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Anxiety:

Anxiety is marked by distressing persistent anxiety or maladaptive behaviors that reduce anxiety. Anxiety disorders are marked by a number of behaviors, including excessive worry, fears, phobias, obsessions and compulsions, nervousness, and self-criticism.

There are a variety of different anxiety disorders and the following is a brief descriptor of some of the common ones.

Generalized Anxiety Disorder (GAD): An anxiety disorder in which a person is continually tense and jittery, worried about bad things happening, and often aroused (racing heart, clammy hands, stomach butterflies, and sleeplessness). Often individuals with GAD are unable to identify the root of the cause for their anxiety. Experiences of anxiety episodes are unpredictable and often frightening. Sufferers often fear the fear itself and may avoid situations where panic has occurred in the past (Myers, 1999).

Phobias: focus anxiety on a specific object, event, or situation. Phobias are irrational fears that disrupt behaviors. A fear becomes a phobia when it provokes a compelling but irrational desire to avoid the situation or the object. While some individuals learn to live with phobias, others may have specific phobias that are debilitating. Social phobia is an intense fear of being in social situations, and may result in an individual avoiding speaking up, eating out, going to school, and being in groups in crowds.

Obsessive-compulsive disorder: Characteristics include repetitive thoughts that are too difficult to control (obsessions), or the uncontrollable need to repeat specific acts (compulsions) (NASP, 2004). Obsessive thoughts and compulsory behaviors become problematic when they interfere with everyday functioning or cause distress. Obsessive thoughts may be around germs, order or offensive material. Compulsions are considered rituals, such as checking to make sure the door is locked or washing hands numerous times a day (Myers, 1999).

Post-Traumatic Stress Disorder: Although this topic is often associated with soldiers who have experienced combat, PTSD may also be seen in individuals who have experienced traumatic personal events, such as death, physical or sexual assault, or a disaster. Some symptoms may include anxiety, nightmares, and flashbacks of the event (NASP, 2004).

Treatment:

Anxiety is common among school aged children, and often times professional help is not needed. However, if anxiety is so severe that your child can’t perform daily task, such as leaving the house, or going to school, then interventions may be necessary. Some questions to consider when deciding if your child needs professional help are:

• Is anxiety typical for a child this age?
• Is the anxiety more severe in certain situations?
• Has this been a long term problem or more recent?
• Are there events that may be contributed to the problems? (i.e.: recent move or death)
• Is your child’s anxiety affecting him/her in personal, social or academic realms?

If you are concerned about your child’s anxiety after considering some of these questions, it is advisable to talk to a professional, such as a school psychologist or school guidance/adjustment counselor. Individual counseling, group, or family counseling may be beneficial for a child. In some cases, physicians may recommend medication. At this point, medication for childhood disorders is not well researched, and side effects must be monitored. However, this treatment option may be helpful when combined with counseling approaches.

Some techniques to consider at home:

• Be consistent in how you handle problems and administer discipline
• Anxiety is not a willful misbehavior, therefore be patient and prepared to listen. Don’t be critical or cynical, as this will most likely lead to the problem getting worse.
• Maintain realistic and attainable goals and expectations for your child. Do not communicate that perfection is expected; often anxious children try to please adults, and have perfectionist tendencies if they feel that this is what is expected.
• Maintain a consistent, but flexible routine for homework, chores and activities (making a calendar to display at home is beneficial).
• Accept mistakes as part of growing up. Praise and reinforce effort, even if success is less than expected.
• If your child is nervous about an upcoming event (i.e.: giving speech in class, play, etc.), rehearse, to increase confidence and decrease discomfort.
• Teach your child to manage their own anxiety. Teach them how to organize materials and time (i.e.: by setting a schedule, having color and label coordinated folders for work). If anxiety increases during a particular situation, teach the child relaxation techniques. These can include counting to 10 or backwards from 20 (depending on age), taking deep breaths (deep breath in for four counts, holding breath for four counts, and exhaling for four counts, repeat four times), and guided imagery (closing eyes and imaging a peaceful or relaxing event (i.e.: going to the beach, going for a hike, reading a favorite book).

Do not assume that your child’s anxiety will just go away or that your child is being difficult. Always seek professional help if the problem persists or continues to interfere with daily activities. Furthermore, untreated anxiety can lead to depression and other problems. However, anxiety problems can be treated effectively, especially if detected at an early age (NASP, 2004).

Some additional resources include:

This website provides a nice overview of shyness, along with strategies for parents and teaching staff.

• Anxiety Disorders Association of America: www.aada.org

Overview of anxiety disorders.

National Mental Health Association: www.nmha.org

• Provides information regarding the prevalence of anxiety disorders and treatment.

Depression:

Depression is a health problem that affects people of all ages, including children and adolescents. Depression is generally categorized as a persistent experience of a sad or irritable mood, as well as the inability to experience pleasure in nearly all activities. Traditional symptoms of depression include feelings of loneliness and sadness, diminished self-esteem, hopelessness, pessimism, and negative thinking. Other symptoms may include a change in appetite, disrupted sleep patterns, increase or diminished activity level, impaired attention and concentration, and markedly decreased feelings of self-worth. Children and adolescents who are experiencing depression may seem reserved or introverted, with some anxiety and emotional ability. They rarely take chances and may appear agitated at times and may experience mild to moderate problems in relating to other people. Children and adolescents with depression are typically not capable of “snapping out” of their emotional state on their own. Depression is a form of mental illness that affects the entire person, including how they are feeling, thinking, and acting (NASP, 2004 ; Reynolds & Kamphaus, 2004).

There is research that indicates that the onset of depression is occurring earlier in life today than in the past decades. Furthermore, depression often coexists with other mental health problems such as chronic anxiety and disruptive behavior disorders. Research from the University of Oregon suggests that 28% of all adolescents (ages 13-19) will experience at least one episode of major depression. The rate for children under the age of 13 is 1-2%. More alarming data shows that in 2001, suicide was the third leading cause of death among 15-24 year olds, with up to 7% of adolescents who develop major depressive disorder possibly committing suicide (NASP, 2004).

Some warning signs and risk factors for depression may include:

• Children and teens under significant stress
• Experience of a significant loss
• Children and teens with attention, learning or conduct disorders
• During adolescence, girls develop depressive disorders twice as often as boys
• Family history of the disorder, particularly if a parent experienced depression at an early age
• Previous depressive episodes
• Anxiety disorders
• Family conflicts
• Uncertainty regarding sexual orientation
• Poor academic performance
• Substance abuse disorders
• Loss of parent or loved one
• Break up of a romantic relationship
• Chronic illness
• Abuse or neglect
• Significant trauma (including natural disasters)

If you are concerned about your child after reading through some of the symptoms and characteristics of depression or if there are several risk factors that pertain to your child, there may be a need to consult with a professional. The good news is that depression is treatable, and almost everyone who receives proper and timely intervention can be helped. Early diagnosis and appropriate treatment are both necessary for depressed children and adolescents. A thorough diagnostic evaluation by a mental health professional who specializes in children and teens, may include a physical examination, laboratory tests, interviews with the child and parents, behavioral observations, psychological testing, and consultation with other professionals.

Treating depression:

A comprehensive plan often includes educating the child and the family about depression. It also may include individual counseling or psychotherapy, ongoing evaluation and monitoring, and sometimes psychiatric medications.

How can you help?

It is important that all adults who have frequent contact with the child know and look for warning signs of depression. Sometimes, it may be uncomfortable, but it is important to ask if the child/adolescent has thought about, intends, or has plans to hurt themselves or commit suicide. Many parents are afraid that by discussing suicide, their child will get new ideas, however this is not the case! It is important to ask your child if you suspect suicidal tendencies, as you may be saving a life. If a child admits to feeling suicidal, stay with the child and get professional help immediately. Schools should be actively working to facilitate prevention, identification and treatment for depression. Since students spent a lot of their time in schools, where they are constantly observed and evaluate, collaboration between families, schools, and community agencies is essential in working to help children and adolescents overcome depression, and most importantly keep them safe (NASP, 2004).

Additional resources include:

American Psychological Association: www.apa.org

Depression and Bipolar Support Alliance: www.dbsalliance.org

National Institute of Mental Health: www.nimh.nih.gov

National Mental Health Association: www.nmha.org

SOS High School Suicide Prevention Program: mentalhealthscreening.org/programs/youth

Yellow Ribbon Suicide Prevention Program: www.yellowribbon.org

ADHD:

Attention Deficit Hyperactivity Disorder (ADHD) is a disruptive behavior disorder characterized by:

• Inattention which may include difficulty concentrating on school work or attending to the lesson/assignment/task at hand
• Impulsivity which may include frequently interrupting conversations, or activities
• Overactivity which may be marked by difficulty to remain seated when required to do so

All these characteristics should be considered in the realm of what is beyond expected and appropriate for a child’s gender and age.

Approximately 3-7% of school-aged children in the United States have ADHD. Children with ADHD typically first exhibit symptoms during preschool or early elementary school years; usually these symptoms continue through the child’s life. Boys are more likely to be diagnosed with ADHD than girls.

• • There are three subtypes of ADHD based on DSM-IV Criteria

• ADHD Predominantly Inattentive Type: children who exhibit problems only with inattention and concentration. Problem areas may arise with working memory, planning, organizing and self-monitoring. (A1)
  • Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:
• Inattention
  • Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
  • Often has trouble keeping attention on tasks or play activities.
  • Often does not seem to listen when spoken to directly.
  • Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
  • Often has trouble organizing activities.
  • Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
  • Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
  • Is often easily distracted.
  • Is often forgetful in daily activities.
• ADHD Predominantly Hyperactive-Impulsive Type: children who exhibit problems with hyperactivity and impulsivity (A2)
  • Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:
• Hyperactivity
  • Often fidgets with hands or feet or squirms in seat.
  • Often gets up from seat when remaining in seat is expected.
  • Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
  • Often has trouble playing or enjoying leisure activities quietly.
  • Is often "on the go" or often acts as if "driven by a motor".
  • Often talks excessively.
• Impulsivity (part of A2)

• o Often blurts out answers before questions have been finished.
• o Often has trouble waiting one's turn.
• o Often interrupts or intrudes on others (e.g., butts into conversations or games).
• o Some symptoms that cause impairment were present before age 7 years.
• o Some impairment from the symptoms is present in two or more settings (e.g. at school/home…).
• o There must be clear evidence of significant impairment in social or school functioning.
• o The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

• ADHD Combined Type: (A1&A2) children who exhibit problems in both areas. Deficits relate to executive functioning, with inhibition being a predominant problem.

American Psychiatric Association (APA)’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) is in the process of changing and revising numerous rules for diagnosing and treating mental health problems. Among the changes if criteria for diagnosis of ADHD.

• DSM-V changes will include:
  • Older adolescents and adults (ages 17 and older) only 4 symptoms are required
  • Wording will change for many items, i.e.: Often has difficulty sustaining attention or frequently does not follow through
  • Several noticeable inattentive or hyperactive-impulsive symptoms present by age 12 (current criteria is before seven years of age)
  • Recommending teachers as sources of information

¡ CAUSES of ADHD

• In families with an ADHD child,

¡ 20-25% of siblings have ADHD; a 5-8-fold increase

¡ 20-30% of parents have a lifetime history of ADHD (may not be diagnosed)

¡ In families with 2 affected children, over 60% of families have at least one parent with ADHD

¡ Moms and Dads are equally affected

? Genetic: 81% co-occurrence rate for monozygotic twins

• Brain Activity

? 80% of children w/ADHD had EEG signature of excessive slow waves/deficient fast waves ratio

? Reduced blood flow in frontal lobe responsible for executive functioning

• Chemical imbalance (dopamine & norepinephrine)

What does attention really mean?

¡ Focus/Execute: Scan and selectively respond to stimuli

• Johnny pays attention to the teacher even though Mary is sitting next to him tapping her pencil, lack of air conditioning on 90+ day, and the office has called. Johnny is ignoring internal distracters as well: his chair is hurting his back, he is hungry, and the band-aid on his finger is loose.

¡ Sustain: Stay on task for prolonged period of time

• Nisha watches the first 15 min of a TV show with her mother before she leaves the room and begins another activity. After another 5 minutes she switches to a 3^rdactivity. Nisha has trouble with sustaining attention.

¡ Divided: Respond to more than 1 task simultaneously

• Roberto can listen to his teacher and write stories separately. However, he cannot listen to his teacher while taking notes about what she is saying.

¡ Shift: Reallocate attention resources from 1 activity to another

• Tamera is working on a math assignment and teacher asks class to put away their work and get out reading books. She continues to work on her math.
• Tonya can attend to small bits of information but quickly becomes overwhelmed if too much information is presented to her at once.

¡ ADHD & Learning

¡ Comorbidity = 25%-70% between students diagnosed with a Specific Learning Disability & ADHD

¡ NEW learning requires use of Executive Functioning, therefore children may have:

• Difficulty attending to novel information
• Challenges with filtering out irrelevant information à overloads working memory
• Working memory is important for Long Term Memory encoding & retrieval
• On average children with ADHD perform 1 Standard Deviation below typical children on pre-academic and cognitive measures

¡ Attention Deficit Hyperactivity Disorder (ADHD) is often first identified in children and adolescents in the school systems (Kaiser & Pfiffner, 2011). School personnel are usually the first to recognize symptoms of inattention, hyperactivity and impulsivity in students. Teachers, school counselors, and other support staff have many opportunities to observe students in a wide range of settings and activities, and over the course of ten months.

Psychopharmacological Treatments:

The most common and effective psychopharmacological treatment used to treat attention difficulties, distractibility, impulsivity and other observable social and classroom behavior is stimulant medications.

Stimulants have also been shown to have a modest effect size for academic achievement, and there is some supporting evidence that stimulants may aid in reduction of aggressive behaviors (Brown, 2005). Specifically amphetamine-dextroamphetamine mixtures such as Adderall are currently the most commonly used stimulants.

Although psychopharmacological treatments have shown to be effective in managing symptoms of ADHD, psychosocial treatments are also an important component of reducing behaviors attributed to ADHD.

Combination of behavioral parent training and school consultation, which includes child skills interventions have been shown to be most efficacious psychosocial treatment for children with impairments not only in school, but also in the home (Kaiser & Pfiffner, 2011).

It is important to note there is strong evidence that when psychosocial treatment is used in conjunction with psychopharmacological treatment, the effects for the management of ADHD are the most powerful.

Psychosocial Treatments:

Just as there are numerous psychopharmacological treatments available, psychosocial treatments are often used as well to treat symptoms of ADHD.

Behavioral treatments based on social learning theory, which must be consistent and include salient rewards and consequences have been shown to be effective in working with children with ADHD.

Such behavioral interventions include Behavioral Parent Training (BPT), behavioral school interventions (teacher consultation and daily behavioral report cards) and behavioral summer treatment programs focusing on making environmental changes to the antecedents and consequences in the child’s environment (Kaiser & Pfiffner, 2011).

Behavioral school interventions focus on teachers being active in identifying problematic classroom behaviors, then implementing antecedent and consequential strategies to reduce the frequency and/or intensity of the problematic behaviors. Classroom modification strategies such as seating a child in front of the class to monitor on/off task behaviors and setting up reward systems are evidence based and effective.

Social skills training is one option of direct skill instructions. Students identified with ADHD may have difficulties interacting and establishing healthy relationships with peers. Social skills trainings provide children with didactic instruction on developing positive relationships. This appears to provide benefit when parents provide reinforcements in real work peer interactions in order to make the skills more generalizable (Kaiser & Pfiffner, 2011).

Another skills training option is organizational skills training (OST) which teaches students to organize materials and manage time effectively. This instruction is delivered either in individual or group basis, including instructions and scaffolding. Several preliminary findings suggest that OST result in improvements in targeted organization skills both long and short term (Kaiser & Pfiffner, 2011).

References:

Kamphaus, R. W., DiStefano, C., & Lease, A. M. (2003). A self-report typology of behavioral adjustment for young children. Psychological Assessment, 15 (1), 17-28.

Myers, D. G. (1999). Exploring Psychology, 4^th Ed., Worth Publishers, New York, NY.

National Association of School Psychologists (2004). Helping Children at Home and School II: Handouts for Families and Educators. Bethesda, MD.

Reynolds, C. R. & Kamphaus, R.W. (2004). Behavior Assessment System for Children, 2^nd Ed., AGS Publishing, Circle Pines, MN.

Robins, L. N. (1979). Follow-up studies. In H. C. Quay & J. S. Werry (Eds.), Psychopathological disorders of childhood (2^nd ed., pp. 483-513). New York: Wiley.

DuPaul, G. J., & Carlson, J. S. (2005). Child psychopharmacology: How school psychologists can contribute to effective outcomes. School Psychology Quarterly, 20,206-221.

Brown, R. T. (2005). Recent advances in pharmacotherapies for the externalizing disorders. School Psychology Quarterly, 20, 118-134.

Kaiser, N. M., & Pfiffner, L. J. (2011). Evidence-based psychosocial treatments for childhood ADHD. Psychiatric Annals, 441, 9-15.

U.S. Food and Drug Administration (2011). Should your child be in a clinical trial? Retrieved from http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm048699.htm