School Interface with Psychological Disorders

1. School Interfacewith Psychological Disorders

2. Changing Role of Schools • 3 R’s • Mandates • Physical health • Nutrition • Exercise • Moral/ethical • Mental health

3. Expectations of Schools • Instruction • Monitored by “system” with standards (Atlanta) • Administrative • Documentation • Organization • Implementation of policies • Classroom regulation and control • Communication • Parents • “Non-educational” personnel

4. These Students now included in your classroom……. • Attention Deficit Disorder • Asperger’s Syndrome • Depression • Anxiety • Post-traumatic Stress Disorder • Bipolar Disorder

5. Diagnostic and Statistical Manual of Mental Disorders(DSM) • American Psychiatric Association • Parallel to International Classification of Disease (ICD) system..1893……..Developed by World Health Organization (ICD-11) • DSM-I, 1952 • DSM-IV-TR, 2000 • DSM-V, 2012 ???????????????? • ???? May 2013 ????????????

6. DSM 5 • Nothing “official” • First major revision since 1994 • DSM IV TR (2000) • Task Force = 13 “work groups” • Since June 2012, “open comment Period” • More than 12,000 comments documented • Proposed release is May 2013 (Annual meeting of American Psychiatric Assoc)

7. 20 chapters • Similarities in disorders • Symptom overlap • Decrease in Diagnostic Choices • Removal of multiaxial system • Point on a continuum or “spectrum”

8. Categorical vs Spectrum • Previous works have focused on need for consistency and standardization • Red bumps on face • Family Doc Dx Measles • Move to Seattle • ER Doc Dx with poison ivy and changes meds • Continuum or spectrum view is less constrictive but also challenges standardization

9. Several “minor wording changes” • “New” or newly recognized/redefined • Attenuated Psychosis Syndrome • Internet use/Gaming Disorder • Non-suicidal self injury • Suicidal behavior disorder • Autism Spectrum Disorder • Schizophrenia Spectrum • Hoarding Disorder • Cont’d…………………………………….

10. Binge Eating Disorder • Excoriation (skin picking) Disorder • Disruptive mood dysregulation disorder • children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year

11. Learning Disorder • has been changed to Specific Learning Disorder and the previous types of Learning Disorder (Dyslexia, Dyscalculia, and Disorder of Written Expression) are no longer being recommended.

12. Callis homepage • http://cstl-cla.semo.edu/callis • scroll down to bottom center for “DSM 5 Resources”

13. “Rejected” for inclusion • Anxious depression • Hypersexual disorder • Parental alienation syndrome • Sensory processing disorder

14. DSM 5 is Controversial • “Saving Normal: An Insider's Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life” • Author: Allen Frances • was chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine,

15. Allen’s list of “worst changes” • “During the past two decades, child psychiatry has already provoked three fads- a tripling of Attention Deficit Disorder, a more than twenty-times increase in Autistic Disorder, and a forty-times increase in childhoodBipolar Disorder.” • Disruptive Mood Dysregulation Disorder: DSM 5 will turn temper tantrums into a mental disorder

16. Allen (cont’d)………. • “DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation “ • “Painful experience with previous DSM's teaches that if anything in the diagnostic system can be misused and turned into a fad”

17. Dr. Mark Phillips: Comments ADHD(Edutopia, Jan 2013) • under the new proposed DSM-5, fewer symptoms would be needed to diagnose a child with ADHD. • The proposed DSM-5 places the bar so low that thousands of children who didn't have ADHD according to DSM-IV would meet the "test" according to DSM-5. • The rationale of the Task Force is that there are individuals who do not meet the criteria but are still impaired, and decreasing the diagnostic criteria would make them entitled to insurance benefits. ……….

18. Phillips (cont’d)……… • But the bottom line is that this lowering of the bar will increase the number of children diagnosed and treated with drugs. • We already have a well-documented problem with the overzealous prescribing of psychiatric drugs in this country, and many teachers and parents have voiced specific concern about over-diagnosing and medicating kids for signs of ADHD.

19. The proposed changes to ADHD in the DSM-5 include: • 1. Changing the diagnostic criteria from "symptoms being present before seven years of age" to "symptoms being present before twelve years of age." • This new criteria would read: "B. Several noticeable inattentive or hyperactive-impulsive symptoms were present by age 12."

20. For the Inattentive type and Hyperactive/Impulsive subtypes of ADHD, a minimum of only four symptoms need to be met if a person is 17 years of age or older. The current DSM-IV-TR criteria of meeting a minimum of six symptoms for the Inattentive type or Hyperactive/Impulsive Type would still apply for those 16 years of age or younger.

21. Recommending teachers as sources of information. • The wording that comes before the list of symptoms may read: "In children and young adolescents, the diagnosis should be based on information obtained from parents and teachers. When direct teacher reports cannot be obtained, weight should be given to information provided to parents by teachers that describe the child's behavior and performance at school. ………………………………

22. ADHD • ADHD is one of the most common childhood disorders. • Approximately 3-7% of school-aged children have the disorder. • Prevalence rates seem to vary by community, with some research indicating that larger cities may have rates as high as 10-15%.

23. According to the Centers for Disease Control • 4.4 million youth between the ages of 4-17 have been diagnosed with Attention-Deficit/Hyperactivity Disorder. • The DSM IV-TR suggests that the prevalence rate of ADHD in children is 3% to 7%, and 2% to 5% in adults. • Using these prevalence rates it can be estimated that in a classroom of 25 to 30 children, at least one of those children will have ADHD.

24. The fundamental area of controversy related to ADHD is whether or not this collection of symptoms should be considered a mental disorder. • Although there are documented brain differences and significant evidence of impairment in daily functioning in individuals with ADHD, there is a large school of thought that views ADHD "symptoms" as simply an extreme expression of normal human behavior.

25. According to DSM diagnostic criteria, ADHD develops in childhood, with at least some symptoms present prior to age 7. • Estimates of children whose symptoms continue into adulthood range up to 60%.

26. Manner in which Brain Develops • Brain develops • Inside out • Back to Front • Prefrontal Cortex • Not fully developed until mid 20’s in many subjects

27. Two Major Developmental Periods of Brain • First 3 years of life • Second burst about 11 for girls and 12 for boys • Shaping White Matter • Full development about 25

28. By age six, the brain is already 95 percent of its adult size.

29. Brain size does not equal intellectual or emotional maturity Although the brain is 80 percent developed at adolescence, research indicates that brain signals essential for motor skills and emotional maturity are the last to extend to the brain’s frontal lobe, which is responsible for many of the skills essential for driving.

30. Maturation of the Prefrontal Cortex • The prefrontal cortex is often referred to as the “CEO of the brain.” • This brain region is responsible for cognitive analysis and abstract thought, and the moderation of “correct” behavior in social situations.

31. FRONTAL LOBE Seat of personality, judgment, reasoning, problem solving, and rational decision making Provides for logic, understanding of consequences, and emotional/behavioral regulation Governs impulsivity, aggression, ability to organize thoughts, and plan for the future Controls capacity for abstraction, attention, cognitive flexibility, and goal persistence Undergoes significant changes during adolescence — not fully developed until mid20’s (Giedd, 2002)

32. “Executive functions” of the human prefrontal cortex include: • Focusing attention • Organizing thoughts and problem solving • Foreseeing and weighing possible consequences of behavior • Considering the future and making predictions • Forming strategies and planning • Ability to balance short-term rewards with long term goals

33. Shifting/adjusting behavior when situations change • Impulse control and delaying gratification • Modulation of intense emotions • Inhibiting inappropriate behavior and initiating appropriate behavior • Simultaneously considering multiple streams of information when faced with complex and challenging information U.S. Department of Health & Human Services

34. COMPONENTS OF EXECUTIVE FUNCTIONS AND SAMPLE BEHAVIORS

35. Brown et al., 2008

36. Brain imaging techniques are currently not used to diagnose ADHD, but evidence collected from these types of studies are providing more detailed clues as to the causes of this disorder. • Expense • Reliability

37. Children with ADHD generally sustain more accidents and injuries than the average child. Reduced awareness or inattention, impulsivity, and poor decision-making often leads to rushing into situations without thinking. • For example, a young child may forget to check both ways when crossing the street or while riding a bike, even going so far as to dash in front of a car in a parking lot without thought for the consequences. • Teenagers with ADHD who drive may have more traffic violations or accidents than those without ADHD.

38. The general symptoms of ADHD include: • Failure to pay attention or a failure to retain learned information • Fidgeting or restless behavior • Excessive activity or talking • The appearance of being physically driven or compelled to constantly move • Inability to sit quietly, even when motivated to do so • Engaging in activity without thinking before hand • Constantly interrupting or changing the subject • Poor peer relationships • Difficulty sustaining focused attention • Distractibility • Forgetfulness or absentmindedness • Continual impatience • Low frustration tolerance • When focused attention is required, it is experienced as unpleasant • Frequent shifts from one activity to another • Careless or messy approach to assignments or tasks • Failure to complete activities • Difficulty organizing or prioritizing activities or possessions

39. Neurotransmitters and ADHD • Neurotransmitters are chemical messengers that occur in the brain and central nervous system. • More recent evidence suggests that the relationship between dopamine and ADHD is complicated. Researchers have found reduced overall levels of dopamine • in individuals with ADHD, the small amount of dopamine present doesn't have enough time to exert its effects before it is reabsorbed by neurons.

40. Medication • 1937, amphetamine (a central nervous system stimulant) was used successfully to treat a group of children with ADHD-like behaviors, including limited self-control, aggressiveness, defiance, resistance to discipline and extreme emotionality. • Later studies suggested that stimulant medications also seemed to reduce disruptive behavior and improve academic performance. • During the 1950's, further evidence suggested that amphetamines were extremely helpful in the treatment of hyperactive children. • The FDA approved dextroamphetamines (e.g, Dexedrine) for treating childhood disorders in 1958. • In the 1970's, stimulant medication was the most popular treatment for ADHD. • The use of Dexedrine decreased from 1962 to the mid 80's as Ritalin became the medication of choice.

41. As of 2003, approximately 2.5 million young people were being treated with medication for ADHD symptoms. • Although increasing medication rates may be related to improved awareness and diagnosis, some professionals have different theories. • Some researchers speculate that increasing ADHD prevalence and treatment rates may be related to changes associated with living in the digital age, such as decreased levels of physical activity and less exposure to the natural environment, which is thought to lead to increased amounts of restless and impulsive behavior

42. Like all medications, stimulants may produce side effects. • Parents and teachers need to be aware of potential side effects and know how to manage them. • The most common side effects include weight loss from appetite suppression, insomnia, and a characteristic "over-concentrated" or extremely focused appearance. • Taking medications with food often helps combat the initial "dosing" stomachache…….Orange juice !!!!!

43. Stimulant medication is the primary treatment for ADHD, especially with regard to improving concentration. However, other medications are often prescribed along with stimulants to help control side effects, comorbid (i.e., co-occurring) symptoms of depression or other mood disorders, or when stimulants are not working. • Antidepressants are the second line of treatment and may be used in combination with stimulants in order to maintain treatment effects throughout the night. They are not as helpful with concentration, but can be quite effective in reducing impulsivity and improving social problems. Typically, antidepressants take a while to build up to optimal doses in the body, so symptom improvement may take a few weeks. However, benefits can last for up to 24 hours. Antidepressant often used with people who have ADHD include:

44. Bupropion (Wellbutrin) - This medication is an atypical antidepressant (an antidepressant medication that does not fit into any of the other medication categories) that can be very helpful in reducing irritability. The appropriate pediatric dosage has not been established, but Wellbutrin is frequently used "off label" or outside of the recommended label instructions with children. Potential side effects include weight loss, anxiety, headaches, dry mouth and confusion. In rare cases, more serious side effects can occur such as allergic reactions, heart palpitations and seizures.

45. Tricyclics (Desipramine, Imipramine) - Tricyclic antidepressants may require lower dosages to treat ADHD than when used to treat depression. They have a quicker onset of action than most other non-stimulant medications. Tricyclics block norepinephrine and dopamine receptors in the brain (causing the brain to produce higher levels of these neurotransmitters), which seems to decrease impulsivity, inattention, and poor concentration. The primary side effects of this medication include slowed or irregular cardiac conduction and exacerbation of untreated glaucoma. The risk versus the benefit must be carefully weighed for each individual.

46. Comorbidity is the medical term for two or more disorders that occur at the same time. • The high comorbidity rate between ADHD and other disorders has essentially created confusion regarding the definition of a "true" ADHD diagnosis. Since most children or adults with ADHD also have a second diagnosis, and both sets of symptoms frequently overlap,

47. Oppositional Defiant Disorder • Depression • Anxiety • Bipolar Disorder • Conduct Disorder • Sensory Integration Disorder • Learning Disorder • Early Speech/Communication problems

48. MTA Study • Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) Study • the largest study to date of ADHD treatment found that combining medication and psychosocial interventions is the best strategy for helping individuals deal with their symptoms.

49. The NIMH-funded Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) study was a multisite study designed to evaluate the leading treatments for ADHD, including behavior therapy, medications, and the combination of the two. The study's primary results were published in 1999. Follow-up data continues to be published.

50. The MTA was a multisite study designed to evaluate the leading treatments for ADHD, including behavior therapy, medications, and the combination of the two. The study included nearly 600 children, ages 7-9, who were randomly assigned to one of four treatment modes: • intensive medication management alone; • intensive behavioral treatment alone; • a combination of both; or • routine community care (the control group).