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School Interface
with
Psychological Disorders
Changing Role of Schools
• 3 R’s
• Mandates
–Physical health
–Nutrition
–Exercise
–Moral/ethical
–Mental health
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
These Students now included in
your classroom…….
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Attention Deficit Disorder
Asperger’s Syndrome
Depression
Anxiety
Post-traumatic Stress Disorder
Bipolar Disorder
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 ????????????
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)
• 20 chapters
– Similarities in disorders
– Symptom overlap
• Decrease in Diagnostic Choices
• Removal of multiaxial system
• Point on a continuum or “spectrum”
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
• 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
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Cont’d…………………………………….
• 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
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.
Callis homepage
• http://cstl-cla.semo.edu/callis
• scroll down to bottom center
for “DSM 5 Resources”
“Rejected” for inclusion
–Anxious depression
–Hypersexual disorder
–Parental alienation syndrome
–Sensory processing disorder
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,
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.”
• Disruptive Mood Dysregulation Disorder: DSM
5 will turn temper tantrums into a mental
disorder
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”
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. ……….
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.
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 hyperactiveimpulsive symptoms were present by age 12."
• 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.
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. ………………………………
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%.
• According to the Centers for Disease Control
• 4.4 million youth between the ages of 4-17 have
been diagnosed with AttentionDeficit/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.
• 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.
• 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%.
Manner in which Brain Develops
• Brain develops
– Inside out
– Back to Front
• Prefrontal Cortex
– Not fully developed until mid 20’s in many
subjects
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
By age six, the brain is
already 95 percent of
its adult size.
Brain size does not equal
intellectual or
emotional maturity
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.
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.
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)
“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
• 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
COMPONENTS OF EXECUTIVE FUNCTIONS AND
SAMPLE BEHAVIORS
COMPONENTS
Goal Directedness
Initiation/Inhibition
Flexibility/Perseverance
BEHAVIORS
Establishing and
maintaining goals;
evaluating progress, using
strategies
Initiating behavior
independently, self-cueing,
inhibiting inappropriate
behaviors
Generating novel
possibilities, flexibility,
performing contingency
based revisions, strategizing
COMPONENTS
BEHAVIORS
Abstract Reasoning
Using rule-guided
thinking, forming
concepts, using
hierarchical and temporal
relationships
Reward Appraisal
Evaluating reward
likelihood, using reward
appraisal to guide
behavior
Social Appraisal
Understanding social
norms and cues,
incorporating social
information into decision
making
Brown et al., 2008
• 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
• 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.
The general symptoms
of ADHD include:
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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
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.
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 1958.
• 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.
• 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
• 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 !!!!!
• 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:
• 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.
• 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 nonstimulant 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.
• 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,
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Oppositional Defiant Disorder
Depression
Anxiety
Bipolar Disorder
Conduct Disorder
Sensory Integration Disorder
Learning Disorder
Early Speech/Communication problems
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.
• 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 1999.
Follow-up data continues to be published.
• 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 79, 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).
Accommodations that a Special Education teacher
could use when working with an ADHD child include:
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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!
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.
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
• “Pediatric Bipolar”
Bipolar Disorder
• Bipolar disorder, also known as manicdepressive 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.
• 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.
• Kraepelin's (1921) initial term
for the condition we now call
"bipolar" was
• "manic depressive insanity."
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.
• Carlson, G.A. (1998). Mania and ADHD:
comorbidity or confusion. J Affect Disord,
51(2):177-87.
• 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): 171-95
• 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
• 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):1541-7.
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.
• 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.
• 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.
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
• (Am J Psychiatry 2009; 166:795-804)
• 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.
Signs and Symptoms
Thanks to: Debra
Caywood-Rukas
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
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
YOUNGER CHILDREN
•Poor sleep and night terrors
•High activity level
•Easily startled
•Bedwetting
•Oppositional behavior
Thanks to: Debra
Caywood-Rukas
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
Definitions
•Normal mood variations
M
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Time
Pathological mood variations
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D
-indicated by
Polarity and
Severity
Unipolar – Major Depressive Disorder
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Bipolar I
•Severe mania and severe depression
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Manic phase of bipolar disorder
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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
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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
Bipolar II
•Mild mania and severe depression
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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
• Low appetite or increased appetite
• Fatigue
• Loss of interest in activities once considered
enjoyable
• Problems concentrating
• Irritability
• Chronic pain without a known cause
Cyclothymic Disorder
•Mild mania and mild depression
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• 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).
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)
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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.
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.
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
Bipolar…………
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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
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
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Motor & vocal tics
Learning disabilities
Poor short-term memory
Lack of organization
Fascination with gore or morbid topics
Hypersexuality
Manipulative behavior
Bossiness
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Lying
Suicidal thoughts
Destruction of property
Paranoia
Hallucinations & delusions
Migraine headaches
Self-mutilating behaviors
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).
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.
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)
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."
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).
• 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 selfregulation, and thus rely entirely on caregivers
for modulation of emotional reactions
(Sroufe, 1989).
• It is not surprising, then, children who meet
criteria for ADHD, anxiety disorders, PDD, and
PTSD manifest disturbance in emotion
regulation.
How is ADHD different from bipolar
disorder?
• Bipolar disorder is primarily a 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.
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.
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.
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.
• 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.
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
“Mood-stabilizers”
Medication
Medicine combinations
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.
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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
Thanks to: Debra
Caywood-Rukas
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
Thanks to: Debra
Caywood-Rukas
alleviate/prevent frustration
– 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
• 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.
• true psychotic grandiosity is rare in children
but it does occur
Comorbidity
• 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.
Comorbidity with ADHD
• male gender and rates of ADHD/externalizing
disorder decrease with age of bipolar onset.
• 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).
• 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.
• 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.
• 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.
• 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.
• 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.
Manic symptoms include:
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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 tiring
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
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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 http://psychcentral.com/news/2012/12/09/brainabnormalities-linked-to-comorbid-adhd-in-bipolar-disorder/48851.html
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.
• 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.
• Symptoms of Mania: The "Highs" of Bipolar Disorder
• Heightened mood, exaggerated optimism and selfconfidence
• 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
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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
Children and Adolescents
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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.
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
• 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.
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Bipolar disorder is often misdiagnosed as:
ADHD or ADHD with depression
Depression
Borderline personality disorder
Post-traumatic stress disorder (PTSD)
Substance abuse
• 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.
• 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.
• 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.
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).
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.
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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.
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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.
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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.
• 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).
• 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.
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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.
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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).
• 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.
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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.
• 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).
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
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
Symptoms of Impulsivity during the
elementary school years can include:
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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
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
Symptoms of Hyperactivity during
adolescence can include:
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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
Symptoms of Impulsivity during
adolescence can include:
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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
• 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.
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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.
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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.
With Peers
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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.
Anxiety
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Separation Anxiety
Phobias
Social Anxiety Disorder
Panic Disorder
Generalized Anxiety Disorder
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.