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COMMONWEALTH ASSOCATION FOR EDUCATION, ADMINISTRATION AND MANAGEMENT VOLUME 2 ISSUE 4 ISSN NO 2322-0147 APRIL 2014 BEHAVIORAL DISORDERS AMONG SCHOOL CHILDREN – AN OVERVIEW INDEXED WITH PARIS, DAIS.NET, DRJI, WORLDCAT, EBSCO-USA, J-GATE (EDITOR-IN-CHIEF) DR MUJIBUL HASAN SIDDIQUI ASSISTANT PROFESSOR, DEPARTMENT OF EDUCATION, ALIGARH MUSLIM UNIVERSITY, ALIGARH-202002, UTTAR PRADESH, INDIA www.ocwjournalonline.com website: www.ocwjournalonline.com Excellence International Journal of Education and Research (Multi- subject journal) Excellence International Journal Of Education And Research VOLUME 2 ISSUE 4 ISSN 2322-0147 BEHAVIORAL DISORDERS AMONG SCHOOL CHILDREN – AN OVERVIEW By Dr. Rama Reddy Karri Director, Manasa Hospital, Rajahmundry Andhra Pradesh Retired Professor of Psychiatry GSL Medical College Rajahmundry Dr.R.S.S.Nehru Assistant Professor School of Education and Education Technology Centre for Teacher Education Koraput, Odisha-764020 Research Guide, Bharathiar University, Coimbatore, TN Mobile: 9440594179 /9966004695 E-mail: [email protected] INTRODUCTION Psychological well-being in children is necessary for their healthy emotional, physical, social, educational, and cognitive development. Childhood is an important time to promote healthy development as many adult mental disorders have related antecedent problems in childhood (David Mrazek & Patricia J. Mrazek, 2009). There are limited studies based on children and adolescents in India and most of the studies were done as part of adult psychiatric epidemiological studies. Currently we have tertiary care centres for treatment of mental disorders but a large gap exists in the areas of prevention and early intervention (Murray C.J & Lopez Ad, 1996). Many children and their parents were not using the mental health services due to various reasons like lack of trust, social stigma and inability to recognize the existing problem. We need appropriate and updated prevalence rates and patterns of the diseases for planning and implementation of mental health services for children (Bower P et al, 1999). Studies on children of school age Excellence International Journal Of Education And Research (Multi-subject journal) Page 484 Excellence International Journal Of Education And Research VOLUME 2 ISSUE 4 ISSN 2322-0147 have tended to focus on nutritional and other health problems related to communicable diseases. School-age children may also suffer a variety of disabilities, emotional and behavioural problems. As countries develop their school health services, it should be necessary to ascertain the prevalence of different disorders in order to develop relevant interventions and other resources (Zubrick Sr., Silburn Sr. & Barlon P Blaire, 2000). There is increase in need and use of child mental health services as there is a rise in number of problems like substance abuse, child abuse, teenage pregnancy, school dropouts, suicides (Andres J. Pumariega, 2009). Twenty per cent of students aged 6-17 years worldwide currently have significant impairing pathology. Ten per cent do not receive any treatment. Most of the public schools do not have educational psychologists or social workers to identify the affected children. Children with biological vulnerabilities are more susceptible to psychiatric disorders when they face traumatic experiences, family pressures, peer, school, or other stressors contributing to dysfunctional behaviors. Research does not provide adequate data about prevalence and demographic details of children suffering from psychological problems. School Mental Health has been a major mental health movement which covers up the large population of children and adolescents, but has been effectively implemented only in cities and not in smaller towns and rural areas in the last four decades. Research publications during the 60s, 70s and 80s reported that mental retardation formed bulk of population attending child guidance clinics (CGC) during that period. While emotional and behavioral disturbances were less identified and referred, the trend has changed recently. All spectrums of diagnostic categories are now referred and treated at various teaching hospitals, psychiatry departments, pediatric departments, various colleges of social work and large number run by NGOs (Malhotra HK, 1977). The last three decades has shown highly specialized clinics rendering specialized services to children with learning disability, autism, cerebral palsy and mental retardation mostly in metros and urban areas. Such centers do run the genetic clinic and research in specific disorders. Development clinics for 0 to 3 years age group for various disability groups and multiple disability groups have special focus of identification, assessment and therapy. All these centers are attended by general psychiatrists rendering highly specialized services (Malhotra HK, Excellence International Journal Of Education And Research (Multi-subject journal) Page 485 Excellence International Journal Of Education And Research VOLUME 2 ISSUE 4 ISSN 2322-0147 1977). Child Mental Health Policy and School Mental Health programs have provided excellent opportunity to enhance mental health program for children and adolescents. The focus is rightly on preschool children and school based mental health program, which will prevent illness and possibly promote positive mental health. It also ensures that it will reduce behavioral disorders in children and prevent adult psychopathology. Effectiveness of child mental health intervention programs will surely help in addressing mental health disorders among adults (Shastri PC, 2008). In order to achieve desired outcomes one should embrace all those services that contribute to the mental health care of children and adolescents, whether provided by health, education, social services or other agencies. It is also crucial to partner with services whose primary function is not mental health care, such as GPs and schools. They can always contribute by offering general advice and treatment for less severe problems, contribute towards mental health promotion, identify problems early in their development and refer to more specialist services. This is to explicitly acknowledge that supporting children and adolescents with mental health problems is not the responsibility of specialist services alone (Shastri PC, Shastri JP & Shastri D, 2010). Importance of need for school-based programs has been reflected in inclusion of life skill education program by NCERT and CBSC in present syllabus. According to the UNESCO report, 2008 (U.N.D.P. Report, 2008) India stands at a) 102nd position in the "Education for all developmental index" out of 129 countries b) 132nd place in the list of 172 nations on human development index (HDI). Ten per cent of 5-15 year old has a diagnosable mental health disorder. This suggests that around 50 million children under 18 would benefit from specialist services. There are up to 20 million adolescents with severe mental health disorders. Around 90% children with a mental health disorder are not currently receiving any specialist service. School Mental Health Research The number of health promotion and prevention initiatives addressing mental health difficulties is rapidly expanding. By the end of 2002, there were estimated to be over 1200 outcome studies on prevention, health promotion, and drug abuse prevention in youth (Philip J, 1980). The New Freedom Commission on Mental Health’s Achieving the Promise: Excellence International Journal Of Education And Research (Multi-subject journal) Page 486 Excellence International Journal Of Education And Research VOLUME 2 ISSUE 4 ISSN 2322-0147 Transforming Mental Health Care in America emphasized the importance of mental health in learning and social/emotional development of children and youth, recommending improved and expanded school-based mental health services (Malhotra S et al., 2009). A number of school-based programs and initiatives have been developed to address broad goals including health promotion, early identification, crisis response, and prevention and treatment of emotional and behavioral disorders (Begum S, Rao KN & Sudarshan CY, 2010). These programs may use one or more distinct delivery mechanisms including full-service schoolbased health centers, screening programs, and classroom and school-based strategies and curricula (Bhola P & Kapur M, 2003). Most programs face system obstacles and methods of delivering service to young people in schools, ranging from the practical challenges in maintaining school-based health centers (Sidans A & Nijhswan M, 1999; Dalal M, Pakur M & Kaliaperumal, 1990) to the implementation and sustainability of evidence-based schoolwide programming (Rao PN, 1978) and the viability of screening programs ( Sinha UK &Kapur M, 1999). Despite the growing number of school-based mental health initiatives, there is no identified best practice model for delivering and sustaining these programs. Direct service-models include school based mental health centers, crisis intervention, schoolcommunity mental health center collaborations, and fee-for-service mental health contracts. Indirect service models include school system consultation, prevention and intervention programs and early identification screening programs, Web-based mental health resources, and on-site or video consultation with other mental health clinicians. The model adopted by a school depends on resources, state law, student and school needs and priorities, and the focus of the consultant. Universal prevention programs address the school system as a whole and aim to better the overall educational climate and learning environment by coordinating community and outside resources. Specific intervention/prevention models target a wide range of risk behaviors including anxiety, depression, substance abuse, and bullying/violence. Evidence examining the effectiveness of whole-school programs suggests that the effectiveness of universal programs (delivered to all students) is modest in addressing specific problems but can have broad impact on school climate and has more success with a focus on developing protective factors than by decreasing negative risk factors. In some cases indicated prevention programs (delivered to students with elevated symptoms) and selected prevention programs Excellence International Journal Of Education And Research (Multi-subject journal) Page 487 Excellence International Journal Of Education And Research VOLUME 2 ISSUE 4 ISSN 2322-0147 (delivered to high-risk students) may be more effective in targeting specific problems (Bansal PD & Barman R, 2011) Young people can have mental, emotional, and behavioral problems that are real, painful and costly. These problems, often called “disorders”, are sources of stress for children and their families, schools and communities . Although it is difficult to get accurate estimates of child mental disorders, the few available epidemiological data indicate that 12-51%; with the average around 29% of the world's children suffer from emotional and other mental problems that warrant mental health treatment. Out of this group, 6-19% is seriously emotionally disturbed children who need intensive psychiatric care (Davis et al., 1998). In addition, there are untold numbers of at-risk children who need attention and secondary preventive service. Recent evidence indicates that emotional and behavioral disorders frequently lead to poor school performance and to dropping-out of school. This wastes educational resources and seriously impairs the economic and social potential of such children (Nikapota et al., 1991). Some disorders are more common than others, and conditions range from mild to severe. Often, a child has more than one disorder (SAMHSA's National Mental Health Information Center, 2003). There is an ample weight of evidence suggesting that, several risk factors including child, familial, and environmental risk factors play an important role in the genesis of emotional and behavioural problems in schoolchildren (Cummins Mental Health Centre, 2003; American Psychiatric Association, 1994). Many environmental factors can affect mental health, including exposure to violence, extreme stress, and the loss of an important person (SAMHSA's National Mental Health Information Centre, 2003). Although children under 15 yrs. of age constitute about 40 to 50 percent of the population of the developing countries, child psychiatry in these countries has shown significant development only in the past two decades (Nikapota, 1991). Epidemiological studies in India in both rural and urban setting have shown wide variation in the prevalence rate of psychiatric disorders in children. However, epidemiological studies in school children in Indian setting are very few in numbers. Prevalence rate of 20 to 33 per cent of psychiatric disorders in school children has been reported in Indian setting (Jiloha and Murthy, 1981; Deivasigamani, 1990). This is quite high in comparison to the recently reported prevalence rate of 12 to 14 percent in school children of some developed countries like Japan and France. Excellence International Journal Of Education And Research (Multi-subject journal) Page 488 Excellence International Journal Of Education And Research VOLUME 2 ISSUE 4 ISSN 2322-0147 Behavioral Disorders during Childhood Psychiatric disorders diagnosed in childhood are divided into two categories: childhood disorders and learning disorders. As the scope of the study excludes learning disorders, only childhood disorders are described below. These disorders are usually first diagnosed in infancy, childhood, or adolescence, as laid out in the DSM IV TR. The fourth edition of DSM (DSMIV TR; American Psychiatric Association, 2000) begins with a chapter devoted to disorders that begin in infancy, childhood, and adolescence. The following disorders are included in that section: mental retardation, learning disorders, motor skills disorders, communication disorders, pervasive developmental disorders (such as autistic disorder and Asperger’s disorder), attention-deficit and other disruptive behavior disorders (such as conduct disorder and oppositional defiant disorder), feeding and eating disorders of infancy, or early childhood, tic disorders, elimination disorders, and others such as separation anxiety disorder (SAD), selective mutism, and reactive attachment disorder of infancy or early childhood. However, many disorders described in other sections of the manual may also be present in children and adolescents. These include mood and anxiety dis orders, schizophrenia, somatoform disorders, and eating disorders. Therefore, it is important that the clinicians who work with children and adolescents do not restrict themselves to the so-called “child disorders” section. Additionally, physicians who work with adults would be well served to familiarize themselves with the disorders that first appear in childhood, since many of these persist into adulthood. The following paragraphs briefly describe the diagnostic categories most often used with children and adolescents. Disorders of development Disorders of development and attachment are most often present at an early age. Examples include mental retardation, pervasive developmental disorders, and re active attachment disorder. Mental retardation is de fined as general intellectual functioning that is significantly below average. It is coded on axis II, and it is separated into mild, moderate, severe, and profound subgroups based on the degree of intellectual impairment defined by the IQ and the level of adaptive functioning. An IQ score below 65–70 (that is, two standard deviations below the mean) is the upper limit of mental retardation. Parallel impairments in adaptive functioning are also required to fulfill the criteria. Excellence International Journal Of Education And Research (Multi-subject journal) Page 489 Excellence International Journal Of Education And Research VOLUME 2 ISSUE 4 ISSN 2322-0147 Pervasive developmental disorders The PDDs are defined by impairments in reciprocal social interaction and communication and by a restricted range of behavior, interests, and activities. Autistic disorder, Asperger’s disorder, Rett’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS) are all identified. Children with these disorders exhibit varying abnormalities of language function that may profoundly affect their abilities to communicate with others and to make their wishes and needs known. There is also a qualitative impairment in reciprocal social interaction and relatedness, even, with primary caregivers. Additionally, these children often have an in ability to play symbolically, so pretend play is limited or non-existent. Stereotyped movements such as hand flapping or head banging may be present, or there may be a fascination with parts of objects, such as the wheels on toy cars. There is often, but not always, an associated degree of mental retardation in individuals with autistic disorder (approximately two-thirds have an IQ below 70). The onset of autistic disorder is usually evident in the first years of life and, by definition, occurs before age 3. Reactive attachment disorder is another disorder that is present in preschool children. The features of this disorder begin before a child is 5 years old with disturbed and developmentally inappropriate social relatedness (for example, a child may be overly friendly with strangers or withdrawn). By definition, the unrelatedness is associated with pathogenic care of the child. Children who come to the physician with failure to thrive without a medical cause often qualify for this diagnosis. Attention-deficit hyperactivity disorder There are more diagnostic categories that may apply to the school-age child. The most prominent among these are ADHD and disruptive behavior disorders. However, a variety of cognitive and learning disorders, such as specific developmental or communication disorders, may also become apparent at this age. ADHD is a disorder characterized by a pattern of inattention and hyperactivity- impulsivity that is excessive relative to the behavior of other children of the same age and gen der. Children with this disorder may have difficulty remaining seated, waiting their turn, completing Excellence International Journal Of Education And Research (Multi-subject journal) Page 490 Excellence International Journal Of Education And Research VOLUME 2 ISSUE 4 ISSN 2322-0147 assignments, sustaining attention, or organizing their work. By definition, some of these symptoms must be present before a child reaches 7 years of age, and there must be some symptoms causing impairment in more than one setting (for example, at home, at school, or in other activities). ADHD often begins in preschool years and commonly extends into adolescence or adulthood, but the largest number of cases can be found in school-age children. Individuals with this disorder are commonly both inattentive and hyperactiveimpulsive, although a smaller number of children may have disturbances in only one of these domains. Many children with ADHD show symptoms of aggression and defiance; comorbid learning, behavior, mood, and anxiety disorders are often present. However, although these conditions may coexist with ADHD, they must be distinguished from it. When multiple disorders are present, they should all be diagnosed. ADHD, as it is more commonly known, will normally be present in a child by the age of seven, and behavior issues must be seen in two or more setting, (i.e. school, church, home, etc.) but the behavioral issues need to be more than what would be expect for a child’s age. There need to be at least six instances over a six month period for a child to be considered for diagnoses. This disorder is diagnosed in about 3-7% of school are children, but 65-80% of the cases will grow out of it as adolescence ends. Some characteristics of those who have ADHD include: erratic behavior, being disorganized, worn out clothes, intrusive or aggressive behaviors, and the ability to not be able to tell right from wrong. There are two different ways for ADHD to be typed as: 1. Inattentive type: the ability to not pay attention or focus in their daily actives. 2. Hyperactive/Impulsive type: Being extremely active and having impulsive movements, being fidgety and having outbursts in inappropriate places. Oppositional defiant disorder Oppositional defiant disorder or ODD is related to both attention deficit and conduct disorder, but the behavior that is exhibited is not destructive or aggressive. This disorder is psychological; those who have it may be annoying or annoyed easily, may argue with adults, blame others for their mistakes, and may be defiant. Excellence International Journal Of Education And Research (Multi-subject journal) Page 491 Excellence International Journal Of Education And Research VOLUME 2 ISSUE 4 ISSN 2322-0147 Oppositional defiant disorder (ODD) and conduct disorder (CD) are the other disruptive behavior disorders listed in DSM-IV. ODD is defined by the presence of persistent minor violations of age-appropriate social norms. Children with ODD often argue with adults, lose their temper, and refuse to follow rules, deliberately annoy people, and blame others for their actions. They are often angry and resentful. Exclusionary criteria for this disorder include the presence of a psychotic, mood, or conduct disorder. Conduct disorder Conduct disorder is defined by the DSM-IV-TR as any behavior that violates the rights of others or societal norms. There are four categories that are used to determine if a child’s behavior violates these rights: 1. 2. 3. 4. aggression towards people or animals destruction of property deceitful nature or theft serious violations of laws There needs to be at least three instances of behavior that fit into these categories within a year period and at least one within the last six months for a diagnosis. This disorder is normally diagnosed in 4-16% of boys and 1-9% of girls, who come in for help. Boys normally fight, steal, and vandalize, while girls have issues with lying, truancy, and running away from home. CD is a behavior pattern in which the basic rights of others or major age-appropriate societal norms are violated. Examples include aggression directed toward people and animals, destruction of property, deceitfulness or theft, and serious violation of rules. This diagnosis takes precedence over ODD if criteria for both diagnoses are met, since approximately 90% of children with CD also meet criteria for ODD. There is good evidence that ODD represents a developmental precursor to CD in a subgroup of children. Learning disorders (see Chapter 6) are defined by academic functioning that is significantly below what is expected for an individual’s chronologic age, measured intelligence, and ageappropriate education. These disorders may involve deficits in reading, mathematics, and written expression. The accurate diagnosis of learning disorders re-quires the use of Excellence International Journal Of Education And Research (Multi-subject journal) Page 492 Excellence International Journal Of Education And Research VOLUME 2 ISSUE 4 ISSN 2322-0147 standardized intelligence and achievement tests to establish a discrepancy score. (That is, the score on a standardized achievement test is below what would be expected from the level of intellectual functioning as measured on a standardized IQ test.) Communication disorders The communication disorders, which are characterized by difficulties in speech or language, include expressive language disorder, mixed receptive expressive language disorder, phonologic disorder, and stuttering. Communication disorders often appear in preschool years, but they may not be properly identified until the child is in a school setting. Expressive language disorder is characterized by lower than expected abilities in vocabulary, use of tenses, production of complex sentences, and word recall. Mixed receptive –expressive language disorder involves an impaired understanding of language and a concomitant difficulty with expressive language. Phonologic disorder consists of errors in sound production and substitutions or omissions of sounds that would be developmentally expected. Stuttering is a disturbance of the fluency and time patterning of speech. Tic disorder Primary tic disorders, including Tourette syndrome, are usually diagnosed in childhood and have childhood onset as part of their definition. Chronic tic disorders are often comorbid with other mental disorders diagnosed in childhood, including ADHD and learning disabilities, as well as anxiety and mood disorders, most prominently obsessive-compulsive disorder. Several types of tic disorders are listed in DSM-IV. The most common is transient tic disorder, which involves the transient presentation of single or multiple motor or vocal tics. A tic is a sudden, rapid, recurrent, non- rhythmic, stereotyped movement or vocalization. Tics may be simple or complex. Tourette syndrome is the least common but most dramatic of the tic disorders. The diagnosis is made when there is a history of multiple motor tics and at least one vocal tic. The average age of onset of tics is 7 years. Approximately 40–50% of children with Tourette syndrome in clinical samples also have symptoms of ADHD. Tourette syndrome is also often comorbid with obsessive-compulsive disorder (OCD). However, it is not clear to what extent Tourette syndrome causes impairment in non-referred samples, since Excellence International Journal Of Education And Research (Multi-subject journal) Page 493 Excellence International Journal Of Education And Research VOLUME 2 ISSUE 4 ISSN 2322-0147 referral bias as a function of psychiatric comorbidity is not uncommon. (That is, cases with co morbidity and cases of greater impairment are more likely to be referred for treatment.) Elimination disorders Enuresis and encopresis comprise the elimination disorders in DSM-IV. These disorders have a minimum age threshold defined by the child’s chronologic age or equivalent developmental level. Encopresis is the repeated passage of feces in inappropriate places by a child who is at least 4 years old. Enuresis is the repeated voiding of urine into the bed or clothes by a child who is at least 5 years old. Separation anxiety disorder Separation anxiety disorder is a condition in which there is developmentally inappropriate and extreme anxiety about separation from home, parents, or primary caregivers. This is the most common anxiety disorder in childhood. It can have such symptoms as school avoidance or phobia, sleep disturbance, and nightmares. This disorder commonly follows an acute life event such as the medical illness of the child or parent, the loss of a close family member, parental separation, or the birth of a new sibling. Most often, separation anxiety disorder lasts for a limited time and good return to normal function results from the use of simple behavioral measures and encouragement. Eating disorders The eating disorders involve severe disturbances in eating behavior and perceptions of body shape and weight. These disorders have received considerable attention since the late 1970s, and there has been a resultant increase in case identification. Anorexia nervosa is the refusal to maintain a minimally normal body weight accompanied by an unshakable fear of gaining weight or becoming fat. Bulimia nervosa involves repeated episodes of binge eating and purging behavior in an attempt to control weight gain. Self-induced vomiting, use of laxatives or diuretics, and compulsive exercising may all are seen. The most common age of onset of anorexia nervosa is in the mid-teenage years, and the disorder is much more common in females. Bulimia nervosa has a later age of onset and often begins in the late teens or the 20s. Both disorders may be characterized by serious medical complications and comorbid psychopathologic conditions. Anorexia Nervosa Excellence International Journal Of Education And Research (Multi-subject journal) Page 494 Excellence International Journal Of Education And Research VOLUME 2 ISSUE 4 ISSN 2322-0147 Anorexia Nervosa can be thought of as a “distorted body image” disorder, since many adolescents who have Anorexia see themselves as overweight and unattractive. In Anorexia Nervosa, the individual refuses to maintain a minimally normal body weight, is intensely afraid of gaining weight, and has no realistic idea of the shape and size of his or her body. Signs of anorexia nervosa include extremely low body weight, dry skin, hair loss, depressive symptoms, constipation, low blood pressure, and bizarre behaviors, such as hiding food or binge eating. Bulimia Nervosa Bulimia Nervosa is characterized by episodes of “binge and purge” behaviors, where the person will eat enormous amounts of food, then induce vomiting, abuse laxatives, fast, or follow an austere diet to balance the effects of dramatic overeating. Essential features are binge eating and compensatory methods to prevent weight gain. Bulimia Nervosa symptoms include the loss of menstruation, fatigue or muscle weakness, gastrointestinal problems or intolerance of cold weather. Depressive symptoms may follow a binge and purge episode. Childhood onset adult disorders Apart from the above described categories, general psychiatric conditions which are known to occur even in adults can have their onset in children. Examples are Major Depressive Disorder (296), Generalized Anxiety Disorder (300), and Separation Anxiety Disorder (309). However, some children develop more chronic symptoms and impairment. Disorders that are also diagnosed in children and adolescents that are not described in the childhood section of DSM-IV include schizophrenia and other psychotic disorders, mood disorders, other anxiety disorders [such as obsessive compulsive disorder and generalized anxiety disorder (GAD)], eating disorders, substance use disorders, and gender identity disorder. Schizophrenia is phenotypically similar in children and adults, although children may have a less pronounced onset of symptoms and may not meet the full criteria for months or years after they are first brought to a physician. Children with schizophrenia have blunted or inappropriate affect, isolation, withdrawal, auditory and visual hallucinations, and thought disorders. There is some indication that the “negative symptoms” (such as thought disorder Excellence International Journal Of Education And Research (Multi-subject journal) Page 495 Excellence International Journal Of Education And Research VOLUME 2 ISSUE 4 ISSN 2322-0147 and isolation) predominate over the “positive symptoms” (such as hallucinations and delusions). However, the only diagnostic criterion that actually differs in children is that they may fail to reach expected levels of social and academic functioning (rather than deteriorate from a predetermined level). Schizophrenia is rare before puberty and must be aggressively distinguished from the PDDs, developmental language disorders, and mood disorders (depression and bipolar disorders) when it occurs in this age group. Since the 1980s, there has been considerable interest in the subject of mood disorders in children and adolescents. Even though it is now recognized that children of all ages can develop depression and often show the same symptoms as adults, major depressive disorder (MDD) is not as common in young children as in adolescents and adults. There are only minor differences in the diagnostic criteria for the mood disorders in children and adolescents when compared with adults. Associated changes in a depressed child or adolescent include social withdrawal, academic decline, oppositional behavior and noncompliance. A child or adolescent with MDD may have an irritable rather than depressed mood, and he may fail to make expected weight gain instead of having a significant weight loss. In children or adolescents with dysthymic disorder, the mood may again be irritable rather than depressed, and the duration of the mood need only be 1 year, as compared with 2 years for adults. Even though there are no differences in the criteria for bipolar disorder as a function of age, it can be much more challenging to diagnose bipolar disorder in children and the presentation can more typically include irritability tantrums, and agitation. Again, whereas bipolar disorder can exist in prepubertal children, it is not often present in its typical form until after puberty. The “adult” anxiety disorders include panic disorder, specific phobias, social phobia, obsessive-compulsive disorder, posttraumatic stress disorder (PTSD), acute stress disorder, and generalized anxiety disorder. Anxiety disorders may be present in children and adolescents as well as in adults, and they do not appear to be particularly different in children. OCD is characterized by recurrent intrusive thoughts or behaviors. OCD symptoms often have their onset in childhood or adolescence, although the specific disorder may not be identified for several years. Common signs of OCD in children are excessive hand washing and avoidance of supposedly contaminated objects. Adolescents may have any of the disorders that begin in childhood, or they may have the initial onset of any of the disorders Excellence International Journal Of Education And Research (Multi-subject journal) Page 496 Excellence International Journal Of Education And Research VOLUME 2 ISSUE 4 ISSN 2322-0147 commonly seen in adults. Developmental differences related to a psychopathologic condition must be considered. For example, ADHD is often seen in adolescents, but there are usually fewer hyperactivity and impulsivity symptoms than in the school-aged child. Symptoms of several of the personality disorders may become clinically apparent in the adolescent period, although they are not usually diagnosed until an adolescent reaches 18 years of age. Dis orders that are common in adolescents include the eating disorders, anorexia nervosa and bulimia nervosa, and the substance related disorders. These include disorders of drug use and abuse. They may involve the use of alcohol, cannabis, cocaine, or other substances. Substance abuse is defined as substance use that interferes with a person’s capacity to meet obligations in work, school, or home that results in a physically dangerous situation, legal problems, or continued use despite recurrent problems. Substance dependence preempts a diagnosis of abuse. Dependence involves a long-standing pattern of abuse that shows tolerance, withdrawal, and a lack of control over the substance. Inclusion education for school children with Behavioral disorders 'Inclusion' in education and schooling is not a new idea. During the past decade or so, this approach to provision has become the dominant consensual notion amongst most educationalists in most of the countries. Its adoption rests on a general consensus in the research literature that all teachers are qualified to teach children with special needs. Therefore, 'Inclusive Education' has come to mean the integration into mainstream schools of children with special or particular learning needs or disabilities (physical, intellectual, emotional), rather than in "Special" schools. Although children with behavioral disorders do not come under a special disability category, they do drain extra energy from the teachers and poise special challenges to the teachers and peers. Inclusion education is the latest trend in our country. Students in an inclusive classroom are generally placed with their chronological age-mates, regardless of whether the students are working above or below the typical academic level for their age. Also, to encourage a sense of belonging, emphasis is placed on the value of friendships. Teachers often nurture a relationship between a student with special needs and a same-age student without a special educational need. This is used to show students that a diverse group of people make up a community, that no one type of student is better than another, and to Excellence International Journal Of Education And Research (Multi-subject journal) Page 497 Excellence International Journal Of Education And Research VOLUME 2 ISSUE 4 ISSN 2322-0147 remove any barriers to a friendship that may occur if a student is viewed as "helpless." Such practices reduce the chance for elitism among students in later grades and encourage cooperation among groups. Hence it is necessary to know how many children have behavioural problems and how far this has influenced their academic performance and how they have fit into the mainstream. There is no much literature to understand how the teachers and peers receive and cope up with the children with behavioural disorders. REFERENCES 1. 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