Children Who Can’t Pay Attention/ADHD

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Parents are distressed when they receive a note from school saying that their child won’t listen to the teacher or causes trouble in class. One possible reason for this kind of behavior is Attention Deficit/Hyperactivity Disorder (ADHD).

Even though the child with ADHD often wants to be a good student, the impulsive behavior and difficulty paying attention in class frequently interferes and causes problems. Teachers, parents, and friends know that the child is misbehaving or different but they may not be able to tell exactly what is wrong.

Any child may show inattention, distractibility, impulsivity, or hyperactivity at times, but the child with ADHD shows these symptoms and behaviors more frequently and severely than other children of the same age or developmental level. ADHD occurs in 3-5% of school age children. ADHD must begin before the age of seven and it can continue into adulthood. ADHD runs in families with about 25% of biological parents also having this medical condition.

A child with ADHD often shows some of the following:

  • trouble paying attention
  • inattention to details and makes careless mistakes
  • easily distracted
  • loses school supplies, forgets to turn in homework
  • trouble finishing class work and homework
  • trouble listening
  • trouble following multiple adult commands
  • blurts out answers
  • impatience
  • fidgets or squirms
  • leaves seat and runs about or climbs excessively
  • seems “on the go”
  • talks too much and has difficulty playing quietly
  • interrupts or intrudes on others

A child presenting with ADHD symptoms should have a comprehensive evaluation. Parents should ask their pediatrician or family physician to refer them to a child and adolescent psychiatrist, who can diagnose and treat this medical condition. A child with ADHD may also have other psychiatric disorders such as conduct disorder, anxiety disorder, depressive disorder, or bipolar disorder. These children may also have learning disabilities.

Without proper treatment, the child may fall behind in schoolwork, and friendships may suffer. The child experiences more failure than success and is criticized by teachers and family who do not recognize a health problem.

Research clearly demonstrates that medication can help improve attention, focus, goal directed behavior, and organizational skills. Medications most likely to be helpful include the stimulants (various methylphenidate and amphetamine preparations) and the non-stimulant, atomoxetine. Other medications such as guanfacine, clonidine, and some antidepressants may also be helpful.

Other treatment approaches may include cognitive-behavioral therapy, social skills training, parent education, and modifications to the child’s education program. Behavioral therapy can help a child control aggression, modulate social behavior, and be more productive. Cognitive therapy can help a child build self-esteem, reduce negative thoughts, and improve problem-solving skills. Parents can learn management skills such as issuing instructions one-step at a time rather than issuing multiple requests at once. Education modifications can address ADHD symptoms along with any coexisting learning disabilities.

A child who is diagnosed with ADHD and treated appropriately can have a productive and successful life.

Re-printed with Permission from American Academy of Child & Adolesccent Psychiatry

Conduct Disorder

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“Conduct disorder” refers to a group of behavioral and emotional problems in youngsters. Children and adolescents with this disorder have great difficulty following rules and behaving in a socially acceptable way. They are often viewed by other children, adults and social agencies as “bad” or delinquent, rather than mentally ill. Many factors may contribute to a child developing conduct disorder, including brain damage, child abuse, genetic vulnerability, school failure, and traumatic life experiences.

Children or adolescents with conduct disorder may exhibit some of the following behaviors:

Aggression to people and animals

  • bullies, threatens or intimidates others
  • often initiates physical fights
  • has used a weapon that could cause serious physical harm to others (e.g. a bat, brick, broken bottle, knife or gun)
  • is physically cruel to people or animals
  • steals from a victim while confronting them (e.g. assault)
  • forces someone into sexual activity

Destruction of Property

  • deliberately engaged in fire setting with the intention to cause damage
  • deliberately destroys other’s property

Deceitfulness, lying, or stealing

  • has broken into someone else’s building, house, or car
  • lies to obtain goods, or favors or to avoid obligations
  • steals items without confronting a victim (e.g. shoplifting, but without breaking and entering)

Serious violations of rules

  • often stays out at night despite parental objections
  • runs away from home
  • often truant from school

Children who exhibit these behaviors should receive a comprehensive evaluation. Many children with a conduct disorder may have coexisting conditions such as mood disorders, anxiety, PTSD, substance abuse, ADHD, learning problems, or thought disorders which can also be treated. Research shows that youngsters with conduct disorder are likely to have ongoing problems if they and their families do not receive early and comprehensive treatment. Without treatment, many youngsters with conduct disorder are unable to adapt to the demands of adulthood and continue to have problems with relationships and holding a job. They often break laws or behave in an antisocial manner.

Treatment of children with conduct disorder can be complex and challenging. Treatment can be provided in a variety of different settings depending on the severity of the behaviors. Adding to the challenge of treatment are the child’s uncooperative attitude, fear and distrust of adults. In developing a comprehensive treatment plan, a child and adolescent psychiatrist may use information from the child, family, teachers, and other medical specialties to understand the causes of the disorder.

Behavior therapy and psychotherapy are usually necessary to help the child appropriately express and control anger. Special education may be needed for youngsters with learning disabilities. Parents often need expert assistance in devising and carrying out special management and educational programs in the home and at school. Treatment may also include medication in some youngsters, such as those with difficulty paying attention, impulse problems, or those with depression.

Treatment is rarely brief since establishing new attitudes and behavior patterns takes time. However, early treatment offers a child a better chance for considerable improvement and hope for a more successful future.

Re-printed with Permission from American Academy of Child & Adolesccent Psychiatry

Children With Oppositional Defiant Disorder

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All children are oppositional from time to time, particularly when tired, hungry, stressed or upset. They may argue, talk back, disobey, and defy parents, teachers, and other adults. Oppositional behavior is often a normal part of development for two to three year olds and early adolescents. However, openly uncooperative and hostile behavior becomes a serious concern when it is so frequent and consistent that it stands out when compared with other children of the same age and developmental level and when it affects the child’s social, family, and academic life.

In children with Oppositional Defiant Disorder (ODD), there is an ongoing pattern of uncooperative, defiant, and hostile behavior toward authority figures that seriously interferes with the youngster’s day to day functioning.

Symptoms of ODD may include:

  • frequent temper tantrums
  • excessive arguing with adults
  • active defiance and refusal to comply with adult requests and rules
  • deliberate attempts to annoy or upset people
  • blaming others for his or her mistakes or misbehavior
  • often being touchy or easily annoyed by others
  • frequent anger and resentment
  • mean and hateful talking when upset
  • seeking revenge

The symptoms are usually seen in multiple settings, but may be more noticeable at home or at school. Five to fifteen percent of all school-age children have ODD. The causes of ODD are unknown, but many parents report that their child with ODD was more rigid and demanding than the child’s siblings from an early age. Biological and environmental factors may have a role.

A child presenting with ODD symptoms should have a comprehensive evaluation. It is important to look for other disorders which may be present; such as, attention-deficit hyperactive disorder (ADHD), learning disabilities, mood disorders (depression, bipolar disorder) and anxiety disorders. It may be difficult to improve the symptoms of ODD without treating the coexisting disorder. Some children with ODD may go on to develop conduct disorder.

Treatment of ODD may include: Parent Training Programs to help manage the child’s behavior, Individual Psychotherapy to develop more effective anger management, Family Psychotherapy to improve communication, Cognitive-Behavioral Therapy to assist problem solving and decrease negativity, and Social Skills Training to increase flexibility and improve frustration tolerance with peers. A child with ODD can be very difficult for parents. These parents need support and understanding.

Parents can help their child with ODD in the following ways:

  • Always build on the positives, give the child praise and positive reinforcement when he shows flexibility or cooperation.
  • Take a time-out or break if you are about to make the conflict with your child worse, not better. This is good modeling for your child. Support your child if he decides to take a time-out to prevent overreacting.
  • Pick your battles. Since the child with ODD has trouble avoiding power struggles, prioritize the things you want your child to do. If you give your child a time-out in his room for misbehavior, don’t add time for arguing. Say “your time will start when you go to your room.”
  • Set up reasonable, age appropriate limits with consequences that can be enforced consistently.
  • Maintain interests other than your child with ODD, so that managing your child doesn’t take all your time and energy. Try to work with and obtain support from the other adults (teachers, coaches, and spouse) dealing with your child.
  • Manage your own stress with exercise and relaxation. Use respite care as needed. Many children with ODD will respond to the positive parenting techniques.

Parents may ask their pediatrician or family physician to refer them to a child and adolescent psychiatrist, who can diagnose and treat ODD and any coexisting psychiatric condition.

Re-printed with Permission from American Academy of Child & Adolesccent Psychiatry

Bipolar Disorder In Children And Teens

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Children and teenagers with Bipolar Disorder have manic and/or depressive symptoms. Some may have mostly depression and others a combination of manic and depressive symptoms. Highs may alternate with lows.

Research has improved the ability to diagnose Bipolar Disorder in children and teens. Bipolar Disorder can begin in childhood and during the teenage years, although it is usually diagnosed in adult life. The illness can affect anyone. However, if one or both parents have Bipolar Disorder, the chances are greater that their children may develop the disorder. Family history of drug or alcohol abuse also may be associated with greater risk for Bipolar Disorder.

Manic symptoms include:

  • severe changes in mood-either unusually happy or silly, or very irritable, angry, agitated or aggressive
  • unrealistic highs in self-esteem – for example, a teenager who feels all powerful or like a superhero with special powers
  • great increase in energy and the ability to go with little or no sleep for days without feeling tired
  • increase in talking – the adolescent talks too much, too fast, changes topics too quickly, and cannot be interrupted
  • distractibility – the teen’s attention moves constantly from one thing to the next
  • repeated high risk-taking behavior; such as, abusing alcohol and drugs, reckless driving, or sexual promiscuity

Depressive symptoms include:

  • irritability, depressed mood, persistent sadness, frequent crying
  • thoughts of death or suicide
  • loss of enjoyment in favorite activities
  • frequent complaints of physical illnesses such as headaches or stomach aches
  • low energy level, fatigue, poor concentration, complaints of boredom
  • major change in eating or sleeping patterns, such as oversleeping or overeating

Some of these signs are similar to those that occur in teenagers with other problems such as drug abuse, delinquency, attention-deficit hyperactivity disorder, or even schizophrenia.

Teenagers with Bipolar Disorder can be effectively treated. Treatment for Bipolar Disorder usually includes education of the patient and the family about the illness, mood stabilizing medications such as lithium and valproic acid, and psychotherapy. Mood stabilizing medications often reduce the number and severity of manic episodes, and also help to prevent depression. Psychotherapy helps the child understand himself or herself, adapt to stresses, rebuild self-esteem and improve relationships.

The diagnosis of Bipolar Disorder in children and teens is complex and involves careful observation over an extended period of time. A thorough evaluation by a child and adolescent psychiatrist identify Bipolar Disorder and start treatment.

Re-printed with Permission from American Academy of Child & Adolesccent Psychiatry

The Depressed Child

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Not only adults become depressed. Children and teenagers also may have depression, which is a treatable illness. Depression is defined as an illness when the feelings of depression persist and interfere with a child or adolescent’s ability to function.

About 5 percent of children and adolescents in the general population suffer from depression at any given point in time. Children under stress, who experience loss, or who have attentional, learning, conduct or anxiety disorders are at a higher risk for depression. Depression also tends to run in families. The behavior of depressed children and teenagers may differ from the behavior of depressed adults. Child and adolescent psychiatrists advise parents to be aware of signs of depression in their youngsters.

If one or more of these signs of depression persist, parents should seek help:

  • Frequent sadness, tearfulness, crying
  • Hopelessness
  • Decreased interest in activities; or inability to enjoy previously favorite activities
  • Persistent boredom; low energy
  • Social isolation, poor communication
  • Low self esteem and guilt
  • Extreme sensitivity to rejection or failure
  • Increased irritability, anger, or hostility
  • Difficulty with relationships
  • Frequent complaints of physical illnesses such as headaches and stomachaches
  • Frequent absences from school or poor performance in school
  • Poor concentration
  • A major change in eating and/or sleeping patterns
  • Talk of or efforts to run away from home
  • Thoughts or expressions of suicide or self destructive behavior

A child who used to play often with friends may now spend most of the time alone and without interests. Things that were once fun now bring little joy to the depressed child. Children and adolescents who are depressed may say they want to be dead or may talk about suicide. Depressed children and adolescents are at increased risk for committing suicide. Depressed adolescents may abuse alcohol or other drugs as a way to feel better.

Children and adolescents who cause trouble at home or at school may also be suffering from depression. Because the youngster may not always seem sad, parents and teachers may not realize that troublesome behavior is a sign of depression. When asked directly, these children can sometimes state they are unhappy or sad.

Early diagnosis and treatment are essential for depressed children. Depression is a real illness that requires professional help. Comprehensive treatment often includes both individual and family therapy. For example, cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) are forms of individual therapy shown to be effective in treating depression. Treatment may also include the use of antidepressant medication. For help, parents should ask their physician to refer them to a qualified mental health professional, who can diagnose and treat depression in children and teenagers.

Re-printed with Permission from American Academy of Child & Adolesccent Psychiatry

The Anxious Child

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All children experience anxiety. Anxiety in children is expected and normal at specific times in development. For example, from approximately age 8 months through the preschool years, healthy youngsters may show intense distress (anxiety) at times of separation from their parents or other persons with whom they are close. Young children may have short-lived fears, (such as fear of the dark, storms, animals, or strangers). Anxious children are often overly tense or uptight. Some may seek a lot of reassurance, and their worries may interfere with activities. Parents should not discount a child’s fears. Because anxious children may also be quiet, compliant and eager to please, their difficulties may be missed. Parents should be alert to the signs of severe anxiety so they can intervene early to prevent complications. There are different types of anxiety in children.

Symptoms of separation anxiety include:

  • constant thoughts and intense fears about the safety of parents and caretakers
  • refusing to go to school
  • frequent stomachaches and other physical complaints
  • extreme worries about sleeping away from home
  • being overly clingy
  • panic or tantrums at times of separation from parents
  • trouble sleeping or nightmares

Symptoms of phobia include:

  • extreme fear about a specific thing or situation (ex. dogs, insects, or needles)
  • the fears cause significant distress and interfere with usual activities

Symptoms of social anxiety include:

  • fears of meeting or talking to people
  • avoidance of social situations
  • few friends outside the family

Other symptoms of anxious children include:

  • many worries about things before they happen
  • constant worries or concerns about family, school, friends, or activities
  • repetitive, unwanted thoughts (obsessions) or actions (compulsions)
  • fears of embarrassment or making mistakes
  • low self esteem and lack of self-confidence

Severe anxiety problems in children can be treated. Early treatment can prevent future difficulties, such as loss of friendships, failure to reach social and academic potential, and feelings of low self-esteem. Treatments may include a combination of the following: individual psychotherapy, family therapy, medications, behavioral treatments, and consultation to the school.

If anxieties become severe and begin to interfere with the child’s usual activities, (for example separating from parents, attending school and making friends) parents should consider seeking an evaluation from a qualified mental health professional or a child and adolescent psychiatrist.

Re-printed with Permission from American Academy of Child & Adolesccent Psychiatry

The Child With Autism

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Most infants and young children are very social creatures who need and want contact with others to thrive and grow. They smile, cuddle, laugh, and respond eagerly to games like “peek-a-boo” or hide-and-seek. Occasionally, however, a child does not interact in this expected manner. Instead, the child seems to exist in his or her own world, a place characterized by repetitive routines, odd and peculiar behaviors, problems in communication, and a total lack of social awareness or interest in others. These are characteristics of a developmental disorder called autism.

Autism is usually identified by the time a child is 30 months old and always by three years of age. It is often discovered when parents become concerned that their child may be deaf, is not yet talking, resists cuddling, and avoids interaction with others.

A preschool age child with “classic” autism is generally withdrawn, aloof, and fails to respond to other people. Many of these children will not even make eye contact. They may also engage in odd or ritualistic behaviors like rocking, hand flapping, or an obsessive need to maintain order.

Many children with autism do not speak at all. Those who do may speak in rhyme, have echolalia (repeating a person’s words like an echo), refer to themselves as a He or She, or use peculiar language.

The severity of autism varies widely, from mild to severe. Some children are very bright and do well in school, although they have problems with school adjustment. They may be able to live independently when they grow up. Other children with autism function at a much lower level. Mental retardation is commonly associated with autism.

Occasionally, a child with autism may display an extraordinary talent in art, music, or another specific area.

The cause of autism remains unknown, although current theories indicate a problem with the function or structure of the central nervous system. What we do know, however, is that parents do not cause autism.

Children with autism need a comprehensive evaluation and specialized behavioral and educational programs. Some children with autism may also benefit from treatment with medication. Child and adolescent psychiatrists are trained to diagnose autism, and to help families design and implement an appropriate treatment plan. They can also help families cope with the stress which may be associated with having a child with autism.

Although there is no cure for autism, appropriate specialized treatment provided early in life can have a positive impact on the child’s development and produce an overall reduction in disruptive behaviors and symptoms.

Re-printed with Permission from American Academy of Child & Adolesccent Psychiatry

Asperger’s Disorder

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Asperger’s Disorder is the term for a specific type of pervasive developmental disorder which is characterized by problems in development of social skills and behavior. In the past, many children with Asperger’s Disorder were diagnosed as having autism, another of the pervasive developmental disorders, or other disorders. While autism and Asperger’s have certain similarities, there are also important differences. For this reason, children suspected of having these conditions require careful evaluation.

In general, a child with Asperger’s Disorder functions at a higher level than the typical child with autism. For example, many children with Asperger’s Disorder have normal intelligence. While most children with autism fail to develop language or have language delays, children with Asperger’s Disorder are usually using words by the age of two, although their speech patterns may be somewhat odd.

Most children with Asperger’s Disorder have difficulty interacting with their peers. They tend to be loners and may display eccentric behaviors. A child with Asperger’s, for example, may spend hours each day preoccupied with counting cars passing on the street or watching only the weather channel on television. Coordination difficulties are also common with this disorder. These children often have special educational needs.

Although the cause of Asperger’s Disorder is not yet known, current research suggests that a tendency toward the condition may run in families. Children with Asperger’s Disorder are also at risk for other psychiatric problems including depression, attention deficit disorder, schizophrenia, and obsessive-compulsive disorder.

Child and adolescent psychiatrists have the training and expertise to evaluate pervasive developmental disorders like autism and Asperger’s Disorder. They can also work with families to design appropriate and effective treatment programs. Currently, the most effective treatment involves a combination of psychotherapy, special education, behavior modification, and support for families. Some children with Asperger’s Disorder will also benefit from medication.

The outcome for children with Asperger’s Disorder is generally more promising than for those with autism. Due to their higher level of intellectual functioning, many of these children successfully finish high school and attend college. Although problems with social interaction and awareness persist, they can also develop lasting relationships with family and friends.

Re-printed with Permission from American Academy of Child & Adolesccent Psychiatry

Obsessive-Compulsive Disorder In Children And Adolescents

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Obsessive-Compulsive Disorder (OCD), usually begins in adolescence or young adulthood and is seen in as many as 1 in 200 children and adolescents. OCD is characterized by recurrent intense obsessions and/or compulsions that cause severe discomfort and interfere with day-to-day functioning. Obsessions are recurrent and persistent thoughts, impulses, or images that are unwanted and cause marked anxiety or distress. Frequently, they are unrealistic or irrational. They are not simply excessive worries about real-life problems or preoccupations. Compulsions are repetitive behaviors or rituals (like hand washing, hoarding, keeping things in order, checking something over and over) or mental acts (like counting, repeating words silently, avoiding). In OCD, the obsessions or compulsions cause significant anxiety or distress, or they interfere with the child’s normal routine, academic functioning, social activities, or relationships.

The obsessive thoughts may vary with the age of the child and may change over time. A younger child with OCD may have persistent thoughts that harm will occur to himself or a family member, for example an intruder entering an unlocked door or window. The child may compulsively check all the doors and windows of his home after his parents are asleep in an attempt to relieve anxiety. The child may then fear that he may have accidentally unlocked a door or window while last checking and locking, and then must compulsively check over and over again. An older child or a teenager with OCD may fear that he will become ill with germs, AIDS, or contaminated food. To cope with his/her feelings, a child may develop “rituals” (a behavior or activity that gets repeated). Sometimes the obsession and compulsion are linked; “I fear this bad thing will happen if I stop checking or hand washing, so I can’t stop even if it doesn’t make any sense.”

Research shows that OCD is a brain disorder and tends to run in families, although this doesn’t mean the child will definitely develop symptoms if a parent has the disorder. Recent studies have also shown that OCD may develop or worsen after a streptococcal bacterial infection. A child may also develop OCD with no previous family history.

Children and adolescents often feel shame and embarrassment about their OCD. Many fear it means they’re crazy and are hesitant to talk about their thoughts and behaviors. Good communication between parents and children can increase understanding of the problem and help the parents appropriately support their child.

Most children with OCD can be treated effectively with a combination of psychotherapy (especially cognitive and behavioral techniques) and certain medications for example, serotonin reuptake inhibitors (SSRI’s). Family support and education are also central to the success of treatment. Antibiotic therapy may be useful in cases where OCD is linked to streptococcal infection. Seeking help from a child and adolescent psychiatrist is important both to better understand the complex issues created by OCD as well as to get help.

Re-printed with Permission from American Academy of Child & Adolesccent Psychiatry

Children With Learning Disabilities

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Parents are often worried when their child has learning problems in school. There are many reasons for school failure, but a common one is a specific learning disability. Children with learning disabilities usually have a normal range of intelligence. They try very hard to follow instructions, concentrate, and “be good” at home and in school. Yet, despite this effort, he or she is not mastering school tasks and falls behind. Learning disabilities affect at least 1 in 10 schoolchildren.

It is believed that learning disabilities are caused by a difficulty with the nervous system that affects receiving, processing, or communicating information. They may also run in families. Some children with learning disabilities are also hyperactive; unable to sit still, easily distracted, and have a short attention span.

Child and adolescent psychiatrists point out that learning disabilities are treatable. If not detected and treated early, however, they can have a tragic “snowballing” effect. For instance, a child who does not learn addition in elementary school cannot understand algebra in high school. The child, trying very hard to learn, becomes more and more frustrated, and develops emotional problems such as low self-esteem in the face of repeated failure. Some learning disabled children misbehave in school because they would rather be seen as “bad” than “stupid.”

Parents should be aware of the most frequent signals of learning disabilities, when a child:

  • has difficulty understanding and following instructions.
  • has trouble remembering what someone just told him or her.
  • fails to master reading, spelling, writing, and/or math skills, and thus fails
  • has difficulty distinguishing right from left; difficulty identifying words or a tendency to reverse letters, words, or numbers; (for example, confusing 25 with 52, “b” with “d,” or “on” with “no”).
  • lacks coordination in walking, sports, or small activities such as holding a pencil or tying a shoelace.
  • easily loses or misplaces homework, schoolbooks, or other items.
  • cannot understand the concept of time; is confused by “yesterday, today, tomorrow.”

Such problems deserve a comprehensive evaluation by an expert who can assess all of the different issues affecting the child. A child and adolescent psychiatrist can help coordinate the evaluation, and work with school professionals and others to have the evaluation and educational testing done to clarify if a learning disability exists. This includes talking with the child and family, evaluating their situation, reviewing the educational testing, and consulting with the school. The child and adolescent psychiatrist will then make recommendations on appropriate school placement, the need for special help such as special educational services or speech-language therapy and help parents assist their child in maximizing his or her learning potential. Sometimes individual or family psychotherapy will be recommended. Medication may be prescribed for hyperactivity or distractibility. It is important to strengthen the child’s self-confidence, so vital for healthy development, and also help parents and other family members better understand and cope with the realities of living with a child with learning disabilities.

Re-printed with Permission from American Academy of Child & Adolesccent Psychiatry