a similar manner, mice provided with a 10% sucrose solution also became insulin resistant and had impaired cognitive function [ 58].

Morganstern et al. suggest a role for acetylcholine in the mediation of the effect of high-fat diet in reducing anxiety. These studies showed that high-fat diet increased open arm entries in the EPM and increased exploration of a novel object but, interestingly, also induced a reduction in acetylcholine esterase suggesting that high fat diet may increase neurotransmission via acetylcholine in the frontal cortex and hypothalamus [ 59]. In terms of sugar intake, acetylcholine has also been implicated in the generation of anxiety. Avena et al. described elevated acetylcholine levels in the nucleus accumbens as well as suppressed levels of dopamine, and suggested that these may be responsible for increased anxiety following withdrawal from sucrose [ 36]. Review of various types of anxiety disorders in humans and rodents has identified similarities in the activation of neuronal pathways in the medial prefrontal cortex [ 60, 61].

The central feeding pathways are known to contain orexigenic and anorexigenic neuropeptides which are responsive to changes in diet and energy status, but their role in behaviour, mood, and, indeed, anxiety regulation is less well understood. Recently, it has been shown that stress which results in anxious behaviour increases activation of POMC and AGRP in arcuate neurons [ 62], while ablation of POMC neurons in the hypothalamus creates a phenotype with increased anxiety-related behaviour on the EPM [ 63]. There is also some evidence that treatment with NPY can influence anxiety although contradictory findings make it difficult to determine the role it may play [ 64]. This would suggest that there is some potential for "traditional" feeding pathways to also mediate anxiety-related behaviour in response to diet.

Opioid pathways are strongly involved in preference for certain types of food, and, in a study where rats were divided into groups based on fat or sugar preference, responses differed depending on the opioid system being challenged [ 65]. Injection of opioid agonists increased fat preference, but when sweet foods were preferred over high-fat foods, neither the agonist, DAMGO, nor the antagonist, naltrexone, injected into the PVN affected the amount of preferred food consumed [ 65]. However, in a similar study looking at rats that had developed a food preference, the antagonist, naltrexone, injected into the amygdala, suppressed intake of the preferred food without affecting intake from other foods [ 66]. μ-opioid receptors have also been shown to play a crucial role in motivation for and liking of sugar (sucrose) and fat (corn oil), where an antagonist injected into the nucleus accumbens shell of rats produced fully reversible changes in feeding behaviour [ 67]. Likewise, opioids have a known role in anxiety; activation of delta opioid receptors suppresses anxious behaviour in the EPM [ 68]. For a review on the role of opioids in anxiety, see [ 69]. This confirms a dual role of opioids in mediating the intake of palatable foods and in regulating anxiety, making them likely facilitators of the effects of high-fat and high-sugar foods on anxiety-related behaviour.

Levels of dopamine receptor (D) expression within the nucleus accumbens are responsive to high-fat diet, with D1 levels decreasing and D2 levels increasing [ 31]. This would suggest that the ratio of these receptors may be important in mediating what is, in this case, an anxiogenic effect of high-fat diet. High-sugar diets have also been found to affect dopamine receptor expression. In a model of intermittent exposure to sucrose Spangler et al. showed that there was also variation in the response of dopamine receptors in the nucleus accumbens to high-sugar consumption which decreased D2 and increased levels of D3 [ 70].

shows a summary of some of the potential mediators involved in diet-anxiety interactions. This highlights that there appear to be interactions between classical homeostatic feeding pathways, both peripheral and central, stress pathways, and central reward pathways in response to both diet and anxiety, which then give rise to behavioural outcomes. The exact relationships are however still unclear and further research is needed to identify the specific involvement of different brain regions and the hormones and neurotransmitters involved in these interactions.

5. Discussion

The effects of mood on eating habits and preferences have been investigated at a number of levels and over an extended period [ 71], but it is only recently that the focus of such investigation has been turned on its head through examination of the effects of diet and food components on mood, behavior, and future dietary preferences. Here, we have examined the effects of diet on anxiety-related behaviour and have highlighted that foods high in fat and/or sugar, or that are highly palatable, have the potential to impact on behaviour in animal models and, by extrapolation, in humans. Whether food modulates anxiety through anxiolytic or anxiogenic actions is likely to depend not only on its composition, but also on previous dietary experiences and maternal diet during and prior to pregnancy as well as contemporary stress-inducing experiences. This makes the role of food in regulating anxiety a highly complex topic, but also an area where increased understanding could lead to the development of strategies to use and adapt food and eating behaviour to beneficially address metabolic and mood disorders.

Currently, it appears that high fat is anxiolytic while diets high in sugar may have more anxiogenic characteristics. In terms of human lifestyle choices the situation is likely to be less clear cut, and mixed palatable diets are perhaps more relevant. Typically therefore, it is these diets which offer the greatest challenge of interpretation and manipulation, being highly variable in composition. Nevertheless, there is potential for these diets to be optimised and designed with beneficial effects for anxiety and general health.

Variation in mood affects food choice, shifting food preference towards foods high in fat and sugar [ 72], but, in the light of the evidence discussed above, this modification in preference may lead in turn to changes in anxiety and mood, thereby creating a feedback cycle. It is possible that in the wild, and across human evolution, consuming a high energy diet and being "cautious" could constitute beneficial behaviour conferring survival advantage and ensuring ingestion of sufficient energy supplies while reducing risk of predation. It can be speculated that ingestion of an anxiogenic food could lead to increased wariness and ingestion of familiar foods, whereas anxiolytic foods could increase exploration of the environment, and discovery of new palatable foods. Either scenario could have the potential to change behaviour and the mix of macronutrients and energy in the diet. In modern society with its wide range of food choice but where obesity and anxiety disorders are increasing, increased understanding of relationships with food at psychological and physiological levels including the associations between dietary choice and mood may be relevant to longer-term metabolic and mental health and be amenable to manipulation.

The research described above has all focused on common strains of laboratory rodents. It is important to remember that there are two reasons why an animal may be anxious. It may be predisposed to have an anxious character, for example, through genetic manipulation or selective breeding. This is known as trait anxiety. However, anxiety in response to stress or diet is known as state anxiety, and it is this form of anxiety that is most relevant here. However, it would be interesting to see whether responses to diet differ depending on the initial trait anxiety of the animal and, indeed, whether diet could be anxiolytic under these conditions. The choice of stock diets fed in such studies could then become important in terms of alleviating the side effects of drugs and improving animal welfare and even lifespan. In terms of diet-regulating anxiety, it is the basal levels of anxiety which are perhaps most interesting, but it will also be important, from the point of view of animal welfare, to establish the extent of the dietary effect on behaviour before challenging the animal to further stress or treatments.

Although research in this area is gathering momentum, a key issue in this and other related areas is the difficulty in comparing the outcomes of trials that involve differences in diet, species, strain, sex and life stage, and so forth, coupled to variation in duration, environment, and outcome measure. These issues have been aired in the context of diet-induced obesity in adult life [ 73, 74] and also apply to dietary impact on anxiety behaviour. Given the endless possibilities of diets that could be investigated under different feeding schedules, it would be pragmatic to focus on core dietary components in order to build up as complete a picture as possible. Even with the high profile already being afforded diets high in fat and sugar, there are still very large gaps in current knowledge. The effects of high-sugar diets during pregnancy, for example, have to date been studied to only a limited degree. Also, the quantities of fat or sugar needing to be consumed before there is a measurable effect, how long lasting is that effect, and how is it affected by trait anxiety and random stressful events remain to be determined.

The body of evidence reviewed here strongly supports the contention that diet has the potential to induce or ameliorate anxiety-related behaviour, but it remains to be definitively established how these events are regulated and whether there is potential to use these pathways to identify diets which may be beneficial in promoting healthy energy balance and mental health.

Acknowledgments

The authors were funded by the European Community's 7th Framework Programme under Grant agreement 245009 (NeuroFAST) and by the Scottish Government.

References

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A substantial proportion of noncommunicable disease originates in habitual overconsumption of calories, which can lead to weight gain and obesity and attendant comorbidities. At the other end of the spectrum, the consequences of undernutrition in early life and at different stages of adult life can also have major impact on wellbeing and quality of life.

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Credit: Julius-Maximilians-Universität Würzburg, JMU

An overactive molecular signal pathway in the brain region of the amygdala can lead to obsessive-compulsive disorder (OCD). A research team from Würzburg has established this connection.

Some people have an extreme fear of dirt or bacteria. As a result, they may develop a habit of compulsive washing and repeatedly cleaning their hands or body. They are trapped in a vicious circle, as the fear of new contamination returns quickly after washing. Sufferers see no way out. They are even incapable of changing their behaviour when the excessive washing has led to skin irritation or damage.

Around two percent of the general population suffer from some kind of obsessive-compulsive disorder (OCD) at least once in their life. The disorder is characterised by persistent intrusive thoughts which the sufferers try to compensate for by repetitive ritualized behaviour.

Like depression, eating disorders and other mental diseases, OCD is treated with antidepressants. However, the drugs are non-specific, that is they are not tailored to the respective disease. Therefore, scientists have been looking for new and better targeted therapies that have fewer side effects.
Missing protein triggers urge to wash
Professor Kai Schuh from the Institute of Physiology at the Julius-Maximilians-Universität (JMU) Würzburg (Germany) and his team explore the underlying causes of obsessive-compulsive disorder in collaboration with the JMU's Departments of Psychiatry and Neurology.

"We were able to show in mouse models that the absence of the protein SPRED2 alone can trigger an excessive grooming behaviour," Schuh says. He believes that this finding is crucial as no clear trigger for this type of disorder has been identified until now. Previous research pointed to multiple factors being responsible for developing OCD.

Occurring in all cells of the body, the protein SPRED2 is found in particularly high concentrations in regions of the brain, namely in the basal ganglia and the amygdala. Normally, the protein inhibits an important signal pathway of the cell, the so-called Ras/ERK-MAP kinase cascade. When it is missing, this signal pathway is more active than usual.
Hyperactive signal cascade in the brain
"It is primarily the brain-specific initiator of the signal pathway, the receptor tyrosine kinase TrkB, that is excessively active and causes the overshooting reaction of the downstream components", biologist Dr. Melanie Ullrich explains.

Administering an inhibitor to attenuate the overactive signal cascade in the animal model improves the obsessive-compulsive symptoms. Moreover, the JMU research team was able to treat the OCD with an antidepressant, similarly to standard therapy in humans. Their detailed results have been published in the journal Molecular Psychiatry.
New targets for therapies pinpointed
"Our study delivers a valuable new model that allows the disease mechanisms to be investigated and new therapy options for obsessive-compulsive disorders to be tested," Professor Schuh says.

The recently discovered link between OCDs and the Ras/ERK-MAP kinase cascade also opens up new targets for therapy. Drugs that inhibit this cascade are already available and some of them are approved for human treatment.

According to Melanie Ullrich, these are cancer drugs, as overactivation of the Ras/ERK-MAP kinase cascade is also a frequent trigger of cancer: "So we are wondering whether such drugs could also be effective in the treatment of obsessive-compulsive disorders and whether they are beneficial in terms of side effects."

More information: M Ullrich et al. OCD-like behavior is caused by dysfunction of thalamo-amygdala circuits and upregulated TrkB/ERK-MAPK signaling as a result of SPRED2 deficiency, Molecular Psychiatry (2017). DOI: 10.1038/mp.2016.232

Provided by Julius-Maximilians-Universität Würzburg

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An overactive molecular signal pathway in the brain region of the amygdala can lead to obsessive-compulsive disorder (OCD). A research team from Würzburg has established this connection. Some people have an extreme fear of dirt or bacteria. As a result, they may develop a habit of compulsive washing and repeatedly cleaning their hands or body.

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Angelo State University - Library Online Resources

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From Dr. Tamar Chansky Creator of Worrywisekids.org

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Council for Children with Behavioral Disorders

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Inside Higher Ed | Higher Education News, Events and Jobs

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More than half of the college students who visited their campus counseling centers during the 2015-16 academic year reported symptoms of anxiety, according to a survey by the Association for University and College Counseling Center Directors.

This marks the seventh year in a row that anxiety has been the top complaint among students seeking mental health services. This year, 51 percent of students who visited a counseling center reported having anxiety, followed by depression (41 percent), relationship concerns (34 percent) and suicidal ideation (20.5 percent). Many students reported experiencing multiple conditions at once.

Since 2009, when anxiety overtook depression as the No. 1 concern among college students, the number of students experiencing anxiety has steadily increased.

This survey was conducted between September 2015 and August 2016. In total, 529 counseling center directors representing that many institutions responded to the survey, with an even split between public and private institutions. The majority of respondents came from four-year colleges, but community colleges, professional schools and art schools were also included.

In an effort to reflect the makeup of their student bodies, counseling centers have diversified their clinical staff members. Of new hires, 62.2 percent are white, 15.3 percent black, 7.5 percent Latino and 10 percent Asian. This compares to current clinical staff, who are 70.9 percent white, 10.1 percent black, 7.3 percent Latino and 7.9 percent Asian.

"Student populations have become more diverse," said Micky Sharma, president of the AUCCCD and director of counseling and consultation services at Ohio State University. "Counseling services work to create a staff that represents their student bodies."

At Ohio State, for example, the counseling center now offers clinical services in nine different languages to meet the needs of their international students, who make up about 12 percent of the student body, Sharma said.

Regardless of race, ethnicity, gender or sexual orientation, "anyone could show up with anxiety or depression or a relationship issue," Sharma said. "A university counseling center is charged with providing help for everybody."

Another key finding in the survey is that 41.6 percent of counseling centers hired additional staff members in the last academic year, compared to about 26 percent in 2011 and 36 percent in 2016.

College counseling centers continue to grow to match the demands of their students, according to David Reetz, the lead researcher and coordinator for the 2016 survey and director of counseling and psychological services at the Rochester Institute of Technology.

"More students are seeking services because we continue to be more and more aware that a student's health and well-being have a lot to do with their success in their academic programs and the quality of their student life experience," Reetz said.

In fact, of the students surveyed, about 72 percent who used counseling services said it helped their academic performance in some way.

As more students continue to seek out mental health services and campus counseling centers try to keep up with new hires, the question of student wait times becomes key.

For the first time, this year's survey asked counseling center directors about average wait times for students based on the number of business days between when the appointment was scheduled and when it occurred.

The survey team found that, on average, students waited between six and eight business days for counseling services. However, as might be expected, institutions with a lower ratio of professional staff to students saw shorter wait times.

Reetz noted that the wait-time average is a "tricky number," given that some students opt to schedule their first appointment farther out to accommodate their own schedules.

"Students don't necessarily want to be seen right away," Reetz said, adding that, generally, "the more staff a center has, the shorter that wait time is between initial contact and first appointment."

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Anxiety and depression are the primary concerns for students seeking counseling services

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Survey of campus counseling centers finds increased demand for services, as well as additional positions and more diversity in hiring.

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NYTimes How to help a child with anxiety

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NYTimes How to help a child with anxiety

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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.