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School Interface with Psychological Disorders. Changing Role of Schools 3 R’s Mandates – Physical health – Nutrition – Exercise – Moral/ethical – Mental.

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Presentation on theme: "School Interface with Psychological Disorders. Changing Role of Schools 3 R’s Mandates – Physical health – Nutrition – Exercise – Moral/ethical – Mental."— Presentation transcript:

1 School Interface with Psychological Disorders

2 Changing Role of Schools 3 R’s Mandates – Physical health – Nutrition – Exercise – Moral/ethical – Mental health

3 Expectations of Schools Instruction – Monitored by “system” with standards (Atlanta) Administrative – Documentation – Organization – Implementation of policies – Classroom regulation and control Communication – Parents – “Non-educational” personnel

4 These Students now included in your classroom……. Attention Deficit Disorder Asperger’s Syndrome Depression Anxiety Post-traumatic Stress Disorder Bipolar Disorder

5 Diagnostic and Statistical Manual of Mental Disorders (DSM) American Psychiatric Association Parallel to International Classification of Disease (ICD) system..1893……..Developed by World Health Organization (ICD-11) DSM-I, 1952 DSM-IV-TR, 2000 DSM-V, 2012 ???????????????? ???? May 2013 ????????????

6 DSM 5 Nothing “official” First major revision since 1994 – DSM IV TR (2000) Task Force = 13 “work groups” Since June 2012, “open comment Period” – More than 12,000 comments documented Proposed release is May 2013 (Annual meeting of American Psychiatric Assoc)

7 20 chapters – Similarities in disorders – Symptom overlap Decrease in Diagnostic Choices Removal of multiaxial system Point on a continuum or “spectrum”

8 Categorical vs Spectrum Previous works have focused on need for consistency and standardization Red bumps on face – Family Doc Dx Measles – Move to Seattle – ER Doc Dx with poison ivy and changes meds Continuum or spectrum view is less constrictive but also challenges standardization

9 Several “minor wording changes” “New” or newly recognized/redefined – Attenuated Psychosis Syndrome – Internet use/Gaming Disorder – Non-suicidal self injury – Suicidal behavior disorder – Autism Spectrum Disorder – Schizophrenia Spectrum – Hoarding Disorder – Cont’d…………………………………….

10 Binge Eating Disorder Excoriation (skin picking) Disorder Disruptive mood dysregulation disorder – children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year

11 Learning Disorder has been changed to Specific Learning Disorder and the previous types of Learning Disorder (Dyslexia, Dyscalculia, and Disorder of Written Expression) are no longer being recommended.

12 Callis homepage scroll down to bottom center for “DSM 5 Resources”

13 “Rejected” for inclusion – Anxious depression – Hypersexual disorder – Parental alienation syndrome – Sensory processing disorder

14 DSM 5 is Controversial “Saving Normal: An Insider's Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life” Author: Allen Frances – was chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine,

15 Allen’s list of “worst changes” “During the past two decades, child psychiatry has already provoked three fads- a tripling of Attention Deficit Disorder, a more than twenty-times increase in Autistic Disorder, and a forty-times increase in childhood Bipolar Disorder.”Attention Deficit childhoodBipolar Disorder Disruptive Mood Dysregulation Disorder: DSM 5 will turn temper tantrums into a mental disorder

16 Allen (cont’d)………. “DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation “ “Painful experience with previous DSM's teaches that if anything in the diagnostic system can be misused and turned into a fad”

17 Dr. Mark Phillips: Comments ADHD (Edutopia, Jan 2013) under the new proposed DSM-5, fewer symptoms would be needed to diagnose a child with ADHD. The proposed DSM-5 places the bar so low that thousands of children who didn't have ADHD according to DSM-IV would meet the "test" according to DSM-5. The rationale of the Task Force is that there are individuals who do not meet the criteria but are still impaired, and decreasing the diagnostic criteria would make them entitled to insurance benefits. ……….

18 Phillips (cont’d)……… But the bottom line is that this lowering of the bar will increase the number of children diagnosed and treated with drugs. We already have a well-documented problem with the overzealous prescribing of psychiatric drugs in this country, and many teachers and parents have voiced specific concern about over-diagnosing and medicating kids for signs of ADHD.

19 The proposed changes to ADHD in the DSM-5 include: 1. Changing the diagnostic criteria from "symptoms being present before seven years of age" to "symptoms being present before twelve years of age." This new criteria would read: "B. Several noticeable inattentive or hyperactive- impulsive symptoms were present by age 12."

20 For the Inattentive type and Hyperactive/Impulsive subtypes of ADHD, a minimum of only four symptoms need to be met if a person is 17 years of age or older. The current DSM-IV-TR criteria of meeting a minimum of six symptoms for the Inattentive type or Hyperactive/Impulsive Type would still apply for those 16 years of age or younger.Impulsive

21 Recommending teachers as sources of information. The wording that comes before the list of symptoms may read: "In children and young adolescents, the diagnosis should be based on information obtained from parents and teachers. When direct teacher reports cannot be obtained, weight should be given to information provided to parents by teachers that describe the child's behavior and performance at school. ………………………………parents

22 ADHD ADHD is one of the most common childhood disorders. Approximately 3-7% of school-aged children have the disorder. Prevalence rates seem to vary by community, with some research indicating that larger cities may have rates as high as 10-15%.

23 According to the Centers for Disease Control 4.4 million youth between the ages of 4-17 have been diagnosed with Attention- Deficit/Hyperactivity Disorder. The DSM IV-TR suggests that the prevalence rate of ADHD in children is 3% to 7%, and 2% to 5% in adults. Using these prevalence rates it can be estimated that in a classroom of 25 to 30 children, at least one of those children will have ADHD.

24 The fundamental area of controversy related to ADHD is whether or not this collection of symptoms should be considered a mental disorder. Although there are documented brain differences and significant evidence of impairment in daily functioning in individuals with ADHD, there is a large school of thought that views ADHD "symptoms" as simply an extreme expression of normal human behavior.

25 According to DSM diagnostic criteria, ADHD develops in childhood, with at least some symptoms present prior to age 7. Estimates of children whose symptoms continue into adulthood range up to 60%.

26 Manner in which Brain Develops Brain develops – Inside out – Back to Front Prefrontal Cortex – Not fully developed until mid 20’s in many subjects

27 Two Major Developmental Periods of Brain First 3 years of life Second burst about 11 for girls and 12 for boys – Shaping White Matter Full development about 25

28 By age six, the brain is already 95 percent of its adult size.

29 Although the brain is 80 percent developed at adolescence, research indicates that brain signals essential for motor skills and emotional maturity are the last to extend to the brain’s frontal lobe, which is responsible for many of the skills essential for driving. Brain size does not equal intellectual or emotional maturity

30 Maturation of the Prefrontal Cortex The prefrontal cortex is often referred to as the “CEO of the brain.” This brain region is responsible for cognitive analysis and abstract thought, and the moderation of “correct” behavior in social situations.

31 FRONTAL LOBE Seat of personality, judgment, reasoning, problem solving, and rational decision making Provides for logic, understanding of consequences, and emotional/behavioral regulation Governs impulsivity, aggression, ability to organize thoughts, and plan for the future Controls capacity for abstraction, attention, cognitive flexibility, and goal persistence Undergoes significant changes during adolescence — not fully developed until mid 20’s (Giedd, 2002)

32 “Executive functions” of the human prefrontal cortex include: Focusing attention Organizing thoughts and problem solving Foreseeing and weighing possible consequences of behavior Considering the future and making predictions Forming strategies and planning Ability to balance short-term rewards with long term goals

33 Shifting/adjusting behavior when situations change Impulse control and delaying gratification Modulation of intense emotions Inhibiting inappropriate behavior and initiating appropriate behavior Simultaneously considering multiple streams of information when faced with complex and challenging information U.S. Department of Health & Human Services

34 COMPONENTS OF EXECUTIVE FUNCTIONS AND SAMPLE BEHAVIORSCOMPONENTSBEHAVIORS Goal DirectednessEstablishing and maintaining goals; evaluating progress, using strategies Initiation/InhibitionInitiating behavior independently, self-cueing, inhibiting inappropriate behaviors Flexibility/PerseveranceGenerating novel possibilities, flexibility, performing contingency based revisions, strategizing

35 COMPONENTSBEHAVIORS Abstract ReasoningUsing rule-guided thinking, forming concepts, using hierarchical and temporal relationships Reward AppraisalEvaluating reward likelihood, using reward appraisal to guide behavior Social AppraisalUnderstanding social norms and cues, incorporating social information into decision making Brown et al., 2008

36 Brain imaging techniques are currently not used to diagnose ADHD, but evidence collected from these types of studies are providing more detailed clues as to the causes of this disorder. – Expense – Reliability

37 Children with ADHD generally sustain more accidents and injuries than the average child. Reduced awareness or inattention, impulsivity, and poor decision-making often leads to rushing into situations without thinking. For example, a young child may forget to check both ways when crossing the street or while riding a bike, even going so far as to dash in front of a car in a parking lot without thought for the consequences. Teenagers with ADHD who drive may have more traffic violations or accidents than those without ADHD.

38 The general symptoms of ADHD include: Failure to pay attention or a failure to retain learned information Fidgeting or restless behavior Excessive activity or talking The appearance of being physically driven or compelled to constantly move Inability to sit quietly, even when motivated to do so Engaging in activity without thinking before hand Constantly interrupting or changing the subject Poor peer relationships Difficulty sustaining focused attention Distractibility Forgetfulness or absentmindedness Continual impatience Low frustration tolerance When focused attention is required, it is experienced as unpleasant Frequent shifts from one activity to another Careless or messy approach to assignments or tasks Failure to complete activities Difficulty organizing or prioritizing activities or possessions

39 Neurotransmitters and ADHD Neurotransmitters are chemical messengers that occur in the brain and central nervous system. More recent evidence suggests that the relationship between dopamine and ADHD is complicated. Researchers have found reduced overall levels of dopamine in individuals with ADHD, the small amount of dopamine present doesn't have enough time to exert its effects before it is reabsorbed by neurons.

40 Medication 1937, amphetamine (a central nervous system stimulant) was used successfully to treat a group of children with ADHD-like behaviors, including limited self-control, aggressiveness, defiance, resistance to discipline and extreme emotionality. Later studies suggested that stimulant medications also seemed to reduce disruptive behavior and improve academic performance. During the 1950's, further evidence suggested that amphetamines were extremely helpful in the treatment of hyperactive children. The FDA approved dextroamphetamines (e.g, Dexedrine) for treating childhood disorders in In the 1970's, stimulant medication was the most popular treatment for ADHD. The use of Dexedrine decreased from 1962 to the mid 80's as Ritalin became the medication of choice.

41 As of 2003, approximately 2.5 million young people were being treated with medication for ADHD symptoms. Although increasing medication rates may be related to improved awareness and diagnosis, some professionals have different theories. Some researchers speculate that increasing ADHD prevalence and treatment rates may be related to changes associated with living in the digital age, such as decreased levels of physical activity and less exposure to the natural environment, which is thought to lead to increased amounts of restless and impulsive behavior

42 Like all medications, stimulants may produce side effects. Parents and teachers need to be aware of potential side effects and know how to manage them. The most common side effects include weight loss from appetite suppression, insomnia, and a characteristic "over-concentrated" or extremely focused appearance. Taking medications with food often helps combat the initial "dosing" stomachache…….Orange juice !!!!!

43 Stimulant medication is the primary treatment for ADHD, especially with regard to improving concentration. However, other medications are often prescribed along with stimulants to help control side effects, comorbid (i.e., co-occurring) symptoms of depression or other mood disorders, or when stimulants are not working. Antidepressants are the second line of treatment and may be used in combination with stimulants in order to maintain treatment effects throughout the night. They are not as helpful with concentration, but can be quite effective in reducing impulsivity and improving social problems. Typically, antidepressants take a while to build up to optimal doses in the body, so symptom improvement may take a few weeks. However, benefits can last for up to 24 hours. Antidepressant often used with people who have ADHD include:

44 Bupropion (Wellbutrin) - This medication is an atypical antidepressant (an antidepressant medication that does not fit into any of the other medication categories) that can be very helpful in reducing irritability. The appropriate pediatric dosage has not been established, but Wellbutrin is frequently used "off label" or outside of the recommended label instructions with children. Potential side effects include weight loss, anxiety, headaches, dry mouth and confusion. In rare cases, more serious side effects can occur such as allergic reactions, heart palpitations and seizures.

45 Tricyclics (Desipramine, Imipramine) - Tricyclic antidepressants may require lower dosages to treat ADHD than when used to treat depression. They have a quicker onset of action than most other non- stimulant medications. Tricyclics block norepinephrine and dopamine receptors in the brain (causing the brain to produce higher levels of these neurotransmitters), which seems to decrease impulsivity, inattention, and poor concentration. The primary side effects of this medication include slowed or irregular cardiac conduction and exacerbation of untreated glaucoma. The risk versus the benefit must be carefully weighed for each individual.

46 Comorbidity is the medical term for two or more disorders that occur at the same time. The high comorbidity rate between ADHD and other disorders has essentially created confusion regarding the definition of a "true" ADHD diagnosis. Since most children or adults with ADHD also have a second diagnosis, and both sets of symptoms frequently overlap,

47 Oppositional Defiant Disorder Depression Anxiety Bipolar Disorder Conduct Disorder Sensory Integration Disorder Learning Disorder Early Speech/Communication problems

48 MTA Study Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) Study the largest study to date of ADHD treatment found that combining medication and psychosocial interventions is the best strategy for helping individuals deal with their symptoms.

49 The NIMH-funded Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) study was a multisite study designed to evaluate the leading treatments for ADHD, including behavior therapy, medications, and the combination of the two. The study's primary results were published in Follow-up data continues to be published.

50 The MTA was a multisite study designed to evaluate the leading treatments for ADHD, including behavior therapy, medications, and the combination of the two. The study included nearly 600 children, ages 7- 9, who were randomly assigned to one of four treatment modes: intensive medication management alone; intensive behavioral treatment alone; a combination of both; or routine community care (the control group).

51 Accommodations that a Special Education teacher could use when working with an ADHD child include: Being sensitive to and shaping the curriculum around the interests, abilities and needs of each student Allowing mobility in the classroom (e.g., a child could get a breath of fresh air from the window or a drink of water from down the hall while completing a writing assignment) Avoiding large quantities of worksheets Organizing collaborative learning (e.g., assigning a large project to a small group of students to complete together, rather than one project per student; allowing each person to contribute their own unique skills to the assignment). Minimizing formal tests Making accommodations for tests (e.g., allowing a child to go to the bathroom during the test, or to take half of the test before lunch and the rest after lunch). Communicating with parents and working together to increase a child's success Making learning fun!

52 Social skills training Most children gradually develop an awareness of their impact on and interactions with others. Children with ADHD, on the other hand, can be described as a "bull in a china shop". They move through the day quickly, often without giving much thought to the feelings or needs of others. Hyperactive, aggressive, and impulsive behaviors also cause extreme problems in relationships with peers and adults. Although children with ADHD do care about other people, they are simply unaware of the need to consider the perspective of others. Social skills training classes are designed to improve peer relationships, and teach interpersonal interaction skills that facilitate success in the classroom or at home. These classes differ from individual or group therapy in that the focus is primarily on interpersonal interactions rather than managing emotions or personal change. Group settings are the most common format because they provide ready opportunities to practice recently acquired skills with other children in the class.

53 ADHD is Not: An Attitude Problem - The difficulties associated with ADHD are not due to defiance or getting into a battle about control. Nor are they a sign of laziness or irresponsibility. The behaviors associated with ADHD are chronic and part of the disorder. With help, an individual can learn to manage these behaviors. A Personality Disorder - ADHD is a neurological disorder that often co-exists with other disorders, including personality disorders. An Absolute Problem - The impact of the issues surrounding ADHD vary in degree from person to person and are influenced by the environment. Individuals can learn a range of skills to manage their symptoms and their performance can improve with increased stimulation and behavior-specific reinforcement (i.e., reward) systems (described later). A Lack of Intelligence - Often, individuals with ADHD are highly intelligent and creative. MentalHelp.Net

54 Bipolar Disorder “Pediatric Bipolar”

55 Bipolar disorder, also known as manic- depressive illness, is a brain disorder that causes unusual shifts in mood and energy. It can also make it hard for someone to carry out day-to-day tasks, such as going to school or hanging out with friends. Symptoms of bipolar disorder are severe. They are different from the normal ups and downs that everyone goes through from time to time.

56 They can result in damaged relationships, poor school performance, and even suicide. But bipolar disorder can be treated, and people with this illness can lead full and productive lives. Bipolar disorder often develops in a person's late teens or early adult years, but some people have their first symptoms during childhood. At least half of all cases start before age 25.

57 Kraepelin's (1921) initial term for the condition we now call "bipolar" was "manic depressive insanity."

58 Not “new”……..check these dates: It is difficult to derive a single definition of bipolar disorder. According to Goodwin and Jamison (1990), "The clinical manifestations of manic depressive illness are exceptionally diverse. Expressed through widely disparate temperaments, its symptoms, course, severity, and amenability to treatment differ from individual to individual" (p. 13). There are several permutations of depression and mania (Angst, Gerber-Werder, Zuberbühler, & Gamma, 2004), not all of which have a label.

59 Carlson, G.A. (1998). Mania and ADHD: comorbidity or confusion. J Affect Disord, 51(2): Faedda, G. L., Baldessarini, R. J., Suppes, T, et al. “Pediatric-Onset Bipolar Disorder: A Neglected Clinical and Public Health Problem.” Harvard Review of Psychiatry (1995):

60 Geller, B., Zimerman, B., Williams, M., Bolhofner, K., Craney, J.L., Delbello, M.P., Soutullo,C.A. (2000). Diagnostic characteristics of 93 cases of a prepubertal and early adolescent bipolar disorder phenotype by gender, puberty and comorbid attention deficit hyperactivity disorder. J Child Adolesc Psychopharmacol 10(3):157-64

61 Papolos DF, Faedda GL, Veit S, Goldberg R, Morrow B, Kucherlapati R, Shprintzen RJ. Bipolar spectrum disorders in patients diagnosed with velo-cardio-facial syndrome: does a hemizygous deletion of chromosome 22q11 result in bipolar affective disorder? Am J Psychiatry 1996 Dec;153(12):

62 What Is the COBY Study? Course and Outcome of Bipolar Illness in Youth COBY is an acronym for the Course and Outcome of Bipolar Illness in Youth, a large research effort supported by the National Institute of Mental Health (NIMH). Research in COBY has been conducted in a number of locations and by different research teams. The results of these continuing studies have led to a significantly better understanding of bipolar disorder in kids. Findings include evidence that bipolar disorder does exist in children and, in some cases, looks different then bipolar disorder in adults.

63 Before the COBY study, there had been few studies on the symptom patterns and course of the disorder in the pediatric population. Overall, bipolar disorder appears to affect children and adolescents more severely than adults.

64 This study comprises the largest pediatric bipolar population to date, following the course and outcome of 263 children and adolescents, ages 7-17 years. These findings were published in the February 2006 issue of the Archives of General Psychiatry.

65 Four-Year Longitudinal Course of Children and Adolescents With Bipolar Spectrum Disorders: The Course and Outcome of Bipolar Youth (COBY) Study Birmaher, Boris, Alexson, Goldstein, Strober, Gil Birmaher, Boris (Am J Psychiatry 2009; 166: ) Approximately 2.5 years after onset of their index episode, 81.5% of the participants had fully recovered, but 1.5 years later 62.5% had a syndromal recurrence, particularly depression. One-third of the participants had one syndromal recurrence, and 30% had two or more.

66 Signs and Symptoms MANIC  Feelings of grandiosity or very high self-esteem, euphoric  Extreme talkativeness, racing thoughts  Decreased need for sleep  Highly distractible  Engaged excessively with pleasurable activities, often recklessly Thanks to: Debra Caywood-Rukas

67 DEPRESSION  Ongoing sad, anxious or empty mood  Lack of energy and ability to concentrate  Sleeping too much or too little  Lacks interest in others and activities, irritable, feeling hopeless and worthless  Thoughts of death or suicide Thanks to: Debra Caywood-Rukas

68 YOUNGER CHILDREN Poor sleep and night terrors High activity level Easily startled Bedwetting Oppositional behavior Thanks to: Debra Caywood-Rukas

69 Range of Mood and Emotion severe mania mild to moderate mania (hypomania) normal-balanced mood mild to moderate depression severe depression Thanks to: Debra Caywood-Rukas

70 Definitions Normal mood variations Time

71 Pathological mood variations -indicated by Polarity and Severity

72 Unipolar – Major Depressive Disorder

73 Bipolar I Severe mania and severe depression

74 Manic phase of bipolar disorder Signs and symptoms of the manic or hypomanic phase of bipolar disorder can include: Euphoria Inflated self-esteem Poor judgment Rapid speech Racing thoughts Aggressive behavior Agitation or irritation Increased physical activity

75 Risky behavior Increased drive to perform or achieve goals Decreased need for sleep Easily distracted Frequent absences from school Delusions or a break from reality (psychosis) Poor performance at school

76 Bipolar II Mild mania and severe depression

77 Depressive phase of bipolar disorder Signs and symptoms of the depressive phase of bipolar disorder can include: Sadness Hopelessness Suicidal thoughts or behavior Anxiety Guilt Sleep problems

78 Low appetite or increased appetite Fatigue Loss of interest in activities once considered enjoyable Problems concentrating Irritability Chronic pain without a known cause

79 Cyclothymic Disorder Mild mania and mild depression

80 Diagnosing bipolar disorder in adults is difficult. Distinguishing between normal behaviors and those that may indicate a mental illness such as bipolar disorder in a kid is more challenging because: There are a significant number of other conditions whose symptoms overlap with bipolar disorder, including attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD), obsessive compulsive disorder (OCD), anxiety, depressive disorders and learning disabilities; The span of time in a young life is insufficient to establish a course of illness (Papolos, 2006); Many symptoms are different from those found in adults with bipolar disorder Episodes are much shorter than for adults, spanning only days or even hours; Developmental factors are in full play – “a child's often nonstop motion, lack of impulse control, difficulty tolerating frustration, and vivid imagination are part of a typical, everyday picture” (Papolos, 2006).

81 Diagnoses that mimic, mask, or co-occur with pediatric bipolar disorder include: Attention-deficit hyperactivity disorder (ADHD)* Depression** Oppositional-defiant disorder (ODD) Conduct disorder (CD) Pervasive developmental disorder (PDD) Generalized anxiety disorder (GAD)

82 Panic disorder Obsessive-compulsive disorder (OCD) Tourette's syndrome (TS) Seizure disorders Reactive attachment disorder (RAD) * It is estimated that 85% of children with bipolar disorder also have ADHD and up to 22% of children with ADHD have bipolar disorder.

83 Bipolar disorders may co-occur with ADHD or may mimic its symptoms. About ½ of boys and ¼ of girls with bipolar disorder also meet the criteria for ADHD. Children and adolescents with bipolar disorder often show impulsive inattention and hyperactive behavior, extremely strong feelings, an overbearing manner, irritability, and difficulty waking up in the morning. Children and adolescents with severe bipolar symptoms may have excessive and lengthy temper tantrums that are destructive, and often based on gross distortions of objective events. For example, when a friend wants to play a different game, the bipolar child may think that his friend is trying to purposefully be mean. The child's anger at such mistreatment may result in an extreme temper tantrum. Again, it is critically important to reach an accurate diagnosis. The stimulant medication used to treat ADHD is not usually helpful for bipolar disorder and will likely exacerbate the symptoms.

84 Common Symptoms of Childhood Bipolar Disorder Separation anxiety Rages & explosive temper tantrums (lasting up to several hours) Marked irritability Oppositional behavior Frequent mood swings Distractibility Hyperactivity Impulsivity Restlessness/ fidgetiness

85 Bipolar………… Silliness, goofiness, giddiness Racing thoughts Aggressive behavior Grandiosity Carbohydrate cravings Risk-taking behaviors Depressed mood Lethargy Low self-esteem Difficulty getting up in the morning

86 Bipolar Disorder…………… Social anxiety Oversensitivity to emotional or environmental triggers Bed-wetting (especially in boys) Night terrors Rapid or pressured speech Obsessional behavior Excessive daydreaming Compulsive behavior

87 Motor & vocal tics Learning disabilities Poor short-term memory Lack of organization Fascination with gore or morbid topics Hypersexuality Manipulative behavior Bossiness

88 Lying Suicidal thoughts Destruction of property Paranoia Hallucinations & delusions Hallucinationsdelusions Migraine headaches Self-mutilating behaviors

89 Cardinal symptoms: Grandiosity Misunderstanding can occur with evaluating grandiosity. The first occurs because children may be unable to accurately self-evaluate and distinguish between pretend and reality. Similarly, emotionally disturbed and learning disabled children exhibited decreased ability to distinguish between reality and fantasy in cartoons (Sprafkin, Kelly, & Gadow, 1987).

90 Cardinal symptoms: Elation Besides episodicity, elation and grandiosity should, by definition, distinguish mania from other forms of psychopathology and developmental phenomena. However, many have observed that these symptoms are rare in pediatric bipolar samples (Biederman, Russell, Soriano, Wozniak, & Faraone, 1998; Mick, Spencer, Wozniak, & Biederman, 2005; Wozniak et al., 2005), and theorize that irritability (rather than elation), especially the "super irritability" seen in extremely explosive children, is part of the developmental phenotype of very early onset bipolar disorder. Others insist that, to merit a diagnosis of bipolar disorder, a child must exhibit euphoria and/or grandiosity (Geller, Craney, et al., 2002; Leibenluft et al., 2003). In our experience, euphoria, in contrast to silly, disinhibited behavior, is rarely observable in children in an office setting.

91 Rages "Anger attacks" occur in up to 29% of unipolar and 62% of bipolar depressions (Perlis et al., 2004). The affective storm may be another term for within episode mood dysregulation In preschool and school-age children, severe tantrums have been associated with anxiety disorders (Egger & Angold, 2006)

92 Irritability One approach your doctor may use in diagnosing your child with bipolar disorder is emphasizing irritability as the primary symptom of mania and, therefore, bipolar disorder However, this is a relatively new and emerging theory for diagnosing bipolar disorder, and still up for debate as to how accurate it is. It could indicate other problems, too. Either way, if you have a child with near-constant irritability, it's important to discuss this with your doctor. A bit of background: One group of researchers at Massachusetts General Hospital have taken this approach because they believe “the irritability of pediatric mania [is] qualitatively and quantitatively distinct from other forms of irritability and thus can be used to identify bipolar disorder."

93 Development of emotion regulation The concept of emotion regulation is central to the debate regarding juvenile onset bipolar disorder. In adults, the profile of bipolar disorder is characterized by episodic and dramatic shifts in mood state. These represent a clear change from baseline functioning, and are believed to be driven by endogenous factors, although onset may be influenced by stressful life events (Hammen & Gitlin, 1997; Leibenluft et al., 2003; Post, 1992). In contrast, children diagnosed with bipolar disorder have been described as having chronic and extreme emotional instability characterized by intense and enduring responses to negatively perceived environmental events (Leibenluft et al., 2003). Findings have shown that impairments in emotion regulation are at the core of these children's difficulties (Melnick & Hinshaw, 2000).

94 Gaining the capacity to regulate one's emotional responses is a salient task of late infancy (Zahn-Waxler, McKnew, Cummings, Davenport, & Radke-Yarrow, 1984). Initially, infants are not capable of self- regulation, and thus rely entirely on caregivers for modulation of emotional reactions (Sroufe, 1989).

95 It is not surprising, then, children who meet criteria for ADHD, anxiety disorders, PDD, and PTSD manifest disturbance in emotion regulation.

96 How is ADHD different from bipolar disorder? Bipolar disorder is primarily a mood disorder.mood disorder ADHD affects attention and behavior. It causes symptoms of inattention, hyperactivity, and impulsivity. While ADHD is chronic, bipolar disorder is usually episodic. There are periods of normal mood interspersed with the depression or hypomania.

97 Medications………… Some serious side effects include confusion, irritability, withdrawal, and allergic reactions (e.g., rash, wheezing, or swelling of the hands or face). Another possible serious side effect is the lowering of the brain's seizure threshold. In other words, someone who already has a tendency to have seizures may develop seizures while on stimulant medication.

98 Bipolar Disorder and Substance Abuse About 60% of people with bipolar disorder have trouble with drugs or alcohol. Patients may drink or abuse drugs to relieve the uncomfortable symptoms of their mood swings. This is especially common during the reckless manic phase.

99 Bipolar Disorder and Suicide People with bipolar disorder are 10 to 20 times more likely to commit suicide than people without the illness. Warning signs include talking about suicide, putting affairs in order, and inviting death with risky behavior. Anyone who appears suicidal should be taken very seriously.

100 Teachers have not traditionally been a source of information on mood symptoms. However, because manic behaviors are observable, teachers should be able to provide important information. Like attention problems, manic symptoms should be apparent in more than one setting.

101 Treatment – Just like long-term illnesses such as diabetes and heart disease, bipolar disorder is an illness that requires medication to improve quality of life – Not all medications work for every person – Severity of moods and side effects must be weighed – Medical management by a psychiatrist is best – A combination of medication and talk therapy is most effective, specifically cognitive behavior and family therapy – Long-term management of symptoms reduces risk of suicide ** suicide rate 10-15%, NIMH Thanks to: Debra Caywood-Rukas

102 Medication Lithium reduces manic episodes and aggression. Eskalith, Lithobid, Lithonate – Side effects: upset stomach, tremors, headache, weight gain, tiredness and difficulty with memory. Anticonvulsants/Antiepileptics reduce seizures, mania, aggression. Side effects include upset stomach and drowsiness. – Tegretol: nausea, irritability and agitation – Depakene &, Depakote Valproic: hand tremors and loss of hair – Neurontin/Gabapentin, Lamictal/lamotrigine, Topamax/topiramate and Gabitril tiagabine are the newest medications. Side effects are similar with the addition of rash, nausea & dry mouth “Mood-stabilizers” Medicine combinations Thanks to: Debra Caywood-Rukas

103 School Accommodations – Inform teacher how disorder is manifested and alert to side effects of medication – Is there an IEP? If so, accommodations, modifications and interventions are written along with goals – Counseling with school psychologist or social worker – Reduced work load due to level of concentration and fatigue – Provide clear instructions to alleviate/prevent frustration Thanks to: Debra Caywood-Rukas

104 – Offer instruction, corrections and feedback in a calm, positive manner – Prearrange an area in and/or outside the classroom for the student to retreat to when needed and a discrete cue – Allow extra time to complete assignments – Mutually choose a peer mentor to assist when needed – Consult with the school psychologist for additional information – Employ effective classroom management programs

105 Moreover, although children with attention problems should not be grandiose, an artificially inflated self-regard (Hoza, Pelham, Dobbs, Owens, & Pillow, 2002) could be interpreted by some as grandiosity. That is, a child who says he is the most popular child in the class but has never had an invitation to a birthday party, or says he can build things better than anyone despite evidence to the contrary, or that he is planning on going to college despite having failed every course in high school for the past 2 years, could be interpreted as having an inflated self-esteem. Sometimes such assertions are defensive (i.e., s/he knows full well s/he has no friends, or has poor motor skills, but does not want to admit it), and sometimes a result of poor social awareness.

106 true psychotic grandiosity is rare in children but it does occur

107 Comorbidity

108 attentional difficulties come in all levels of severity, and itself is often complicated by the presence of other comorbidities. It is misleading to compare a manic child with ADHD (and the usual comorbidities) to a child with uncomplicated ADHD.

109 Comorbidity with ADHD male gender and rates of ADHD/externalizing disorder decrease with age of bipolar onset.

110 Shaw, Lacourse, and Nagin (2005) found that the most hyperactive preschoolers were likely to remain chronically hyperactive through age 10, with 19% of these children continuing to manifest "overt conduct problems" (i.e., aggressive behavior) suggesting an externalizing pathway. Others would label these children with severe hyperactivity, fearlessness, and overt conduct problems as having bipolar disorder with comorbid ADHD (Biederman, Faraone, Chu, & Wozniak, 1999; Faraone, 2000; Geller, Craney, et al., 2002), which, similar to Shaw, Lacourse, and Nagin's (2005) findings, has proven to be a chronic, disabling condition (Biederman et al., 2004; Geller et al., 2004).

111 Differentiating between ADHD and/or mania is complicated by several features unique to children. First, in people of all ages, but particularly in those in whom no prior episodes have occurred, distinguishing between true comorbidity versus the early symptoms of mania or depression may be difficult. In schizophrenia, we know that many children have behavior and attention problems prior to the onset of even prodromal symptoms, let alone psychotic symptoms (Cornblatt, Obuchowski, Roberts, Pollack, & Erlenmeyer-Kimling, 1999; Erlenmeyer-Kimling et al., 2000; Meyer et al., 2005). If the onset is acute, with most of the signs and symptoms occurring simultaneously, it is possible to distinguish the episode from its comorbidity. If the onset is gradual, and if there is disagreement about how to interpret the symptoms, disentangling the condition from the comorbidities becomes extremely difficult.

112 Finally, symptoms of ADHD occur in a number of conditions which themselves may be confused with mania or exist with it. The rules of DSM preclude the diagnosis of ADHD if there is "pervasive developmental disorder, schizophrenia, or other psychotic disorder," because ADHD-like symptoms often occur in those conditions. That means that when assessing a child who is exhibiting significant symptoms of hyperactivity, impulsivity, and inattention, one must rule out, or at least consider, PDD, schizophrenia, and other psychotic disorders.

113 Rages occur in inflexible children (Greene, 2001), in children with pervasive developmental disorders (Myles & Southwick, 2005), and in teens with borderline personality disorder (Becker, McGlashan, & Grilo, 2006). Whether the underlying neurobiology of rages is homogeneous, or differs by disorder, remains to be studied. At this point, we can say that although rages may occur in mania, they are not synonymous with or exclusive to it. There is actually little information on the phenomenology of a rage episode. Carlson, Potegal, Gutkovich, and Margulies (2005) have examined rages occurring in psychiatrically hospitalized children and found they last anywhere from 15 min to 2 hr. During a rage, children become agitated (angry and distressed). They are certainly not elated. They meet no other symptoms of mania. Parents often volunteer that their child has a "mood swing" (by which they mean get very angry for no reason immediately obvious to parents) and clinicians appear to accept this as evidence of a manic episode.

114 survey of rage and tantrum behavior in 318 consecutively referred families to the Stony Brook Outpatient Department, Carlson and Blader (2006) found that 16% of parents said that their children had rages (hit, kicked, spit, or needed restraint), compared to more garden variety tantrums (screaming, threatening, slamming doors, etc.) present in 20% of children. Compared to children with tantrums, children with rages were significantly younger, female, and more likely to suffer from speech/language problems. There were no differences in race, income, or parent education, but raging children lived less often with biological mothers and had more lifetime stressors. Children with rages were significantly more likely to have outbursts with changes in routine, and when demands were not immediately met.

115 Bipolar spectrum disorders were diagnosed in less than 25% of either raging or tantruming children. However, compared to the rest of the outpatient sample, raging or tantruming children were significantly more likely to be diagnosed with comorbid ADHD and oppositional defiant disorder/conduct disorder, bipolar spectrum, and speech/language disorders.

116 Manic symptoms include: severe changes in mood, either extremely irritable or overly silly and elated overly-inflated self-esteem, grandiosity increased energy decreased need for sleep, ability to go with very little or no sleep for days without tiringsleep increased talking, talks too much, too fast; changes topics too quickly; cannot be interrupted distractibility, attention moves constantly from one thing to the next hypersexuality, increased sexual thoughts, feelings, or behaviors; use of explicit sexual language increased goal-directed activity or physical agitation disregard of risk, excessive involvement in risky behaviors or activities Depressive symptoms include: persistent sad or irritable mood loss of interest in activities once enjoyed significant change in appetite or body weight difficulty sleeping or oversleeping physical agitation or slowing loss of energy feelings of worthlessness or inappropriate guilt difficulty concentrating recurrent thoughts of death or suicide

117 researchers from the University of California at Los Angeles set out to unravel how ADHD and bipolar disorder individually contributed to brain abnormalities found during MRI. They recruited 85 participants, of whom 17 had bipolar disorder only, 19 had ADHD only, 18 had both bipolar disorder and ADHD, and 31 had no mental disorder. All patients with bipolar disorder were in a non-depressed state at the time of imaging and were not taking lithium. Researchers used MRI to measure participants’ cortical thickness. Analysis of the prefrontal cortex and anterior cingulate cortex showed that overall cortical thickness was lessened in patients with bipolar disorder both with and without comorbid ADHD. However, the effect of bipolar disorder on cortical thickness was different in patients with and without ADHD in the right orbitofrontal cortex and the left subgenual cingulate. In the right orbitofrontal cortex, bipolar disorder was associated with significant cortical thinning only when there was no ADHD diagnosis; furthermore, in the left subgenual cingulate, the presence of ADHD eliminated the cortical thinning associated with bipolar disorder compared to controls. The effects of bipolar disorder and ADHD in these regions were found to be connected, “resulting in a unique phenotypic signature for the comorbid diagnostic group,” write the researchers in the journal Bipolar Disorders. Pedersen, T. (2012). Brain Abnormalities Linked to Comorbid ADHD in Bipolar Disorder. Psych Central. Retrieved on January 26, 2013, from abnormalities-linked-to-comorbid-adhd-in-bipolar-disorder/48851.html


119 Comorbidity with anxiety Depression and anxiety are well-known comorbidities, so it should not be surprising that anxiety disorders and bipolar disorder co-occur with greater frequency than would be expected by chance in community studies There is not much consistency about which subtypes of anxiety disorders are most frequent, and there is likely a high rate of comorbidity between subtypes of anxiety disorder.

120 What is the difference between bipolar disorder and ordinary mood swings? The three main things that make bipolar disorder different from ordinary mood swings are: Intensity: Mood swings that come with bipolar disorder are usually more severe than ordinary mood swings. Length: A bad mood is usually gone in a few days but mania or depression can last weeks or months. With rapid cycling, moods last a short time but change quickly from one extreme to another. With rapid cycling, "level" (ethylic) moods do not last long. Interference with life: The extremes in mood that come with bipolar disorder can severely disrupt your life. For example, depression can make a person unable to get out of bed or go to work or mania can cause a person to go for days without sleep.

121 Symptoms of Mania: The "Highs" of Bipolar Disorder Heightened mood, exaggerated optimism and self- confidence Excessive irritability, aggressive behavior Decreased need for sleep without experiencing fatigue Grandiose thoughts, inflated sense of self-importance Racing speech, racing thoughts, flight of ideas Impulsiveness, poor judgment, easily distracted Reckless behavior In the most severe cases, delusions and hallucinations

122 Symptoms of Depression: The "Lows" of Bipolar Disorder Prolonged sadness or unexplained crying spells Significant changes in appetite and sleep patterns Irritability, anger, worry, agitation, anxiety Pessimism, indifference Loss of energy, persistent lethargy Feelings of guilt, worthlessness Inability to concentrate, indecisiveness Inability to take pleasure in former interests, social withdrawal Unexplained aches and pains Recurring thoughts of death or suicide

123 Children and Adolescents Mania in children often appears as extreme irritability or rage. Children and teens are more likely to have destructive outbursts than to be excited or euphoric. Depression in early life may have symptoms such as headaches, muscle aches, stomachaches or tiredness, frequent absences from school or poor performance in school, talk of or efforts to run away from home, irritability, complaining, unexplained crying, isolation, poor communication and extreme sensitivity to rejection or failure. Other signs of a possible mood disorder are alcohol or substance abuse and difficulty making or keeping friends. Young people may also have a continuous, rapid-cycling, irritable and mixed symptom state that may co-occur with disruptive behavior disorders, particularly attention deficit hyperactivity disorder (ADHD) or conduct disorder (CD). Young people may have features of ADHD and CD before having bipolar symptoms. A child or adolescent who has symptoms of depression along with ADHD-like symptoms that are very severe, with excessive temper outbursts and mood changes, should be evaluated by a psychiatrist or psychologist with experience in bipolar disorder, particularly if there is a family history of the illness. This evaluation is especially important since medications prescribed for ADHD may worsen manic symptoms. Bipolar disorder that begins in late teen or adult years tends to begin suddenly, often with a classic manic episode. In adults, the illness has more defined ups and downs with relatively stable periods between episodes. There is also less co-occurring ADHD or CD among adults with bipolar disorder.

124 Childhood Manic Rating Scale (21 items) Need less sleep than usual; yet does not feel tired the next day Have trouble staying on track and is easily drawn to what is happening around him or her Believe that he or she has unrealistic abilities or powers that are unusual, and may try to act upon them, which causes trouble Talk so fast that he or she jumps from topic to topic Feel irritable, cranky, or mad for hours or days at a time

125 Symptoms of ADHD often mimic symptoms of bipolar disorder. With ADHD, a child or teen may have rapid or impulsive speech, physical restlessness, trouble focusing, irritability, and, sometimes, defiant or oppositional behavior. Children or teens with bipolar disorder often have similar behaviors.

126 Bipolar disorder is often misdiagnosed as: ADHD or ADHD with depression Depression Borderline personality disorder Post-traumatic stress disorder (PTSD) Substance abuse

127 Common outcomes of pediatric bipolar disorder are school refusal, suspension, and dropping-out; impulsive acts of aggression; self-injury; substance abuse; and suicide attempts and completions. Teens with symptoms of untreated bipolar disorder are arrested and incarcerated. Suicide is the third leading cause of death among teens. Children as young as six have attempted to hang, shoot, stab or overdose themselves.

128 The longest study on pediatric bipolar disorder is ongoing under the direction of Barbara Geller, M.D., a child psychiatrist at Washington University in St. Louis. In the mid-1990s, Dr. Geller began observing 93 children whose average age was 10.8 years. All of the children had mania (Bipolar I) which had begun to onset at an average age of 6.8 years. Assessing the children after four years, Geller and colleagues found that children with mania were sicker than adults, less likely than adults to recover, and relapsed sooner than adults with mania. Differences in symptom severity and frequency of cycling between manic and depressive episodes have presented questions as to whether bipolar disorder in youth is the same illness as in adults.




132 Bipolar I disorder. Mood swings with bipolar I cause significant difficulty in your job, school or relationships. Manic episodes can be severe and dangerous. Bipolar II disorder. Bipolar II is less severe than bipolar I. You may have an elevated mood, irritability and some changes in your functioning, but generally you can carry on with your normal daily routine. Instead of full-blown mania, you have hypomania — a less severe form of mania. In bipolar II, periods of depression typically last longer than periods of hypomania. Cyclothymic disorder. Cyclothymic disorder, also known as cyclothymia, is a mild form of bipolar disorder. With cyclothymia, hypomania and depression can be disruptive, but the highs and lows are not as severe as they are with other types of bipolar disorder.


134 Autism Spectrum Disorders (Pervasive Developmental Disorders) Autism is a group of developmental brain disorders, collectively called autism spectrum disorder (ASD). The term "spectrum" refers to the wide range of symptoms, skills, and levels of impairment, or disability, that children with ASD can have. Some children are mildly impaired by their symptoms, but others are severely disabled. ASD is diagnosed according to guidelines listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition - Text Revision (DSM-IV-TR). 1 The manual currently defines five disorders, sometimes called pervasive developmental disorders (PDDs), as ASD: Autistic disorder (classic autism) Asperger's disorder (Asperger syndrome) Pervasive developmental disorder not otherwise specified (PDD-NOS) Rett's disorder (Rett syndrome) Childhood disintegrative disorder (CDD).

135 Asperger’s Syndrome Asperger’s is an autism spectrum disorder. Autism is a developmental disorder than affects the way a child…or adult…interacts with, perceives and interprets the world. A spectrum means that there are many different forms of autism, ranging from very severe to very mild. Those on the more high functioning side usually get a diagnosis of Asperger’s Syndrome. Many children as well as adults may be misdiagnosed…this is unfortunately all too common. Many are initially diagnosed with ADHD or OCD or some other condition before a proper diagnosis is reached. This is unfortunate because it delays the start of effective training and treatments that can help someone with Asperger’s syndrome.

136 Asperger’s Syndrome is primarily a syndrome that has to do with deficits in social functioning. Someone with Asperger’s will have often have trouble both understanding language and using language in a proper way. They often have a pedantic style of talking, and are often referred to as “walking dictionaries.” People with Asperger’s are often very smart, and can talk about facts very easily, but have a lot of trouble with small talk or really any social connections at all, at least when they’re younger. People with Asperger’s syndrome don’t tend to understand sarcasm or jokes, and take everything you say very literally…even when they are adults. They have very concrete thinking, and are very rule oriented. Those with Asperger’s often depend on routines to get through the day, and can be very upset if their routines are interrupted; children may have meltdowns while adults may get angry or autocratic. They are prone to emotional upset if something does not go right. Due to their deficits in social skills, children and adults with Asperger’s syndrome often have trouble making friends. When they are kids, they will not understand the concept of playing with others. They will often do something called “parallel play” where they might play next to, but not with, another kid. They have to be taught to share toys and be flexible enough to play with another child. Adults can become very isolated after years of not being able to establish long-lasting friendships.

137 Obsessive Interests The interests of children and adults often deviate from their peers, especially when they are older. Those with Asperger’s are often obsessive about specific subjects, such as geology, a particular sports team, or trains, and their peers find this uninteresting. This constant focus on one topic and lack of interest in topics that others bring up tends to isolate them further. Obsessive interests are a main fabric of the cloth of Aspergers syndrome. Most kids with Asperger’s have something that they are very interested in and talk about it endlessly. One child might be obsessive about cars. Another “Thomas the Train”. A third with volcanoes. And so forth. Because they are unable to truly show interest in a wide range of subjects that are of interest to their peers, they become social outcasts. This all contributes to the social isolation that is so common in kids with Asperger’s especially when kids start school. While their friends are talking about baseball or video games, the Aspergers child may exclusively talk about volcanoes. It doesn’t take long before his or her peers in school loose interest in both the subject of volcanoes AND in the child.

138 Sensory Issues Are A Common Symptom Of Asperger’s Syndrome People with Asperger’s syndrome often have a lot of difficulty with sensory processing. The typical person can usually tune out extraneous noise, smells and visual stimuli, among others. They do it without even thinking about it, because that’s the way their brain is set up. People with Asperger’s syndrome, however, lack a “barrier” between their brain and the sensory onslaught of the world. They are far, far more sensitive to loud noises – or even soft ones no one else notices; to smells of all kinds…from what comes from your kitchen to the perfume of a passerby on the sidewalk. They often have trouble with the feeling and texture of clothing; with how tight or loose it is, and with the tags on the back. Visual stimuli can also be quite distracting. These sensory concerns need to be minimized for a child with Asperger’s to function in his or her environment, and their concerns need to be taken seriously. Many adults have difficulty holding a job because of the noise, distractions and overall sensory overload of a “cubicle farm” in which they must work. A co-worker tapping a pencil or bright fluorescent lights can overwhelm an adult with Asperger’s.

139 Fixation On Routine Is A Common Symptom Of Asperger’s Syndrome Aspies (as those with Asperger’s syndrome are affectionately called) often fixated on a routine. Following a set routine is extremely common. And any change in routine may cause a meltdown. Yet stubbornly sticking to routine helps those with Asperger’s feel safe and grounded. Yet family, friends, and co-workers can feel that this fixation with routine is extreme. With kids, even small change in routine, like sitting in a different chair around the dinner table, can cause a meltdown. A lot of children with Aspergers need to know exactly what will happen in order not to feel completely overwhelmed. A good tip is to ensure that you tell your child, in advance, if there will be any change in his or her routine (such as an upcoming vacation).

140 Weak Central Coherence This is often called "weak central coherence." In other words, people with Asperger's have trouble, as the metaphor goes, "seeing the forest for the trees." They get so focused on the details of each event that they are unable to see it globally, or see the big picture — they lack perspective. Since details are so overwhelmingly obvious to them, they get distressed when small details are changed. Because of the way they process information and understand the world, it changes their whole meaning and understanding of the world. As a result, routine becomes increasingly important to the Asperger's child and adult. The more they can do everything in exactly the same way every day, the more their experience of the world will remain the same — and the more stable their mood and level of anxiety will remain.

141 Why is it called Asperger syndrome? In 1944, an Austrian pediatrician named Hans Asperger observed four children in his practice who had difficulty integrating socially. Although their intelligence appeared normal, the children lacked nonverbal communication skills, failed to demonstrate empathy with their peers, and were physically awkward. Their speech was either disjointed or overly formal, and their all-absorbing interest in a single topic dominated their conversations. Dr. Asperger called the condition “autistic psychopathy” and described it as a personality disorder primarily marked by social isolation. Asperger’s observations, published in German, were not widely known until 1981, when an English doctor named Lorna Wing published a series of case studies of children showing similar symptoms, which she called “Asperger’s” syndrome. Wing’s writings were widely published and popularized. AS became a distinct disease and diagnosis in 1992, when it was included in the tenth published edition of the World Health Organization’s diagnostic manual, International Classification of Diseases (ICD-10), and in 1994 it was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the American Psychiatric Association’s diagnostic reference book. However, scientific studies have not been able to definitively differentiate Asperger syndrome from highly functioning autism. Because autism is defined by a common set of behaviors. Proposed changes to be announced in DSM-V, which are expected to take effect in mid-2013, will represent the various forms under a single diagnostic category, ASD.

142 What are some common signs or symptoms? Children with Asperger syndrome may have speech marked by a lack of rhythm, an odd inflection, or a monotone pitch. They often lack the ability to modulate the volume of their voice to match their surroundings. For example, they may have to be reminded to talk softly every time they enter a library or a movie theatre. Unlike the severe withdrawal from the rest of the world that is characteristic of autism, children with Asperger syndrome are isolated because of their poor social skills and narrow interests. Children with the disorder will gather enormous amounts of factual information about their favorite subject and will talk incessantly about it, but the conversation may seem like a random collection of facts or statistics, with no point or conclusion. They may approach other people, but make normal conversation difficult by eccentric behaviors or by wanting only to talk about their singular interest. Many children with AS are highly active in early childhood, but some may not reach milestones as early as other children regarding motor skills such as pedaling a bike, catching a ball, or climbing outdoor play equipment. They are often awkward and poorly coordinated with a walk that can appear either stilted or bouncy. Some children with AS may develop anxiety or depression in young adulthood. Other conditions that often co-exist with Asperger syndrome are Attention Deficit Hyperactivity Disorder (ADHD), tic disorders (such as Tourette syndrome), depression, anxiety disorders, and Obsessive Compulsive Disorder (OCD).

143 Two core features of autism are: a) social and communication deficits and b) fixated interests and repetitive behaviors. The social communication deficits in highly functioning persons with Asperger syndrome include lack of the normal back and forth conversation; lack of typical eye contact, body language, and facial expression; and trouble maintaining relationships. Fixated interests and repetitive behaviors include repetitive use of objects or phrases, stereotyped movements, and excessive attachment to routines, objects, or interests. Persons with ASD may also respond to sensory aspects of their environment with unusual indifference or excessive interest.

144 What Are the Symptoms of Asperger's Syndrome? The symptoms of Asperger's syndrome vary and can range from mild to severe. Common symptoms include: Problems with social skills: Children with Asperger's syndrome generally have difficulty interacting with others and often are awkward in social situations. They generally do not make friends easily. They have difficulty initiating and maintaining conversation. Eccentric or repetitive behaviors: Children with this condition may develop odd, repetitive movements, such as hand wringing or finger twisting. Unusual preoccupations or rituals: A child with Asperger's syndrome may develop rituals that he or she refuses to alter, such as getting dressed in a specific order. Communication difficulties: People with Asperger's syndrome may not make eye contact when speaking with someone. They may have trouble using facial expressions and gestures, and understanding body language. They also tend to have problems understanding language in context. Limited range of interests: A child with Asperger's syndrome may develop an intense, almost obsessive, interest in a few areas, such as sports schedules, weather, or maps. Coordination problems: The movements of children with Asperger's syndrome may seem clumsy or awkward. Skilled or talented: Many children with Asperger's syndrome are exceptionally talented or skilled in a particular area, such as music or math.







151 According to the DSM-IV-TR, to meet the criteria for diagnosis, there must be clear evidence of clinically significant impairment in social, academic, or occupational functioning in more than two distinct settings (e.g, at school, at work, or in social settings).

152 Symptoms of Inattention during the elementary school years can include: Failing to pay close attention to details or making careless mistakes when doing schoolwork or other activities Trouble keeping attention focused during play or tasks Appearing not to listen when spoken to Failing to follow instructions or finish tasks Avoiding tasks that require a high amount of mental effort and organization, such as school projects Frequently losing items required to facilitate tasks or activities, such as school supplies Excessive distractibility Forgetfulness Procrastination, inability to begin an activity Associated problems such as low self-esteem, depression, or anxiety

153 Symptoms of Hyperactivity during the elementary school years can include: Diminished need for sleep Fidgeting with hands or feet, or squirming in seat Leaving seat often, even when inappropriate Running or climbing at inappropriate times Difficulty with quiet play Frequent feelings of restlessness Excessive speech

154 Symptoms of Impulsivity during the elementary school years can include: Social immaturity Frequent arguments with parents and peers Disregards socially-accepted behavioral expectations Requires more supervision than average Inconsistent with responsibilities and chores Continually striving to be the center of attention Answering a question before the speaker has finished Failing to await one's turn Interrupting the activities of others at inappropriate times Poor peer relationships

155 Symptoms of Inattention during adolescence can include: Frequently shifting from one uncompleted task to another Difficulty organizing activities Serious academic inconsistencies Ongoing underachievement Difficulties with household activities (cleaning, paying bills, etc.) Often viewed as lazy or disinterested Associated mood or behavior problems become more pronounced

156 Symptoms of Hyperactivity during adolescence can include: Decreased hyperactivity Pronounced feelings of restlessness Low self-esteem Intense need to stay busy and/or to do several things at once. Discipline problems High-risk behavior

157 Symptoms of Impulsivity during adolescence can include: Continued poor peer relationships Low self-esteem Discipline problems Continued frequent arguments Drug and alcohol abuse Risk-taking behavior Impulsive spending, leading to financial difficulties

158 Many consider the inability to think before acting and to tolerate delay to be the most significant problems for adolescents and adults with ADHD. Impulsivity can interfere greatly with social relationships, because individuals tend to display their emotions without thinking, blurt out inappropriate comments, and engage in behaviors that can be dangerous or hurtful without considering the consequences beforehand. Children who are very impulsive may take away another child's toy or hit when they get upset. Their impulsivity may make it hard for them to wait for things they want or to take their turn in games. Individuals with ADHD may choose to do things that are immediately rewarding in a small way, rather than waiting for a much larger long-term benefit in the future.

159 Poor school performance and underachievement are almost universal for individuals with ADHD. A child who has extreme trouble sitting still at school, or is otherwise disruptive to the learning of other students (e.g., interrupting others during quiet work time) will be very noticeable. Initially, hyperactive or impulsive behaviors, like interrupting or touching others, may be viewed as a discipline or environmental problem rather than a legitimate mental health issue. As a result, a child who exhibits hyperactive or impulsive symptoms may be judged as having eaten too much sugar or having parents that are too permissive at home. In contrast, the child who appears to be a daydreamer (who actually has ADHD Inattentive Type), is often overlooked, or, if noticed at all, viewed as lazy or unmotivated. Most children with ADHD are first identified as having problems while they are in the school setting (particularly those with hyperactive or impulsive behaviors) since the teacher is forced to intervene with such students on a frequent basis. As mentioned before, some researchers believe that fewer girls are diagnosed with ADHD because they are more likely to have inattentive behaviors that do not draw attention in the same ways as do hyperactive behaviors. This is particularly problematic because early identification and treatment of this disorder is strongly linked to better outcomes.

160 When children have Attention-Deficit/Hyperactivity Disorder, their behaviors have a profound effect on the entire family system. The high activity level, moodiness, constant difficulties, and problems at school can generate a great deal of tension and anxiety for both the parents and siblings of children with ADHD. There are frequent family conflicts, often revolving around social gatherings, meals and other activities that can be unpleasant events as a result of the child's behaviors. The strain on the parents can be overwhelming. The typical parenting response to such behaviors is reactionary, rather than preventative or corrective. For example, a child who is constantly on the go, touching things and people, and engaging in angry outbursts will demand a lot of time and energy from parents who must be vigilant to ensure that nothing gets broken and no one gets hurt. Parents often react to the child's behavior once it has occurred and find it difficult to get ahead of the behavior and take action to avoid behavioral problems. Raising a child, or children, with ADHD can lead to excess stress for the parents and a breakdown in communication between not only parent and child, but also between parents. Parents may argue with each other over discipline because nothing seems to work. They often experience their own negative emotions such as feelings of sadness, guilt, anger and helplessness. Parents with ADHD have an even harder time as they struggle to balance their own symptoms with those of their child. As parents learn about the nature of ADHD and what to do about the symptoms, their ability to correct or prevent such behaviors will improve. We will discuss parenting tips in more detail in our section on Treatment.

161 With Peers Having ADHD can make it difficult for a child to make and keep friends. This is a critical issue for individuals with ADHD, since children's immediate happiness is strongly tied to their relationships with other children. Difficulties in maintaining relationships, particularly friendships with peers, can have a severe impact on a person's self-esteem and long-term development. Research shows that children with ADHD are often rejected by their peers, or taken advantage of by them, and tend to become loners who may be at a higher risk for developing anxiety, mood disorders, substance abuse, and delinquency. Problems with peers often begin in preschool, especially for hyperactive children. Bossiness, trouble taking turns, and impulsive acting out cause peer difficulties in elementary and secondary school. The aggressive behavior that Hyperactive/Impulsive Type children display can also lead to peer rejection. Perhaps as the result of difficult peer relationships, children with ADHD tend to be less involved in school activities. Children with predominately Inattentive ADHD may be perceived as shy or withdrawn and are often targets for bullies. Despite the frequent peer problems and painful rejection that often occurs, these children may be singled out by parents or school personnel for extra discipline. Research indicates that children with ADHD may be punished more often at home or school as adults struggle to correct their behavior.

162 Anxiety Separation Anxiety Phobias Social Anxiety Disorder Panic Disorder Generalized Anxiety Disorder

163 Symptoms in children and adolescents Instead of clear-cut depression and mania or hypomania, the most prominent signs of bipolar disorder in children and adolescents can include explosive temper, rapid mood shifts, reckless behavior and aggression. In some cases, these shifts occur within hours or less — for example, a child may have intense periods of giddiness and silliness, long bouts of crying and outbursts of explosive anger all in one day.

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