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Mental Health Disorders in Young Children and Youth A Primer for Youth Workers Focus of Training Understand the difference between medical/mental health diagnosis and educational disability Recognize the characteristics of common mental health problems/educational disabilities Respond to children and youth diagnosed with mental health problems/educational disabilities Diagnostic Information in Mental Health DSM-IV is the accepted guide to psychiatric diagnosis Many disorders show similar symptoms Some tend to occur together in the same child It may take years to reach an accurate diagnosis as symptoms change with time and development Educational Classification Some, but not all, children with a mental health diagnosis will need special education assistance Usual school classifications will be Emotional Disability, Other Health Impairment, or Autism Spectrum Disorder Eligibility does not dictate classroom placement; most of these students succeed in a general education setting Educational Eligibility: Emotional Disability “Emotional disability” means an inability to learn or progress that cannot be explained by cognitive, sensory, or health factors. The student exhibits one or more of the following characteristics over a long period of time and to a marked degree that adversely affects educational performance: A tendency to develop physical symptoms or fears associated with personal or school problems; A general pervasive mood of unhappiness or depression; An inability to build or maintain satisfactory interpersonal relationships; Inappropriate behaviors or feelings under normal circumstances; Episodes of psychosis. Educational Eligibility: Other Health Impairment “Other health impairment” means having limited strength, vitality, or alertness, including a heightened alertness to environmental stimuli, that results in limited alertness with respect to the educational environment that: Is due to chronic or acute health problems Adversely affects a student’s educational performance. Educational Eligibility: Autism Spectrum Disorder Autism spectrum disorder is a lifelong developmental disability that includes autistic disorder, Asperger’s syndrome, and other pervasive developmental disorders, as described in the current version of the American Psychiatric Association’s Diagnostic and Manual of Mental Disorders. The disability is generally evident before three years of age and significantly affects verbal, nonverbal, or pragmatic communication and social interaction skills and results in an adverse effect on the student’s educational performance. Other characteristics often associated include the following: Engagement in Resistance to Repetitive activities Stereotyped movements Environmental change; or Change in daily routines Unusual responses to sensory experiences. 504 Plans Federal law that protects qualified individuals from discrimination based on their disability. Individuals with disabilities are defined as persons with a physical or mental impairment which significantly limits one or more major life activities. People who have a history of, or who are regarded as having a physical or mental impairment that substantially limits one or more major life activities, are also covered. Major life activities include caring for one’s self, walking, seeing, hearing, speaking, breathing, working, performing manual tasks, and learning. About Mental Health Diagnoses Disorders first Diagnosed in Infancy, Childhood, or Adolescence Fetal Alcohol Syndrome Schizophrenia and other Psychotic Disorders Mood Disorders Anxiety Disorders Eating Disorders Disorders First Diagnosed in Infancy, Childhood, or Adolescence Pervasive Developmental Disorders Attention-Deficit and Disruptive Behavior Disorder Tic Disorders Other Disorders of Infancy, Childhood, or Adolescence Pervasive Developmental Disorders Autistic Disorder Rett’s Disorder Childhood Disintegrative Disorder Asperger’s Disorder Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS) Characteristics of Autism Markedly abnormal or impaired development in social interaction. Characteristics of Autism Markedly abnormal or impaired development in communication. Characteristics of Autism Markedly restricted repertoire of activities and interests Asperger’s Syndrome Previously thought of as “high functioning autism.” The most outstanding characteristic of a child with Asperger’s is impairment in social interactions, which may include failure to use or comprehend nonverbal gestures in others, failure to develop age-appropriate peer relationships, and a lack of empathy. Autism Spectrum Disorder: Strategies and Accommodations Create a structured, predictable environment. Use visual supports when possible. Foster a climate of tolerance and understanding. Avoid long strings of verbal instruction. Give advance warning of changes in schedules, transitions, personnel, etc. Learn each child’s “triggers” to prevent meltdowns. Do not force eye contact. Minimize visual and auditory distractions; modify environment as reasonable for sensory issues. The brain must sift through thousands of incoming messages per second, attending to the important signals and muffling the less urgent. A child with an impaired sensory integration system may have no way to sort out the flood of information which assaults him or her at all times. Attention Deficit Hyperactivity Disorder: Symptoms and Behaviors Children with inattentive disorder may: Have a short attention span Have problems with organization Fail to pay attention to details Be unable to maintain attention Be easily distracted Have trouble listening even when spoken to directly Fail to finish their work Make lots of mistakes Be forgetful Attention Deficit Hyperactivity Disorder: Symptoms and Behaviors Children with hyperactive-impulsive disorder may: Fidget and squirm Have difficulty staying seated Run around and climb on things excessively Have trouble playing quietly Be “on the go” as if “driven by a motor” Talk too much Blurt out an answer before a question is completed Have trouble taking turns in games or activities Interrupt or intrude on others Attention Deficit Hyperactivity Disorder: Symptoms and Behaviors Children with combined attention deficit hyperactivity disorder show symptoms of both inattention and hyperactivity or impulsivity. Attention Deficit Hyperactivity Disorder: Strategies and Accommodations Provide consistent structure and clearly define your expectations. Allow the child to move about with reason, and provide breaks for movement. Have a “secret code” to let the child know he has gotten off task and must refocus. Reduce stress and pressure when possible, as children with ADHD are easily frustrated. Oppositional Defiant Disorder: Symptoms and Behaviors Sudden, unprovoked anger Arguing with adults Defiance or refusal to comply with adult requests or rules Blaming others for their misbehavior Easily annoyed by others Being resentful and angry Oppositional Defiant Disorder Strategies and Accommodations Try to avoid power struggles – state your position clearly and concisely. Choose your battles wisely. Establish clear rules and enforce them consistently. Avoid topics which may be a source of argument. Discuss strategies for dealing with anger. Provide consistency, structure, and clear consequences for misbehavior. Minimize downtime and plan transitions carefully. Structure activities so the student with ODD is not left out or always the last one picked. Conduct Disorder: Symptoms and Behaviors Bullying or threatening other children Poor attendance or chronic truancy Little empathy for others and lack of appropriate feelings of guilt or remorse Low self-esteem masked by bravado Lying to peers or adults Frequent physical fights; use of weapons Destruction of property Conduct Disorder Strategies and Accommodations Remember that praise is important, but needs to be sincere. Be aware that adults can unconsciously form and express negative impressions. Try to monitor your emotions and communicate a positive regard for the child. Remember that children with conduct disorder like to argue – maintain calm, respect, and detachment. Give the student options. Avoid escalating prompts, such as shouting, touching, nagging, or cornering the child. Rules should be few, fair, clear, displayed, taught, and consistently enforced. Tourette Syndrome: Symptoms and Behavior Repetitive eye blinking Repetitive clearing of the throat Repetitive coughing Repetitive lip licking Repetitive fist clenching Imitating or echoing the words of others Imitating or echoing the motions of others Leg jerks Vocal outbursts Tourette Syndrome: Strategies and Accommodations Concentrate on helping the child develop friendships, experience trust, feel competent in completing activities – not stopping the tics. Teach relaxation and deep breathing exercises. Teach the child to tune into and recognize their emotions and levels of frustration – increased frustration or anxiety can cause an increase in tic behavior. Do not punish the child for engaging in tics or what may appear to be strange habits. Build a culture of tolerance and acceptance. Try to identify sensory triggers (bright lights, loud noises, chaotic activity) and take steps to structure the environment to avoid these triggers. Reactive Detachment Disorder Symptoms or Behaviors Destructive to self or others Absence of guilt or remorse Denial of accountability – always blaming others Poor eye contact Extreme defiance and control issues Stealing Lack of cause and effect thinking Mood swings False abuse allegations Sexual acting out Inappropriately demanding or clingy Poor peer relationships Abnormal eating patterns Preoccupied with gore, fire Toileting issues No impulse control Chronic nonsensical lying Unusual speech patterns or problems Bossy – needs to be in control Manipulative – superficially charming and engaging Reactive Detachment Disorder Strategies and Accommodations Be predictable, consistent, and repetitive. Students with RAD are sensitive to changes in schedules, transitions, surprises, and chaotic social situations. Model and teach appropriate social behaviors. Avoid power struggles – try not to respond emotionally. Identify a (supervised) place for the child to go to regain composure during times of frustration and anxiety. Fetal Alcohol Spectrum Disorders Symptoms or Behaviors Early Childhood Speech or gross motor delays Extreme tactile sensitivity or insensitivity Erratic sleeping and/or eating habits Poor habituation Lack of stranger anxiety Poor or limited abstract reasoning ability (action/consequence connection, judgment and reasoning skills, sequential learning) Fetal Alcohol Spectrum Disorders Symptoms or Behaviors Elementary Years Normal, borderline, or high IQ, but immature Blames others for all problems Volatile and impulsive, impaired reasoning School becomes increasingly difficult Socially isolated and emotionally disconnected High need for stimulation Vivid fantasies and perseveration problems Possible fascination with knives and/or fire Fetal Alcohol Spectrum Disorders Symptoms or Behaviors Adolescent Years No personal or property boundaries Naïve, suggestible, a follower, a victim, vulnerable to peers Poor judgment, reasoning, and memory Isolated, sometimes depressed and/or suicidal Poor social skills Doesn’t learn from mistakes Fetal Alcohol Spectrum Disorders Strategies and Accommodations Be as consistent as possible. The way something is learned the first time will have the most lasting effect. Use a lot of repetition – these children need more time and more repetition to learn. Use multi-sensory instruction to build more neurological connections. Be specific, yet brief – be as concrete as possible. Increase supervision when possible – with emphasis on positive reinforcement of appropriate behavior. Model appropriate behavior – point it out when you see it. Post all rules and schedules in a fashion the child can understand. Apply consequences immediately. Ensure the child’s attention and check for understanding. Encourage the use of positive self-talk. Schizophrenia: Symptoms and Behaviors Confused thinking (fiction versus nonfiction) Vivid and bizarre thoughts and ideas Hallucinations Hearing, seeing, feeling, or smelling things that are not present Delusions Having beliefs that are fixed and false (i.e., aliens are out to get them) Severe anxiety and fearfulness Extreme moodiness Severe problems in making and keeping friends Feelings that people are “out to get them” Odd behavior, including behavior resembling that of a much younger child Disorganized speech Lack of motivation Schizophrenia: Strategies and Accommodations Reduce stress by going slowly when introducing new situations. Encourage other adolescents to be kind and to extend their friendship. Try to identify and capitalize on individual strengths. Mood Disorders: Depression Common Symptoms Sadness that won’t go away Hopelessness Irritability School avoidance Changes in eating and sleeping patterns Frequent complaints of aches and pains Thoughts of death or suicide Self-deprecating remarks Persistent boredom, low energy, or poor concentration Increased activity Mood Disorders: Depression Strategies and Accommodations Help children use realistic and positive statements about their performance and outlook for the future. Acknowledge but don’t minimize the child’s feelings. Openly recognize and acknowledge positive contributions and performance. Depressed children may see things in black and white terms – all bad or all good. It may help to have someone else share things from another perspective. Encourage gradual social interaction. Ask parents what is helpful at home. Don’t be afraid to suggest that parents seek outside help. Mood Disorders: Bipolar Disorder Also know as “manic-depressive” disorder. A brain disorder that causes unusual shifts in a person’s mood, energy, and ability to function. Much more severe than the typical “ups and downs.” One percent of the population over 18 may have bipolar disorder. In children and younger adolescents, the episodes are less clearly defined and may cycle much more quickly, even up to many times per day. Mood Disorders: Bipolar Disorder Symptoms and Behaviors An expansive or irritable mood Depression Rapidly changing moods lasting a few hours to a few days Explosive, lengthy, and often destructive rages Separation anxiety Defiance of authority Hyperactivity, agitation, and distractibility Strong and frequent cravings, often for carbohydrates and sweets Impaired judgment, impulsivity, racing thoughts, and pressure to keep talking Dare-devil behaviors Inappropriate or precocious sexual behavior Delusions and hallucinations Grandiose belief in one’s own abilities that defy the laws of logic (become a rock star overnight, for example) Mood Disorders: Bipolar Disorder Strategies and Accommodations Understand that the child with bipolar disorder may cycle rapidly and be unpredictable – something which seems to be “working” may suddenly cause problems. Identify a “safe” place where the child can go until he regains control. Children with bipolar disorder generally have very poor social skills, and would benefit from direct instruction in social interaction skills. Don’t be afraid to suggest that parent’s seek outside help. Anxiety Disorders The most common anxiety disorders affecting children are: Generalized Anxiety Disorder Phobias Social Phobia Panic Disorder Obsessive-Compulsive Disorder Post Traumatic Stress Disorder Adjustment Disorder Write the “Pledge of Allegiance” under the following conditions: Keep a running count of the number of times you write the letter “e” – if you lose count, you must start over Every time you hear the smack on the table, jerk your head sharply to the right Anxiety Disorders Obsessive-Compulsive Disorder Recurrent, persistent, intrusive thoughts or impulses May perform behaviors in a ritualistic manner Children with OCD may experience a high level of anxiety and shame about their thoughts and behavior Anxiety Disorders: Post Traumatic Stress Disorder Flashbacks, hallucinations, nightmares, recollections, reenactment, or repetitive play referencing the event Emotional distress from reminders of the event Physical reactions from reminders of the event Fear of certain places, things, or situations that remind them of the event Denial of the event A sense of foreshortened future Difficulty concentrating and easily startled Irritability Impulsiveness Anger and hostility Depression and overwhelming sadness or hopelessness Anxiety Disorders: Strategies and Accommodations Try to accommodate situations the child has no control over Educate the child’s peers about particular symptoms, such as the compulsions of OCD Be attentive to changes in the child’s behavior, which may indicate added stress Avoid belittling a child’s fear or anxiety; instead, validate the concern without confirming that the fear is real. Model positive self-talk Help children verbalize their feelings and fears Teach relaxation and deep breathing techniques Adjustment Disorder: Symptoms and Behaviors Appear subdued, irritable, anxious, or withdrawn Resist going to sleep Have frequent tantrums Regress in the ability to toilet independently Have increased separation anxiety Exhibit acting out behaviors that are uncharacteristic for the child, such as biting or hitting Adjustment Disorder Can be further categorized by the specific symptoms experienced: Adjustment disorder with depressed mood Adjustment disorder with anxiety Adjustment disorder with mixed anxiety and depressed mood Adjustment disorder with disturbance of conduct Adjustment disorder with mixed disturbance of emotions and conduct Adjustment disorder, unspecified Adjustment Disorder: Strategies and Accommodations Be attuned to how environmental changes impact a child Help prepare children for changes Allow the child time to adjust to change Do all you can to reassure the child that someone is in control and that their life will go on with as little disruption as possible Share concerns with parents, being sure to focus on the child’s behaviors and avoid drawing conclusions about whether the behaviors are indicative of a mental health problem Eating Disorders: Anorexia and Bulimia Increasingly seen in younger and younger children, with children as young as 4 or 5 expressing the need to diet. Mostly seen in females, although 10-20 percent of adolescents with eating disorders are male. Anorexia and bulimia can exist together or separately. Eating Disorders Symptoms or Behaviors of Note Perfectionist attitude Impaired concentration All or nothing thinking Depressed mood or mood swings Self-deprecating statements Irritability Lethargy Anxiety Fainting spells and dizziness Headaches Hiding food Avoiding snacks or activities Frequent trips to the bathroom Eating Disorders Strategies and Accommodations Stress acceptance in your setting; successful people come in all shapes and sizes. Watch what you say. Comments like “You look terrible,” “I wish I had that problem” are often hurtful and discouraging. Stress progress, not perfection. Avoid high levels of competition. Reduce stress when possible. Evaluation Please complete the evaluation and leave it Be sure to note any topics for future training