Richard Van Acker, Ed. D. University of Illinois at Chicago College of Education (M/C 147)

1. At Added Risk: Mental Health Disorders and Children Who Are Visually Impaired and/or Deaf or Hard of Hearing Richard Van Acker, Ed. D. University of Illinois at Chicago College of Education (M/C 147) 1040 W. Harrison Chicago, Illinois 60607 vanacker@uic.edu

2. Adverse Childhood Experiences

3. Adversity and Mental Health Mental Health Disorders Challenging Behavior

4. Students who are deaf or hard of hearing are more likely to experience… Available research indicates that 10% of hearing boys and 25% of hearing girls experience sexual abuse, vs. 54% of boys who are d/hh and 50% of girls who are d/hh report sexual abuse (Sullivan, Vernon, Scanlan, John, 1987). …a rate of • Neglect • Physical abuse • Sexual abuse twenty-five percent higher than their hearing peers. (Rochester Institute of Technology, 2010) The research also shows a direct correlation between childhood maltreatment and higher rates of negative cognition, depression and post-traumatic stress in adulthood.

5. Risk factors for children who are deaf or hard of hearing • Children are taught to be compliant, often without full understanding of what they are being asked to do by a wide variety of adults in a diverse array of contexts. • These children demonstrate reduced communication skills that both increase their risk of abuse and their ability to report abuse. • Parental and professional lack of awareness of the increased risk and the subsequent lack of education for children regarding sexuality, personal safety, and their right to say “No!” (Shelton, et al., 2008)

6. Visual Impairment and Mental Health • Co-occurring mental disorders are not uncommon for those of us living with a visual impairment. • The sudden loss of eyesight associated with acquired blindness has statistically been known to accompany other issues such as anxiety, depression, phobias, Post Traumatic Stress Disorder (PTSD), and even suicidal thoughts. • While symptoms for these disorders vary based on the individual, these illnesses can have cognitive, behavioral, and whole body (physical) symptomology.

7. Children and young adults with visual impairments had more emotional problems than did their sighted peers. • Girls with visual impairments more often experienced serious symptoms of depression and anxiety than did boys with visual impairments, a finding that was in line with results for the general population. • Two studies with a longitudinal design suggested that emotional problems among children and young adults with visual impairments might lessen over time.

8. Children’s Mental Health Impacts All Classrooms

9. Children’s Mental Health Impacts All Classrooms One in five children in our public schools displays a diagnosable mental health disorder. U.S. Surgeon General (2015)

10. The Great Smoky Mountain Study of Youth 27% of children 9, 11, and 13 years of age have a diagnosable mental health impairment. An additional 16% of children have impaired mental health but do not meet criteria for a disorder. This study also found that only 21% of children with mental health problems receive mental health services. 13% of children have one or both parents with MH concerns. Methodology for Epidemiology of Mental Disorders in Children and Adolescents Study 13% of children and adolescents have anxiety disorders, 6.2% have mood disorders, 10.3% have disruptive disorders, and 2% have substance abuse disorders, for a total of 20.9% having 1 or more mental health disorders. Research Supporting Need

11. Children’s Mental Health Impacts All Classrooms Students who are deaf or hard of hearing are more than twice as likely to display a diagnosable mental health disorder. (Gentili & Holwell, 2011; Purse 2016)

12. Over half of the individuals who will display mental health disorders sometime during their life, will begin to display symptoms between the ages of 11 and 14.

13. Disorders of Social Interaction Autism Spectrum Disorder (ASD) - incorporates four disorders from the previous manual Social Communication Disorder (SCD) is characterized by a persistent difficulty with verbal and nonverbal communication that cannot be explained by low cognitive ability Externalizing Disorders Attention Deficit/ Hyperactivity Disorder Oppositional Defiant Disorder Conduct Disorder Disruptive Mood Dysregulation Disorder (DMDD). It is characterized by severe and recurrent temper outbursts that are grossly out of proportion to the situation in intensity or duration. The outbursts occur, on average, three or more times each week for a year or more. Premenstrual Dysphoric Disorder Internalizing Disorders Anxiety Disorders Depression Posttraumatic Stress Disorder (PTSD) includes a new subtype for children younger than 6. Other Disorders Specific Learning Disorder - no longer limits learning disorders to reading, mathematics and written expression. Intellectual Disability Disorder Eating Disorders Substance Abuse Self-Harming Behavior Tic Disorders Early Onset Major Mental Illness Schizophrenia Bipolar Disorder Types of Child and Adolescent Mental Health Disorders

14. Disorders of Social Interaction Autism Spectrum Disorder (ASD) - incorporates four disorders from the previous manual Social Communication Disorder (SCD) is characterized by a persistent difficulty with verbal and nonverbal communication that cannot be explained by low cognitive ability Externalizing Disorders Attention Deficit/ Hyperactivity Disorder Oppositional Defiant Disorder Conduct Disorder Disruptive Mood Dysregulation Disorder (DMDD). It is characterized by severe and recurrent temper outbursts that are grossly out of proportion to the situation in intensity or duration. The outbursts occur, on average, three or more times each week for a year or more. Premenstrual Dysphoric Disorder Internalizing Disorders Anxiety Disorders Depression Posttraumatic Stress Disorder (PTSD) includes a new subtype for children younger than 6. Other Disorders Specific Learning Disorder - no longer limits learning disorders to reading, mathematics and written expression. Intellectual Disability Disorder Eating Disorders Substance Abuse Self-Harming Behavior Tic Disorders Early Onset Major Mental Illness Schizophrenia Bipolar Disorder Types of Child and Adolescent Mental Health Disorders

15. Disorders of Social Interaction Autism Spectrum Disorder (ASD) - incorporates four disorders from the previous manual Social Communication Disorder (SCD) is characterized by a persistent difficulty with verbal and nonverbal communication that cannot be explained by low cognitive ability Externalizing Disorders Attention Deficit/ Hyperactivity Disorder Oppositional Defiant Disorder Conduct Disorder Disruptive Mood Dysregulation Disorder (DMDD). It is characterized by severe and recurrent temper outbursts that are grossly out of proportion to the situation in intensity or duration. The outbursts occur, on average, three or more times each week for a year or more. Premenstrual Dysphoric Disorder Internalizing Disorders Anxiety Disorders Depression Posttraumatic Stress Disorder (PTSD) includes a new subtype for children younger than 6. Other Disorders Specific Learning Disorder - no longer limits learning disorders to reading, mathematics and written expression. Intellectual Disability Disorder Eating Disorders Substance Abuse Self-Harming Behavior Tic Disorders Early Onset Major Mental Illness Schizophrenia Bipolar Disorder Types of Child and Adolescent Mental Health Disorders The degree of hearing impairment or loss is not correlated with the range of mental health problems.

16. Time of Initial Occurrence for Common Behavior Problems Learning Disorders Emotional and Behavioral Disorders Conduct Disorder Oppositional Defiant Disorder Attention Deficit-Hyperactivity Disorder Compliance Problems Bi-Polar Schizophrenia Drug abuse Bulimia Anorexia nervosa Disruptive Mood Dysregulation Disorder Language Disorders Depression Autism Spectrum Disorder Attachment Disorders Birth 6 years 12 years 18 years Wicks-Nelson & Israel, 2003

17. Seriousness of the Problem Prevalence of Emotional Behavioral Disturbance (EBD) Population Proportions (9 to 17 year-olds) 20% Youth with any diagnosable disorder (1 in 5 students in your classroom likely display a diagnosable mental health disorder). 9-13% Youth with EBD, with substantial functional impairment. 5-9% Youth with EBD & extreme functional impairment. 0.8-1% Youth identified as EBD in the public schools of this nation >1% 5-9% 9-13% 20% 20%

18. Diagnostic Dilemma • Regardless of the presenting symptoms, children and adolescents are most often initially referred for an evaluation for ADHD.

19. ADHD Criteria • Symptoms must be present for 6 months to a degree that is maladaptive and inconsistent with the developmental level of the child. • Clear evidence of clinically significant impairment aligned with several symptoms present in two or more settings. • Onset of impairment must be before age 12 (was 7), even if it was not diagnosed until later.

20. ADHD – Inattentive Symptoms(Must display 6 of 9) • Frequent careless mistakes. • Difficulty sustaining attention in task or play. • Often fails to listen when spoken to directly. • Fails to follow through on tasks or follow directions. • Difficulty organizing tasks and activities. • Avoids tasks that require sustained attention. • Often loses things. • Is easily distracted by extraneous stimuli. • Forgetful in daily activities.

21. ADHD – Hyperactive Impulsive(Must display 6 of 9) • Often fidgets with hands or feet – squirms in seat • Often leaves seat when required to sit • Runs about or climbs excessively. • Often has difficulty playing or engaging in leisure activities quietly • Is often ‘on the go’ or acts ‘as if driven by a motor’ • Often talks excessively • Blurts out answers before questions are completed • Difficulty waiting his or her turn • Often interrupts or intrudes on others

22. ADHD Diagnosis • ADHD- Primarily Inattentive Type – if 6 months of 6 or more inattentive symptoms. • ADHD – Primarily Hyperactive-Impulsive Type – if 6 months of 6 or more hyperactive-impulsive symptoms. • ADHD – Combined Type – if 6 months of displaying 6 or more inattentive symptoms AND 6 months of displaying 6 or more hyperactive-impulsive symptoms. MOST COMMON

23. ADHD Epidemiology • Occurs in 3 – 12 % of school aged children and adolescents. • Boys are 4 to 9 times more likely to display ADHD than girls. Girls more likely to be diagnosed with ADHD Inattentive Type. • Thirty to 50% of individuals with ADHD display a co-morbid disorder (e.g., ODD, CD, ASD, LD, Mood Disorders, Anxiety Disorders)

24. Adversity in Early Childhood • “Toxic stress” early in life can lead to fundamental changes in several regions of the brain, including those that subserve learning and memory (e.g., hippocampus) and those that subserve executive functions (e.g., various regions of the prefrontal cortex). • Adverse Childhood Experience (ACE) Study Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C, et al. (2006) The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci 256: 174-186.

25. Medication and ADHD • Often educators express frustration in a parent’s reluctance to employ medication when their child suffers from ADHD. • Two general classes of medications for ADHD • Methylphenidate –Ritalin, Vyvanse, Concerta • Atomoxeline – Straterra, Clonidine, Intuniv • Only about 1/3 of children respond effectively to medication (some of these children may not actually suffer from ADHD) • Parents concerned about side effects (sleep problems, weight gain, eating disorders, etc.) • Goal of medication = improved ability to attend

26. Co-Morbidity and ADHD • One of the most frequent co-morbid disorder found in children and adolescents with ADHD was Oppositional Defiant Disorder (34%). • Another 28% of children with ADHD displayed co-morbid anxiety disorders. • A large national study found: • 51% of adults with ADHD suffered from co-morbid anxiety disorders, and • 32% suffered from co-morbid depression. -

27. Oppositional Defiant Disorder • A pattern of negativistic, hostile and defiant behavior lasting greater than 6 months of which you have 4 or more of the following: • Extreme loss of temper • Argues with adults • Actively defies or refuses to comply with rules • Often deliberately annoys people • Blames others for his or her mistakes • Often touchy or easily annoyed with others • Often angry or resentful • Often spiteful or vindictive

28. ODD and the Brain • The development of oppositional defiant disorder is associated with changes in the neurotransmitters of the brain. • Neurotransmitters are chemical transmitters of impulses between nerve cells. • Raising or lowering the level of neurotransmitters (i.e., deviation from the norm) leads to a sudden change in mood and changes in the thinking process because of impaired transmission of nerve impulses. That’s why people with ODD have: • a sense of irritation, • they have no fear of punishment, • they often cannot adequately perceive reality and communicate normally in stressful situations. .

29. External Factors Impacting the Development of ODD • The major familial external factors that contribute to the development of ODD disorder: • domestic violence, • abuse (physical or sexual abuse), • indifference of parents, • disastrous financial situation (poverty), or poor quality of life, • drug and alcohol use by parents. • The major school-based external factors include: • excessive punishment or punishment for behavior outside the control of the student, • abuse by adults and peers, and/or • Indifference on the part of teachers

30. Transition of ODD to Conduct Disorder • Oppositional Defiant Disorder in childhood years can develop into serious Conduct Disorder by adolescence. • Young students with ODD have a 2 to 3 fold likelihood of becoming juvenile offenders. • Conduct Disorder – Adolescent Onset – behaviorally typical until middle school – more favorable prognosis and more likely to respond to treatment.

31. Conduct Disorder • Repetitive behaviors that violate the rights of others and/or societal laws, with 3 or more of the following in the past 12 months, with one in the last 6 months: • Aggression or cruelty to people or animals • Destruction of property • Theft • Running away • Affects 12% of boys and 7% of girls

32. Oppositional Defiant Disorder and Conduct Disorder Treatment • Clear, brief, rules and expectations • Consistent and predictable consequences • Frequent recognition and praise for the display of desired behavior • Family therapy • Behavior management training • Collaborative Problem Solving (Ross Greene) • Social skills intervention • Social problem solving skill instruction

33. Autism Spectrum Disorder… • is a neurological condition that results in developmental delays in both social communication and social interaction.

34. Social and Communication Deficits In order to receive a diagnosis of Autism Spectrum Disorder, a person must have all three of the following deficits: • Problems reciprocating social or emotional interaction - This can include difficulty establishing or maintaining back-and-forth conversations and interactions, inability to initiate an interaction, and problems with shared attention or sharing of emotions and interests with others. • Severe problems maintaining relationships - This can involve a complete lack of interest in other people, difficulties playing pretend and engaging in age-appropriate social activities, and problems adjusting to different social expectations. • Non-verbal communication problems - This can include abnormal eye contact, posture, facial expressions, tone of voice, and gestures, as well as an inability to understand these non-verbal signals from other people.

35. Repetitive and Restrictive Behaviors In addition, the individual must display at least two of these behaviors: • Extreme attachment to routines and patterns and resistance to changes in routines • Repetitive speech or movements • Intense and restrictive interests • Difficulty integrating sensory information or strong seeking or avoiding behavior of sensory stimuli

36. One Disorder – Not Five • Previously, there were five autism spectrum disorders, each of which had a unique diagnosis: Autistic Disorder or classic autism, Asperger’s Disorder, Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS), Rett's Syndrome, Childhood Disintegrative Disorder • In the latest revision of the DSM, these disorders do not exist as separate diagnoses on the autism spectrum. Instead, with the exception of Rett's Syndrome, they are subsumed into the diagnosis of "Autism Spectrum Disorder." Rett's Syndrome has become its own entity and will no longer be part of the autism spectrum.

37. Why the Change? • According to The American Psychological Association, the standards for diagnosing autism spectrum disorders have changed for several reasons: • While it's possible to clearly distinguish the difference between people with ASDs and those with neurotypical functioning, it's more difficult to diagnose the sub-disorders validly and consistently. • Since all people with autism spectrum disorders display some of the typical behaviors, it's better to refine the diagnosis by severity than to have a completely separate label. • A single diagnosis of ASD better reflects the current research about the presentation and pathology of autism.

38. Autism and Hearing Loss • Rosenhall et al (1999) found a higher incidence of permanent mild and permanent bilateral moderate to profound hearing loss in children with autism compared to the general population • No correlation exists between the occurrence of hearing loss and the severity of the autism diagnosis (Jure et al, 1991; Rosenhall et al, 1999).

39. Diagnosis/Assessment • One inherent problem with the identification of the incidence of co-occurring autism and hearing loss is the ambiguity surrounding the diagnosis of autism itself. • Because the disruption of language and communicative function that is often noted in individuals with autism may present similarly to deficits found in children with more severe hearing loss, the differentiation of these two populations is challenging

40. Anxiety Disorders • Incredibly strong feelings that situations are dangerous or threatening • These feelings have been demonstrated over an extended period of time • These feelings are triggered by ordinary things that don’t pose significant risk

41. Types of Anxiety Disorders Generalized Anxiety Disorder • Children with a generalized anxiety disorder, or GAD, worry excessively about a variety of things such as grades, family issues, relationships with peers, and performance in sports.  • Children with GAD tend to be very hard on themselves and strive for perfection. They may also seek constant approval or reassurance from others. Obsessive-Compulsive Disorder (OCD) • OCD is characterized by unwanted and intrusive thoughts (obsessions) and feeling compelled to repeatedly perform rituals and routines (compulsions) to try and ease anxiety.  • Most children with OCD are diagnosed around age 10, although the disorder can strike children as young as two or three. Boys are more likely to develop OCD before puberty, while girls tend to develop it during adolescence. Panic Disorder • Panic disorder is diagnosed if a student suffers at least two unexpected panic or anxiety attacks—which means they come on suddenly and for no reason—followed by at least one month of concern over having another attack, losing control, or "going crazy."  Posttraumatic Stress Disorder (PTSD) • Children with posttraumatic stress disorder, or PTSD, may have intense fear and anxiety, become emotionally numb or easily irritable, or avoid places, people, or activities after experiencing or witnessing a traumatic or life-threatening event. 

42. Generalized Anxiety Disorder • Excessive anxiety or worry that is difficult to control, lasts at least 6 months and creates impairment in functioning. Accompanied by at least one of the following: • Restlessness • Fatigue • Difficulty concentrating • Irritability • Muscle tension • Sleep disturbances • Mean age of onset between 10–13 years of age.

43. Generalized Anxiety Disorder • Excessive anxiety or worry that is difficult to control, lasts at least 6 months and creates impairment in functioning. Accompanied by at least one of the following: • Restlessness • Fatigue • Difficulty concentrating • Irritability • Muscle tension • Sleep disturbances • Mean age of onset between 10–13 years of age. Worry themes: - Academics - Natural Disasters - Social Life - Physical Assault

44. Anxiety: Mind and Body MIND Feeling worried all the time. Feeling tired. Unable to concentrate. Sleeping poorly. BODY Irregular heartbeat Sweating easily Muscle tension and pains Breathing heavily Dizziness Faintness Indigestion Diarrhea

45. Fight, Flight or Freeze! • When confronted with a stressful situation the body’s autonomic nervous system moves us into a physiological state to help us address the situation and avoid injury. Blood is shunted from the brain and internal organs and moved to our arms and legs to support fight or flight. Adrenalin and epinephrine are released in quantity to provide strength and endurance. Cortisol floods the bloodstream to prevent swelling and it shuts down action in the upper cortex of our brain – (Not time to think, but rather to act!)

46. The Amygdala • The amygdala is the key player in the extensive neural network involved in the processing of fear and other basic emotions. • Implicit emotional learning and memory • Emotional modulation of memory • Emotional influences on attention and perception • Emotion and social behavior • Emotion inhibition and regulation

47. The Role of Language in Emotion Regulation • Putting feelings into words appears to alleviate negative emotional response • Linguistic processing (e.g., affect labeling) of an emotional image produces reduced amygdala activity

48. Depression Criteria • Depressed mood, feels sad or empty, (irritability in children) by self report or observation. • Diminished interest or pleasure in most activities. • Weight gain or loss – in children failure to make expected weight gain. • Insomnia or hyper-somnia nearly every day. • Psychomotor agitation or retardation nearly every day, observable by others. • Fatigue or loss of energy. • Feelings of worthlessness or guilt (which may be delusional). • Inability to concentrate; inattentiveness. • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan.

49. Depression • At least 5 of 9 symptoms for a 2 week period, representing a change in previous functioning. • At least one of the symptoms must be depressed mood (irritable in children) or loss of interest or pleasure in usual activities. • The symptoms cause clinically significant distress or impairment. • Impacts 3-8% of children and adolescents.

50. Symptoms that Increase with Age: Sleep/Appetite changes Fatigue Boredom (Anhedonia) Psychomotor retardation Hopelessness Delusions Symptoms that Decrease with Age: Somatic complaints Behavioral problems Guilt, irritability Hallucinations Depression Symptoms