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http://www.worrywisekids.org/node/40

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https://www.verywellmind.com/anxiety-disorder-2510539

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Anxiety disorders are serious mental illnesses that cause significant worry or fear that doesn't go away and may even get worse over time. We all feel anxious at times, but with an anxiety disorder, the anxiety tends to be fairly constant and has a very negative and intrusive impact on quality of life.

According to the National Institute of Mental Health (NIMH), approximately 19.1% of adults in the United States have some type of anxiety disorder. Women are also more likely to be affected by anxiety, which is why experts now recommend that women and girls over the age of 13 should be screened for anxiety disorders as part of routine medical care.

Types of Anxiety Disorders

There are several types of anxiety disorders. While all are characterized by symptoms of anxiety, each has its own unique set of characteristics, symptoms, and criteria for diagnosis.

Agoraphobia

Agoraphobia is an irrational and extreme fear of being in a situation where escape is impossible. People often fear that they will experience symptoms of panic or other symptoms in public, which leads them to avoid any situation where they may feel panicked, helpless, or trapped.

These avoidance behaviors are often life-limiting, often causing people to avoid driving, shopping in public, air travel, or other situations. In some cases, this fear can become so severe that people are unable to leave their homes.

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) involves excessive worry and anxiety related to various activities and events. This worry is difficult to control and often shifts from one concern to another.

While there is no specific threat, people with GAD find themselves feeling anxious about everyday daily events, current events in the news, relationships, or potential events that might occur.

Panic Disorder

Panic disorder involves experiencing intense and persistent panic attacks that occur unexpectedly with little or no warning. A panic attack has physical and emotional symptoms such as rapid heartbeat, increased respiration, and feelings of extreme terror.

Selective Mutism

Selective mutism is an anxiety disorder that occurs during childhood. It involves experiencing anxiety, embarrassment, or fear that prevents children from speaking in specific settings, such as while at school or around strangers.

Selective mutism usually occurs between the ages of two and four and is often accompanied by fidgeting, lack of eye contact, and lack of expressions when faced with a situation the child fears.

Social Anxiety Disorder

Social anxiety disorder (SAD), previously known as social phobia, involves a fear of social situations. This fear may center on specific events, such as public speaking, or may involve a more generalized fear of many different social situations.

People who have this condition have an exaggerated sense that other people scrutinize everything they do. They may be very critical of themselves and experience both physical and emotional symptoms of fear in social situations.

Such symptoms include shaking, racing heartbeat, stomach upset, and dread. These symptoms often lead people to avoid social situations whenever possible.

Specific Phobias

Specific phobias involve intense fear of a specific object or situation that is overwhelming, irrational, and out of proportion to the actual threat. When they encounter the source of their fear, people with a specific phobia experience immediate symptoms such as sweating, crying, shaking, rapid heartbeat, and increased respiration.

As often happens with other anxiety disorders, people with a phobia may go to great lengths to avoid the source of their fear. Such avoidance behaviors can cause additional stress and limit daily activities.

Are OCD and PTSD Anxiety Disorders?

The fifth edition of the " Diagnostic and Statistical Manual of Mental Disorders" (DSM-5), which healthcare providers use to diagnose mental health conditions,breaks what have generally been considered anxiety disorders into three categories:

Anxiety disorders

Obsessive-compulsive and related disorders

Trauma- and stressor-related disorders

This differentiation shows that while the disorders have a commonality and are related, they are distinctly different. These classifications have remained in place in the most recent edition of the diagnostic manual, the DSM-5-TR.

While OCD and PTSD are no longer officially categorized as anxiety disorders, they share many characteristics, and anxiety symptoms are common in both conditions.

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) involves experiencing intrusive thoughts, known as obsessions, and behaviors, known as compulsions. Before the publication of the DSM-5, OCD was considered a type of anxiety disorder, because these obsessions create significant anxiety for many people.

Obsessions may focus on things such as a fear of germs, a need to have things in a certain order, or disturbing thoughts about taboo topics. Compulsions are behaviors that people often engage in as a way to relieve the anxiety caused by obsessive thoughts. They might involve actions such as counting, ordering, checking, or washing.

Conditions related to OCD and also listed in the category "OCD and related disorders" include body-dysmorphic disorder, hoarding disorder, and trichotillomania.

Post Traumatic Stress Disorder (PTSD)

Post-traumatic stress disorder (PTSD) is a condition that can occur following a traumatic event. It includes symptoms such as changes in mood, arousal, and reactivity. People may have intrusive thoughts, memories, and nightmares related to the trauma. Flashbacks, hypervigilance, anxiety, and avoidance of reminders are other common symptoms.

Other trauma- and stressor-related disorders in this DSM group include adjustment disorders, and reactive attachment disorder

Recap

Anxiety Disorder Symptoms

Anxiety disorders come with a host of symptoms and no one person has the same experience. Each disorder tends to have different symptoms as well. The symptoms common to anxiety disorders in general include:

Difficulty sleeping

Dizziness

Dry mouth

Feelings of nervousness, worry, panic, fear, and unease

Muscle tightness

Nausea

Rapid or irregular heartbeat

Sweaty or cold hands and/or feet

Tingling or numbness in the hands or feet

Unable to be calm or hold still

When you experience the physical and psychological signs of fear and anxiety such as sweating, racing heart, shortness of breath, trembling, worry, or stress, these are cues that something is happening that could be a threat and that you need to deal with it.

This "flight or fight" reaction activates the physical and psychological resources necessary to deal with the potential danger. Although this system works well most of the time, sometimes it can go into overdrive and do more harm than good. When this happens, it might indicate you have an anxiety disorder.

Millions of American adults (as well as children and teens) will experience an anxiety disorder at some point in their lives. No one knows exactly what causes anxiety disorders, although genetics, environment, stress level, brain changes, and trauma may all play a role.

Researchers are discovering more about these links all the time. A combination of factors likely plays a role in causing anxiety conditions. Some factors that have been implicated include:

Brain chemistry: Severe or prolonged stress can contribute to changes in the chemical balance in the brain. Such changes can play a part in the onset of anxiety disorders.

Experiences: Stressful or traumatic events can also contribute to feelings of anxiety.

Family history: Having close family members with symptoms of anxiety disorders increases the risk that a person will also develop an anxiety condition.

Genetic factors: Certain genes may predispose a person to a higher likelihood of developing an anxiety disorder.

Medical conditions: Some underlying health conditions can contribute to feelings of anxiety. Some of these include chronic pain, heart disease, diabetes, thyroid problems, respiratory conditions, drug use, and drug withdrawal.

Personality: People with certain personality traits, such as introversion and neuroticism, may be more prone to experiencing higher levels of anxiety.

There are no lab tests that can be done to diagnose an anxiety disorder, though a doctor may perform some tests to rule out physical problems. Your doctor may refer you to a mental health professional, such as a psychiatrist, a psychologist, or a counselor, who will use specific diagnostic tools and questions to help determine what sort of disorder you may have.

A doctor or mental health professional will ask questions and use assessment tools to help determine if you have a disorder. They will want to know the nature of your symptoms, how long they last, and how severe they are. They will also want to understand how they interfere with your ability to function in your everyday daily life.

Healthcare practitioners use the "Diagnostic and Statistical Manual of Mental Disorders" (DSM) to diagnose these conditions. Each disorder in the DSM lists specific symptom criteria that a person must meet to be diagnosed with a particular condition.

Treatments

There are a variety of options available to treat anxiety disorders. A mental health professional can help determine what works best for you.

Psychotherapy

Psychotherapy can help people learn to manage the emotional, cognitive, and behavioral aspects of anxiety. One particularly effective form of psychotherapy for anxiety disorders is cognitive behavioral therapy (CBT). This approach focuses on helping people identify the automatic negative thoughts and cognitive distortions that contribute to feelings of anxiety.

Exposure therapy is another type of CBT that can be helpful for some types of anxiety. In this approach, people are gradually exposed to the things that they fear, often while simultaneously using relaxation techniques to help calm the body's stress response.

Medications

Some medications can also be prescribed to help relieve symptoms of anxiety. Some of the medications that are most often used for anxiety include:

Antidepressants can help alter the levels of certain neurotransmitters in the brain to help relieve symptoms of anxiety.

Benzodiazepines work quickly and are often used as a short-term treatment.

Beta-blockers are usually used to treat high blood pressure, but can also help relieve some of the physical symptoms of anxiety.

Coping Strategies

Coping strategies often focus on ways to manage anxiety more effectively. Lifestyle changes such as limiting caffeine intake, getting enough rest, and engaging in regular exercise may be helpful.

Stress management techniques including deep breathing, yoga, and progressive muscle relaxation can also be beneficial when managing feelings of anxiety. Apps for anxiety can help guide you through these techniques.

If you have an anxiety disorder, there are plenty of treatment options available to help you live your life to the fullest. Remember, treatment can take time before you and your physician discover the best options for you. Be patient and keep communication open with your mental health professional in order to figure out the plan best tailored to your individual needs.

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There Are Several Different Anxiety Disorders, Here's What to Know

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Anxiety causes significant worry or fear that doesn't go away and may even get worse over time. Learn the signs of anxiety disorders and treatments that can help.

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Branscome, J., Cunningham, T., Kelley, H., & Brown, C. (2014). ADHD: implications for school counselors. Georgia School Counselors Association Journal, 21(1).

Bray, B. (2020). Living with- and beyond- OCD. Counseling Today. https://ct.counseling.org/2020/01/living-with-and-beyond-ocd/

Conrads, K., & Petty, A. (2019). How school counselors can help with anxiety. Rhode Island School Counselor Association. https://www.schoolcounselor.org/Newsletters/January-2020/How-School-Counselors-Can-Help-with-Anxiety?st=RI#:~:text=Students%20with%20anxiety%20may%20benefit,who%20have%20not%20been%20identified.

National Institute of Mental Health. (n.d.). Bipolar disorder in teens and young adults: know the signs. https://www.nimh.nih.gov/health/publications/bipolar-disorder-in-teens-and-young-adults-know-the-signs

Pacer Center. (2012). Students with disabilities & section 504 of the rehabilitation act of 1973. https://www.pacer.org/parent/php/phpc33.pdf

Stump, S. (2020). The national suicide hotline prevention number will become 3 digits. Today. https://www.today.com/health/national-suicide-prevention-hotline-number-changing-t184914

Texas Education Agency. (n.d). Section 504. https://tea.texas.gov/sites/default/files/504_guide.pdf

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https://childmind.org/guide/bulimia-nervosa-quick-guide/

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What is bulimia nervosa?

Bulimia nervosa is an eating disorder in which a child has periods of out-of-control eating called binging. After eating way too much, the child tries to reverse the binging by doing what's called purging: throwing up on purpose, using laxatives, not eating, or exercising too much. Unlike kids with anorexia nervosa (who are usually extremely thin), kids with bulimia are usually normal weight or somewhat overweight. But the way they maintain their weight is very unhealthy. Bulimia is diagnosed more often in girls than boys and it usually starts in adolescence.

What are the symptoms of bulimia nervosa?

Children with bulimia often hide their binging and purging, so it can be hard to spot.

Common signs of bulimia include:

Eating a lot of food in a very short time

Making up for eating a lot by vomiting, using laxatives, not eating at all, or exercising too much

Having a self-image that is mostly focused on body weight

Missing a lot of meals

Rushing to the bathroom right after eating

Long periods of not eating

Being secretive about eating

Physical effects of vomiting, including sore throat, swollen glands, acid reflux, and teeth damaged by stomach acid

How is bulimia diagnosed?

To be diagnosed with bulimia, a child must eat large amounts of food in a short amount of time (binging) and be unable to control their binge eating. They must also try to make up for the binge eating by throwing up on purpose, using laxatives, not eating, or exercising too much. These behaviors are known as purging. Kids who are diagnosed with bulimia binge and purge at least once a week on average for three months.

The first goal of treatment for bulimia is always to help the child stop binging and purging, which can endanger their health. Two kinds of therapy are most commonly used to treat bulimia nervosa:

Cognitive behavioral therapy (CBT) can help kids understand what causes their binging and purging, develop a more positive body image, and change unhealthy eating habits.

Interpersonal therapy focuses on how the child's relationship with others affects their feelings and eating habits.

If therapy alone isn't working, anti-depressant medications are sometimes prescribed to children experiencing bulimia. Education about nutrition can also help kids learn about the health effects of bulimia and feel motivated to change their behavior.

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Quick Guide to Bulimia Nervosa - Child Mind Institute

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Download our free guide to bulimia nervosa in children and teenagers. Kids with bulimia nervosa have periods of out-of-control eating called binging. After eating way too much, they try to reverse the binging by throwing up, using laxatives, not eating, or exercising too much.

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https://embrywomenshealth.com/what-are-eating-disorders/

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https://jedfoundation.org/news-views/eating-disorders-are-on-the-rise-heres-how-educators-can-help-their-students/

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During the pandemic, eating disorder helpline calls increased by as much as 80% while the number of hospitalizations for adolescents with eating disorders more than doubled . Educators are often the first to identify signs of trouble in children and teenagers, and they can also be a powerful force in helping them get the support they need. That is why it's important that they are able to recognize the signs of an eating disorder and know what to do next.
What Should You Know About Eating Disorders?
Because there are so many myths and stereotypes about eating disorders, not all educators may know what to look for-or what to do if they are concerned.

The most important thing to know is that eating disorders don't have a "look." Eating disorders are complex, brain-based disorders; they can affect all genders, races, body sizes, and socioeconomic backgrounds. Contrary to common misconceptions, families are not to blame for eating disorders and sufferers don't choose to have these illnesses.
What Are Warning Signs You Might Observe in the Classroom?
While many people are aware that weight loss may be a symptom of an eating disorder, it is not the only indicator (and not every eating disorder causes weight loss).

Teachers may notice some of these common behavioral or personality changes:

Falling asleep in class

Feeling cold

Wearing baggy clothing

Not participating in food-based activities or celebrations

Preoccupation with earning straight As or "overworking" on assignments

Low energy or trouble focusing

Compulsive movement/exercise

Frequent illness or injury (stress fractures, etc.)

Excessive water consumption

Resistance to acknowledging or expressing emotions

It is important to note that while malnutrition can take a toll on a student's ability to concentrate and contribute in class, individuals struggling with an eating disorder can be high-achieving in academics and extracurriculars. In fact, an intense drive for excellence can be a sign that a student possesses the perfection-seeking temperament that accompanies many eating disorders.
What Steps Should You Take if You Are Concerned About a Student?
One especially challenging barrier is that a young person with an eating disorder may be experiencing anosognosia, the lack of ability to recognize their own illness . An otherwise logical student may deny troubling behaviors or weight loss.

If you suspect a student may be struggling, check your school's guidelines. Before addressing the student directly or taking further action, you might need to confer with a campus administrator, nurse, or counselor. Learn when it's the right time to reach out to a student or their parent/guardian.

If you do communicate directly with a student, try to approach them from a place of curiosity. Ask questions, listen, and offer words of compassion. Eating disorders are often shrouded in shame, so it is important to share your concerns in a warm, nonjudgmental tone. Even something as simple as "I'm worried, and I'm here to help" can open the door to a conversation.

You can also provide parents/guardians with further resources about eating disorders, such as The Jed Foundation's FAQ . Adults at home and those at school should work together to create a robust support system for young people with eating disorders.

Teachers, counselors, and administrators have a lot to juggle. You don't need to become an expert in eating disorders, but anyone working with young people should be aware of how these illnesses present-and what you can do about it. Caring educators can be life-changing for a student; and when it comes to mental health, they can be life-saving, too.
Oona Hanson is a former classroom teacher turned parent educator who helps families foster positive body image and a healthy relationship with food through her private practice and as a Family Mentor at . She holds a master's degree in Educational Psychology and in English.

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Eating Disorders Are on the Rise: Here's How Educators Can Help Their Students | The Jed Foundation

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During the pandemic, eating disorder helpline calls increased by as much as 80% while the number of hospitalizations for adolescents with eating disorders more than doubled . Educators are often the first to identify signs of trouble in children and teenagers, and they can also be a powerful force in helping them get the support they need.

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https://www.mayoclinic.org/diseases-conditions/eating-disorders/symptoms-causes/syc-20353603

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https://www.mayoclinic.org/diseases-conditions/panic-attacks/symptoms-causes/syc-20376021

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Overview

A panic attack is a sudden episode of intense fear that triggers severe physical reactions when there is no real danger or apparent cause. Panic attacks can be very frightening. When panic attacks occur, you might think you're losing control, having a heart attack or even dying.

Many people have just one or two panic attacks in their lifetimes, and the problem goes away, perhaps when a stressful situation ends. But if you've had recurrent, unexpected panic attacks and spent long periods in constant fear of another attack, you may have a condition called panic disorder.

Although panic attacks themselves aren't life-threatening, they can be frightening and significantly affect your quality of life. But treatment can be very effective.

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Symptoms

Panic attacks typically begin suddenly, without warning. They can strike at any time - when you're driving a car, at the mall, sound asleep or in the middle of a business meeting. You may have occasional panic attacks, or they may occur frequently.

Panic attacks have many variations, but symptoms usually peak within minutes. You may feel fatigued and worn out after a panic attack subsides.

Panic attacks typically include some of these signs or symptoms:

Sense of impending doom or danger

Fear of loss of control or death

Rapid, pounding heart rate

Sweating

Trembling or shaking

Shortness of breath or tightness in your throat

Chills

Hot flashes

Nausea

Abdominal cramping

Chest pain

Headache

Dizziness, lightheadedness or faintness

Numbness or tingling sensation

Feeling of unreality or detachment

One of the worst things about panic attacks is the intense fear that you'll have another one. You may fear having panic attacks so much that you avoid certain situations where they may occur.

When to see a doctor

If you have panic attack symptoms, seek medical help as soon as possible. Panic attacks, while intensely uncomfortable, are not dangerous. But panic attacks are hard to manage on your own, and they may get worse without treatment.

Panic attack symptoms can also resemble symptoms of other serious health problems, such as a heart attack, so it's important to get evaluated by your primary care provider if you aren't sure what's causing your symptoms.

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Causes

It's not known what causes panic attacks or panic disorder, but these factors may play a role:

Genetics

Major stress

Temperament that is more sensitive to stress or prone to negative emotions

Certain changes in the way parts of your brain function

Panic attacks may come on suddenly and without warning at first, but over time, they're usually triggered by certain situations.

Some research suggests that your body's natural fight-or-flight response to danger is involved in panic attacks. For example, if a grizzly bear came after you, your body would react instinctively. Your heart rate and breathing would speed up as your body prepared for a life-threatening situation. Many of the same reactions occur in a panic attack. But it's unknown why a panic attack occurs when there's no obvious danger present.

Risk factors

Symptoms of panic disorder often start in the late teens or early adulthood and affect more women than men.

Factors that may increase the risk of developing panic attacks or panic disorder include:

Family history of panic attacks or panic disorder

Major life stress, such as the death or serious illness of a loved one

A traumatic event, such as sexual assault or a serious accident

Major changes in your life, such as a divorce or the addition of a baby

Smoking or excessive caffeine intake

History of childhood physical or sexual abuse

Complications

Left untreated, panic attacks and panic disorder can affect almost every area of your life. You may be so afraid of having more panic attacks that you live in a constant state of fear, ruining your quality of life.

Complications that panic attacks may cause or be linked to include:

Development of specific phobias, such as fear of driving or leaving your home

Frequent medical care for health concerns and other medical conditions

Avoidance of social situations

Problems at work or school

Depression, anxiety disorders and other psychiatric disorders

Increased risk of suicide or suicidal thoughts

Alcohol or other substance misuse

Financial problems

For some people, panic disorder may include agoraphobia - avoiding places or situations that cause you anxiety because you fear being unable to escape or get help if you have a panic attack. Or you may become reliant on others to be with you in order to leave your home.

Prevention

There's no sure way to prevent panic attacks or panic disorder. However, these recommendations may help.

Get treatment for panic attacks as soon as possible to help stop them from getting worse or becoming more frequent.

Stick with your treatment plan to help prevent relapses or worsening of panic attack symptoms.

Get regular physical activity, which may play a role in protecting against anxiety.

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Panic attacks and panic disorder - Symptoms and causes

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Learn about effective treatment for sudden episodes of intense fear that trigger severe physical reactions when there is no real danger or apparent cause.

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https://www.pacer.org/parent/php/php-c33.pdf

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Individuals with Disabilities Education Act

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Individuals with Disabilities Education Act

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https://sites.ed.gov/idea/

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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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https://www.hhs.texas.gov/

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https://infocenter.nimh.nih.gov/publications/depression

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This brochure provides information about depression including the different types of depression, signs and symptoms, how it is diagnosed, treatment options, and how to find help for yourself or a loved one.

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This brochure provides information about depression including the different types of depression, signs and symptoms, how it is diagnosed, treatment options, and how to find help for yourself or a loved one.

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https://chadd.org/about-adhd/disruptive-behavior-disorders/

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Having ADHD along with a coexisting disruptive behavior disorder (ODD/CD) can complicate diagnosis and treatment and also worsen the prognosis. Even though many children with ADHD ultimately adjust, some (especially those with an associated conduct or oppositional defiant disorder) are more likely to drop out of school, have fewer years of overall education, have less job satisfaction and fare less well as adults. Early diagnosis and treatment of these conditions is by far the best defense against these poorer outcomes.

What are the types of disruptive behavior disorders?

Disruptive behavior disorders include two similar disorders: oppositional defiant disorder (ODD) and conduct disorder (CD). Common symptoms occurring in children with these disorders include: defiance of authority figures, angry outbursts, and other antisocial behaviors such as lying and stealing. It is felt that the difference between oppositional defiant disorder and conduct disorder is in the severity of symptoms and that they may lie on a continuum often with a developmental progression from ODD to CD with increasing age.

Oppositional defiant disorder (ODD) refers to a recurrent pattern of negative, defiant, disobedient and hostile behavior toward authority figures lasting at least six months. To be diagnosed with ODD four (or more) of the following symptoms must be present:

often loses temper

often argues with adults

often actively defies or refuses to comply with adults' requests or rules

often deliberately annoys people

often blames others for his or her mistakes or misbehavior

is often touchy or easily annoyed by others

is often angry and resentful

is often spiteful or vindictive.

These behaviors must be exhibited more frequently than in other children of the same age and must cause significant impairment in social, academic or occupational functioning to warrant the diagnosis.

Conduct disorder (CD) involves more serious behaviors including aggression toward people or animals, destruction of property, lying, stealing and skipping school. The behaviors associated with CD are often described as delinquency. Children exhibiting these behaviors should receive a comprehensive evaluation.

Children and adolescents with ADHD and CD often have more difficult lives and poorer outcomes than children with ADHD alone.
Incidence of ADHD and ODD or CD
Approximately one-third to one-half of all children with ADHD may have coexisting oppositional defiant disorder (ODD). These children are often disobedient and have outbursts of temper. The rate of children meeting full diagnostic criteria for ODD is similar across all ages. Males have a greater incidence of ADHD and ODD, as do children of divorced parents and mothers with low socioeconomic status. Children with the ADHD combined subtype seem to be more likely to have ODD.

In some cases, children with ADHD may eventually develop conduct disorder (CD), a more serious pattern of antisocial behaviors. Conduct disorder may occur in 25 percent of children and 45 percent of adolescents with ADHD. CD is more commonly seen in boys than girls, and increases in prevalence with age. Children with ADHD who also meet diagnostic criteria for CD are twice as likely to have difficulty reading, and are at greater risk for social and emotional problems. Non-aggressive conduct problems increase with age, while aggressive symptoms become less common.

Given the high co-occurrence of ADHD with disruptive behavior disorders, all children with ADHD symptoms and disruptive behaviors need to be assessed for the possibility that ODD or CD may be present in addition to ADHD.
Risks of having ADHD and a disruptive behavior disorder
Children with ADHD and CD are often at higher risk for contact with the police and the court system than children with ADHD alone. These children frequently lie or steal and tend to disregard the welfare of others. In addition, they risk getting into serious trouble at school or with the police. The risk for legal troubles may be mostly attributable to the symptoms of CD rather than ADHD.

Disruptive behavior disorders and untreated ADHD have been found to lead to an increased risk of substance use disorders. In addition, adolescents with disruptive behaviors disorders and ADHD are more likely to be aggressive and hostile in their interactions with others, and to be arrested. It has also been suggested that the greater impulsivity associated with the ADHD may cause greater antisocial behavior and its consequences. Thus, early recognition and treatment of both the ADHD and disruptive behaviors in children is essential.
Treatment of ADHD and Disruptive Behavior Disorders
All children with symptoms of ADHD and ODD/CD need to be assessed so that both types of problem behaviors can be treated. These children are difficult to live with and parents need to understand that they do not need to deal with their ADHD and ODD/CD child alone. Interventions such as parent training at home and behavioral support in the school can make a difference and parents should not hesitate to ask for assistance.

Home Interventions

Parent Training (PT): Parent training has been shown to be effective for treating oppositional and defiant behaviors. Standardized parent training programs are short-term interventions that teach parents specialized strategies including positive attending, ignoring, the effective use of rewards and punishments, token economies, and time out to address clinically significant behavior problems. Such training programs may include periodic booster sessions.

Severe cases of CD may require multisystemic therapy, an intensive family- and community-based treatment that addresses the multiple causes of serious antisocial behavior in youth. This approach is very comprehensive and demanding. The therapist using such an approach must possess access to developmental and clinical expertise. These intervention services are delivered in a variety of settings, such as home, school and peer groups. Academic and school-based problems are included and some therapists work directly with an entire peer group to influence change.

Parent-child interaction therapy is a treatment that teaches parents to strengthen the relationship with their child and to learn behavior management techniques. It has been found to be effective in the long term for young children with ODD and ADHD. Three to six years after treatment, the mothers of children with these disorders reported that the changes in their children's behavior and their own feelings of control had lasted. Mothers' reports of disruptive behavior decreased with time after treatment.

Collaborative Problem Solving (CPS): Another technique that seems to be promising for children with ADHD and ODD is collaborative problem-solving (CPS). CPS is a treatment that teaches difficult children and adolescents how to handle frustration and learn to be more flexible and adaptable. Parents and children learn to brainstorm for possible solutions, negotiate, make decisions, and implement solutions that are acceptable to both. They learn to resolve disagreements with less conflict.

Family Therapy: Often a child's behavior can have an effect on the whole family. Parents of children with ADHD often report marital difficulties. Mothers may be more depressed and siblings may also develop behavior problems. Family therapy is critical to helping a family address these issues and cope with the realities of having a child with ADHD and disruptive behaviors. Seeking out a counselor or family therapist in your neighborhood can help the entire family address these issues.

School Interventions

School-wide Positive Behavioral Supports: In addition to the environment at home, the school can have a significant impact on a child's behavior patterns. Many school systems now have programs in place to provide school-wide positive behavioral supports. The aim of these programs is to foster both successful social behavior and academic gains for all students. These programs consist of: (1) clear, consistent consequences for inappropriate behaviors; (2) positive contingencies for appropriate behaviors; and (3) team-based services for those students with the more extreme behavioral needs.

Tutoring: Children's ADHD symptoms, as well as oppositional symptoms, have been found to be significantly lower in one-on-one tutoring sessions than in the classroom.

Classroom Management: Providing appropriate instructional supports in the classroom can also lessen disruptive behavior. These include: creating an accepting and supportive classroom climate, promoting social and emotional skills, establishing clear rules and procedures, monitoring child behavior, utilizing rewards effectively, responding to mild problem behaviors consistently and effectively managing anger or aggressive behavior.
Medication
Overall results from several clinical studies indicate that medications used for the treatment of ADHD (stimulants as well as non-stimulants) remain an important component in the treatment of ADHD and coexisting ODD/CD. Children with these disorders treated with these medications were not only more attentive, but less antisocial and aggressive. ADHD medications are often effective treatments for aggressive or antisocial behavior in patients with ADHD and certainly play a role in any treatment program. See Managing Medication for Children with ADHD for more information.

In addition to using stimulant medications alone, medication combinations to reduce behavioral and conduct symptoms associated with attention-deficit/hyperactivity disorder appear to be very effective. In several studies, this treatment combination was reported to be well tolerated and unwanted effects were transient.

What can a parent do?

To increase the chance for a successful future and to discourage delinquent behaviors in children with ADHD, diagnosis and intervention is extremely important. It is essential for parents to provide structure and reinforce appropriate behavior. In addition, a positive behavior management plan to lessen anti-social behavior is important. Parents should discuss their child's behavioral symptoms with the pediatrician or family practitioner and seek a referral to a mental health professional who can suggest effective parenting strategies.

In addition, parents should contact their child's school counselor or school psychologist to discuss possible interventions to improve behaviors at school. Having the counselor or psychologist support the teacher in handling classroom behaviors often results in significant behavioral changes and decreases the incidence of expulsion. Consistent behavior management at home, school and elsewhere needs to be enforced.
For more information and further reading
Barkley, Russell. (1998). Your defiant child: 8 steps to better behavior . New York, NY: Guilford Press. This book is divided into two parts, "Getting to Know Your Defiant Child" and "Getting Along with Your Defiant Child." Part two contains an eight-step parenting program built on consistency.

Clark, Lynn. (1996) SOS! Help for parents . Berkeley, CA: Parents Press. This book helps parents learn methods for helping children to improve their behavior and techniques for aiding a variety of child personalities, from the stubborn and willful child to time-out basics. It focuses on the basic skills of time-out and how parents can use these techniques to further a child's behavior modification.

Forgatch, Marion S. and Gerald R. Patterson. (2005) Parents and adolescents living together: Family problem solving. Champaign, IL: Research Press. This book shows parents how to improve their communication and problem-solving skills, hold family meetings and get the whole family involved in solving problems. It explains how parents can teach their teenaged children to be responsible about schoolwork, sexual behavior and drugs and alcohol.

Goldstein, Sam; Robert Brooks and Sharon K. Weiss. (2004) Angry children, worried parents: Seven steps to help families manage anger . Plantation, FL: Specialty Press. This book helps parents cope with anger in their children. It presents the following seven steps to help children learn to manage anger: (1) understand why children become angry; (2) determine when your child needs help; (3) help the child become an active participant in the process; (4) use strategies to manage and express anger; (5) develop and implement a daily management plan; (6) assess and solve problems; and (7) instill a resilient mindset in the child.

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ADHD and Disruptive Behavior Disorders - CHADD

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Having ADHD along with a coexisting disruptive behavior disorder (ODD/CD) can complicate diagnosis and treatment and also worsen the prognosis. Even though many children with ADHD ultimately adjust, some (especially those with an associated conduct or oppositional defiant disorder) are more likely to drop out of school, have fewer years of overall education, have less...

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ADHD: Implications for School Counselors 

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ADHD: Implications for School Counselors 

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https://files.eric.ed.gov/fulltext/EJ1084428.pdf

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Living with-and Beyond-OCD; Counseling Today

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Living with-and Beyond-OCD; Counseling Today

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https://ct.counseling.org/2020/01/living-with-and-beyond-ocd/

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

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

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

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

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

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

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

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

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

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

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

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

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

Washing and cleaning tasks (including personal hygiene)

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

Repeated actions such as blinking or tapping

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Contact the counselors interviewed for this article:

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

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

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

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

Letters to the editor: ct@counseling.org

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

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Living with - and beyond - OCD - Counseling Today

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

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https://iocdf.org/about-ocd/

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What is OCD? | International OCD Foundation

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Obsessive compulsive disorder (OCD) is a mental health disorder that affects people of all ages and walks of life, and occurs when a person gets caught in a cycle of obsessions and compulsions. Obsessions are unwanted, intrusive thoughts, images, or urges that trigger intensely distressing feelings.…

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https://psychiatry.org/patients-families/obsessive-compulsive-disorder/what-is-obsessive-compulsive-disorder

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How School Counselors can Help with Anxiety

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How School Counselors can Help with Anxiety

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https://www.schoolcounselor.org/Newsletters/January-2020/How-School-Counselors-Can-Help-with-Anxiety?st=RI#:~:text=Students%20with%20anxiety%20may%20benefit,who%20have%20not%20been%20identified.

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Many professionals have seen a rise in the number of students who are exhibiting symptoms of anxiety in schools. As school counselors, we know that anxiety disorders can significantly impair children's social skills and academic success. Therefore, it is important that we educate teachers and staff about the signs to look for in students who may be experiencing anxiety related disorders.

Family relationships, grades, friends, health concerns and extracurricular performance are all things students may obsess over. Other signs may be a student needing constant reassurance, frequent nurse visits, physical complaints of stomachaches, headache and other physical symptoms without a known cause. Students may also do other avoiding behaviors and may appear inattentive, restless or irritable. Anxiety can also cause perfectionism. Kids need to know that a small amount of worry is normal, but that knowing how to be in control of your worries is essential to succeed at school.

Most school counselors focus on teaching coping skills instead of trying to be anxiety free. Students with anxiety may benefit greatly from small groups or short-term individual counseling to best learn helpful coping skills. School counselors can also implement school-wide anxiety reduction programs to teach all students coping skills and to reach the students with anxiety who have not been identified.

To help students with anxiety succeed in the classroom, 504 accommodations may be provided. Students may also need an Individualized Education Plan (IEP) to address another diagnosed disability that may affect their learning, and can then receive support for their anxiety as well. Some beneficial accommodations on 504s could be preferred seating, being allowed breaks, small group or separate location for testing, support for classroom presentations or participation, and pre-warning about fire drills or other drills.

Helping students change their mindset about their anxiety is crucial to their success. Helping students see their anxiety as a positive instead of a negative can empower them to learn about their anxiety, their triggers, and the best coping skills for them.

We experienced this with one student who was experiencing high anxiety in class and could never pinpoint a trigger. Over time, we were able to identify when she was experiencing an anxiety attack and the best methods for her to be able to return to class. She brought her own small "coping toolkit" to leave in the school counseling office for when she needed it. We developed a hand signal with her classroom teacher so the student could let her teacher know if she felt an anxiety attack coming on and needed to leave the room. Eventually, she was able to stay in the classroom and work through her anxiety without needing to leave and come to my office. It may take time for students to experience this type of success; however, the lifelong benefit is well worth it!

Kelli Conraads is WySCA president-elect and April Petty is WySCA treasurer and past president.

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How School Counselors Can Help with Anxiety

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Many professionals have seen a rise in the number of students who are exhibiting symptoms of anxiety in schools. As school counselors, we know that anxiety disorders can significantly impair children's social skills and academic success. Therefore, it is important that we educate teachers and staff about the signs to look for in students who may be experiencing anxiety related disorders.

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https://tea.texas.gov/sites/default/files/504_guide.pdf

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https://www.mentalhealth.gov/what-to-look-for/psychotic-disorders

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People with psychotic disorders lose contact with reality and experience a range of extreme symptoms that usually includes: Hallucinations-hearing or seeing things that are not real, such as voices Delusions-believing things that are not true However, these symptoms can occur in people with other health problems, including bipolar disorder, dementia, substance abuse disorders, or brain tumors.

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https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Schizophrenia

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Schizophrenia is a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others. It is a complex, long-term medical illness. The exact prevalence of schizophrenia is difficult to measure, but estimates range from 0.25% to 0.64% of U.S. adults. Although schizophrenia can occur at any age, the average age of onset tends to be in the late teens to the early 20s for men, and the late 20s to early 30s for women. It is uncommon for schizophrenia to be diagnosed in a person younger than 12 or older than 40. It is possible to live well with schizophrenia.

Symptoms

It can be difficult to diagnose schizophrenia in teens. This is because the first signs can include a change of friends, a drop in grades, sleep problems, and irritability-common and nonspecific adolescent behavior. Other factors include isolating oneself and withdrawing from others, an increase in unusual thoughts and suspicions, and a family history of psychosis. In young people who develop schizophrenia, this stage of the disorder is called the "prodromal" period.

With any condition, it's essential to get a comprehensive medical evaluation in order to obtain the best diagnosis. For a diagnosis of schizophrenia, some of the following symptoms are present in the context of reduced functioning for a least 6 months:

Hallucinations. These include a person hearing voices, seeing things, or smelling things others can't perceive. The hallucination is very real to the person experiencing it, and it may be very confusing for a loved one to witness. The voices in the hallucination can be critical or threatening. Voices may involve people that are known or unknown to the person hearing them.

Delusions. These are false beliefs that don't change even when the person who holds them is presented with new ideas or facts. People who have delusions often also have problems concentrating, confused thinking, or the sense that their thoughts are blocked.

Negative symptoms are ones that diminish a person's abilities. Negative symptoms often include being emotionally flat or speaking in a dull, disconnected way. People with the negative symptoms may be unable to start or follow through with activities, show little interest in life, or sustain relationships. Negative symptoms are sometimes confused with clinical depression.

Cognitive issues/disorganized thinking. People with the cognitive symptoms of schizophrenia often struggle to remember things, organize their thoughts or complete tasks. Commonly, people with schizophrenia have anosognosia or "lack of insight." This means the person is unaware that he has the illness, which can make treating or working with him much more challenging.

Causes

Research suggests that schizophrenia may have several possible causes:

Genetics. Schizophrenia isn't caused by just one genetic variation, but a complex interplay of genetics and environmental influences. Heredity does play a strong role-your likelihood of developing schizophrenia is more than six times higher if you have a close relative, such as a parent or sibling, with the disorder

Environment. Exposure to viruses or malnutrition before birth, particularly in the first and second trimesters has been shown to increase the risk of schizophrenia. Recent research also suggests a relationship between autoimmune disorders and the development of psychosis.

Brain chemistry. Problems with certain brain chemicals, including neurotransmitters called dopamine and glutamate, may contribute to schizophrenia. Neurotransmitters allow brain cells to communicate with each other. Networks of neurons are likely involved as well.

Substance use. Some studies have suggested that taking mind-altering drugs during teen years and young adulthood can increase the risk of schizophrenia. A growing body of evidence indicates that smoking marijuana increases the risk of psychotic incidents and the risk of ongoing psychotic experiences. The younger and more frequent the use, the greater the risk.

Diagnosis

Diagnosing schizophrenia is not easy. Sometimes using drugs, such as methamphetamines or LSD, can cause a person to have schizophrenia-like symptoms. The difficulty of diagnosing this illness is compounded by the fact that many people who are diagnosed do not believe they have it. Lack of awareness is a common symptom of people diagnosed with schizophrenia and greatly complicates treatment.

While there is no single physical or lab test that can diagnosis schizophrenia, a health care provider who evaluates the symptoms and the course of a person's illness over six months can help ensure a correct diagnosis. The health care provider must rule out other factors such as brain tumors, possible medical conditions and other psychiatric diagnoses, such as bipolar disorder.

To be diagnosed with schizophrenia, a person must have two or more of the following symptoms occurring persistently in the context of reduced functioning:

Delusions

Hallucinations

Disorganized speech

Disorganized or catatonic behavior

Negative symptoms

Delusions or hallucinations alone can often be enough to lead to a diagnosis of schizophrenia. Identifying it as early as possible greatly improves a person's chances of managing the illness, reducing psychotic episodes, and recovering. People who receive good care during their first psychotic episode are admitted to the hospital less often, and may require less time to control symptoms than those who don't receive immediate help. The literature on the role of medicines early in treatment is evolving, but we do know that psychotherapy is essential.

People can describe symptoms in a variety of ways. How a person describes symptoms often depends on the cultural lens she is looking through. African Americans and Latinos are more likely to be misdiagnosed, potentially due to differing cultural perspectives or structural barriers. Any person who has been diagnosed with schizophrenia should try to work with a health care professional that understands his or her cultural background and shares the same expectations for treatment.

Treatment

There is no cure for schizophrenia, but it can be treated and managed in several ways.

Related Conditions

People with schizophrenia may have additional illnesses. These may include:

Successfully treating schizohprenia almost always improves these related illnesses. And successful treatment of substance misuse, PTSD or OCD usually improves the symptoms of schizophrenia.

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What is Schizophrenia? | NAMI: National Alliance on Mental Illness

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Discover the symptoms, causes, diagnosis advice, treatment options and related conditions of schizophrenia.

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School Counselors’ Recognition of the Ultra-High Risk for Psychosis

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School Counselors’ Recognition of the Ultra-High Risk for Psychosis

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5900376/

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INTRODUCTION

The most common time of onset for psychotic disorders is adolescence and early adulthood []. The onset of psychotic disorders is usually preceded by a prodromal period characterized by non-specific psychiatric and attenuated psychotic symptoms accompanied by functional decline []. "Ultra-high risk" (UHR) for psychosis is defined by the presence of attenuated positive psychotic symptoms without full impairment of reality testing. Recently, the UHR concept was included in "attenuated psychosis syndrome" (APS), a new diagnosis contained in Section 3 of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the section reserved for conditions requiring further research []. Among adolescents who reported psychotic-like experiences, those of 80% remitted, and the symptoms of 20% persisted []. The early detection and treatment of people at risk for psychosis is currently regarded as a promising strategy for preventing the devastating consequences of full-blown psychosis [].

As children and adolescents spend a large portion of their time at school, mental health problems are commonly identified in this setting. School-based detection of those at UHR for psychosis has the benefit of improving access to mental health treatment for students who have psychotic-like experiences. In Korea, mandatory school based mental health screening test for mental health problems of students has been conducted every year. Due to limited school mental health resources, school counselors perform non-counseling related activities beyond their training such as clinical expertise regarding to assessment and referral of clinical high risk students.

Given increasing recognition of the need to identify individuals with UHR risk status, school counselors are facing the challenge of how to understand and deal with these symptoms. Indeed, in view of the essential contribution of the identification of symptoms to the provision of effective mental health services, it is essential to recognize the potential role played by school counselors.

Thus, the current study examined how school counselors diagnose and define the appropriate treatment for those at UHR for psychosis. We assessed respondents' recognition of UHR for psychosis based their responses to a brief vignette depicting a hypothetical student reporting relevant symptoms.

METHODS

Participants

The sample for this anonymous cross-sectional survey, which was conducted in October 2015, consisted of school counselors. In total, 132 school counselors from 125 (81.7%) of the 153 schools and all of three Wee centers in Gwangju metropolitan city participated in the survey and completed the questionnaire. Data on sociodemographic characteristics were collected. The survey was approved by the the Chonnam National University Hospital Institutional Review Board (CNUH-2015-171).

Vignette

The vignette used in this study was developed by the corresponding author (KSW) () based on the vignette developed by Jacobs et al. [] and the manual of Personal Assessment and Crisis Evaluation (PACE) clinic of Orygen Youth Health in Melbourne, Australia []. The vignette described a fictional individual at UHR for psychosis according to the Comprehensive Assessment of At-Risk Mental States (CAARMS) criteria [,]. The protagonist in the vignette met criteria for subthreshold non-bizarre ideation and perceptual abnormality with functional decline. She also met criteria of the DSM-5 criteria for APS. Two authors (LJY and CYC) with extensive experience in this area discussed and further revised the vignette.

First, we asked participants whether the vignette depicted a psychiatric disorder (yes/no/don't know). Participants were asked to identify the most appropriate diagnosis for the hypothetical student from a list of 10 diagnoses. We also asked participants to recommend an appropriate referral and treatment approach for the student by asking them to rate 11 treatment options on the following scale: first choice, second-or-later choice, would not recommend, and no opinion. Participants who diagnosed the protagonist with schizophrenia, delusional disorder, or at UHR for psychosis were considered the "schizophrenia spectrum disorders group," and others were considered the "non-psychotic disorders group."

Statistical analyses

Basic demographic differences among respondents according to the diagnosis chosen were analyzed using the chi-square test. The percentage of respondents choosing each answer was calculated and is presented. SPSS for Windows software (ver. 21.0; IBM Corp., Armonk, NY, USA) was used to perform the statistical tests. All statistical tests were two-tailed, and p-values <0.05 were deemed to indicate statistical significance.

RESULTS

Demographic characteristics of participants

The sample consisted primarily of females (94.7%), and there were no significant differences in the demographic characteristics of respondents according to the diagnosis they selected ().

Diagnosis

In total, 123 (94.6%) respondents recognized that the vignette depicted someone with a mental disorder. The data regarding diagnoses are summarized in , which shows the percentage of respondents choosing each diagnosis. The most common diagnosis was schizophrenia (n=34, 28.1%), followed by delusional disorder (n=32, 26.4%), and depressive disorder (n=23, 19.0%). The diagnosis of UHR for psychosis was selected by 15 (12.4%) subjects.

Referral and treatment

shows the referral recommendations according to the diagnosis chosen by the school counselors. Most participants who diagnosed the protagonist with schizophrenia spectrum disorder selected psychiatric clinics as the optimal referral. Additionally, an average of 58.1% of respondents would refer to Wee center, which is school counseling services, and an average of 37.2% would refer to a private counseling center.

shows treatment preferences according to the diagnosis chosen by school counselors. School counselors who diagnosed the student depicted in the vignette with schizophrenia were likely to recommend antipsychotics (35.3%) and family therapy (35.3%) as the first-line treatment. School counselors who diagnosed the protagonist as being at UHR for psychosis were also likely to prefer family therapy (46.7%). In terms of the medication options for those at UHR for psychosis, antipsychotics were the most frequently chosen.

DISCUSSION

This is the first study to explore the recognition of Korean school counselors regarding students at UHR for psychosis. Participants were presented with a vignette depicting the case of a student who initially presents with recent-onset subsyndromal psychotic symptoms with functional decline. We found that most participants believed that the student was suffering from a psychiatric disorder. However, only 12.4% of the respondents correctly diagnosed her as at UHR for psychosis, whereas over half of respondents described her as suffering from a full-blown psychotic disorder. This reflects the fact that school counselors may be unfamiliar with the concept of high risk for psychosis, and lack confidence in treating this concept as a potential precursor of psychotic symptoms.

About 40% of school counselors did not consider the protagonist in the vignette to be suffering from schizophrenia spectrum disorder but, instead, believed she was dealing with a less severe condition, including depressive disorder (19.0%). Although the vignette did not portray severe depression, many school counselors nonetheless identified the problem in question as depressive disorder, which is a common psychiatric disorder among students. While most school counselors recommended psychiatric treatment for the protagonist in the vignette, a majority also considered a counseling center, which might not offer psychiatric services and might not operate according to the medical model, as would be appropriate for the treatment of a psychotic disorder. Early detection and intervention have an important role in reducing the duration of untreated psychosis (DUP) and ameliorating the presenting symptoms of UHR subjects [,]. However, appropriate psychiatric intervention is commonly delayed within mental health services, including school counseling systems [,]. Therefore, early referral and the timely delivery of transfer information by school counselors may play an important role in improving the diagnostic and treatment approach of subsequent practitioners.

Our findings reflected great variability in the treatment recommendations offered for the protagonist of the vignette. In particular, school counselors who diagnosed her with schizophrenia or at UHR for psychosis recommended both antipsychotics and family therapy. These results may be attributable to recognition on the part of school counselors that antipsychotics have been established as a standard treatment for persons with psychotic symptoms. Additionally, as school counselors are more frequently exposed to information related to familial and environmental problems, they may consider family therapy to be an important resource for treatment. Although low doses of antipsychotics appear to be effective for reducing the severity of the presenting symptoms of UHR subjects, premature recommendations for medication by school counselors may exacerbate a student's experience of being odd and stigmatized, especially if they are adolescents []. Furthermore, there is growing evidence that psychological interventions, such as cognitive-behavioral therapy, and newly emerging treatments, such as omega-3 fatty acids, may be effective in reducing the severity of the symptoms experienced by individuals at UHR for psychosis [⁻]. These results suggest that Korean school counselors were not familiar with preventive approaches to the development of psychotic disorders or with the importance of early intervention. Thus, we should develop educational materials to raise the awareness of school-based gatekeepers of access to mental health treatment regarding psychosis prevention and help school counselors expand their knowledge about treatment options for those at UHR.

This study has several limitations. First, the use of only one vignette to assess school counselors' recognition of UHR for psychosis may have led to difficulties in distinguishing this condition from other psychotic disorders. Second, we asked only two categorical questions regarding the diagnosis of, and treatment for, individuals at UHR for psychosis; that is, we did not assess such additional factors as respondents' experiences with, goals for, and opinions regarding treatment. Future research may benefit from adding vignettes that depict different levels of psychotic symptoms and elicit more information from respondents. Moreover, as there is no "golden standard" treatment for UHR, the range of recommended treatments in our study should be tested for relevance in futures.

In conclusion, this study suggests that Korean school counselors are not sufficiently familiar with the condition known as UHR for psychosis, although they generally recognize the vignette has mental health problems and needs help. To prevent delays in the implementation of appropriate school-based interventions for attenuated psychotic symptoms, school counselors should be provided with proper education and training.

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School Counselors' Recognition of the Ultra-High Risk for Psychosis

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The most common time of onset for psychotic disorders is adolescence and early adulthood []. The onset of psychotic disorders is usually preceded by a prodromal period characterized by non-specific psychiatric and attenuated psychotic symptoms accompanied by functional decline [].