School

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School Common Childhood Disorders. What are
some of the more common childhood psychiatric
disorders that impact schools?
Social-Emotional RTI Building the Model
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Emotional Disturbance Federal Definition
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Emotional Disturbance Federal Definition
This definition has a number of inherent flaws.
It is contradictory, poorly specified, and
redundant. The limiting criteria are poorly and
subjectively defined, and in the case of the
educational impact criterion, redundant and
unclear ... (Gresham et al., 2013)
Source Gresham, F. M., Hunter, K. K., Corwin, E.
P., Fischer, A. J. (2013). Screening,
assessment, treatment, and outcome evaluation of
behavioral difficulties in an RTI mode.
Exceptionality, 21, 19-33.
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Emotional Disturbance Federal Definition
... the social maladjustment clause has received
some criticism as well....Specifically, it states
that students who are socially maladjusted should
not be classified as ED this part of the
definition clearly contradicts Part B (an
inability to build or maintain satisfactory
interpersonal relationships with peers or
teachers). (Gresham et al., 2013)
By excluding students who are socially
maladjusted, but including students who cannot
build or maintain satisfactory interpersonal
relationships, the definition simultaneously
includes and excludes a subset of students, which
is confusing. (Gresham et al., 2013)
Source Gresham, F. M., Hunter, K. K., Corwin, E.
P., Fischer, A. J. (2013). Screening,
assessment, treatment, and outcome evaluation of
behavioral difficulties in an RTI mode.
Exceptionality, 21, 19-33.
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Review of 4 Psychiatric Disorders

• Attention-Deficit/Hyperactivity Disorder
• Disruptive Mood Dysregulation Disorder
• Oppositional Defiant Disorder
• Generalized Anxiety Disorder

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Attention-Deficit/Hyperactivity Disorder
Essential Features

• The individual displays a level of inattention
  and/or hyperactivity-impulsivity that interferes
  with functioning
• Inattention. Six or more symptoms over the past
  six months to a marked degree that impacts
  social/academic functioning
• Fails to give close attention to details
• Has difficulty sustaining attention in tasks or
  play
• Seems not to pay attention when spoken to
• Does not follow through on instructions or finish
  schoolwork
• Has difficulty organizing tasks and activities
• Avoids or dislikes tasks requiring sustained
  mental effort
• Often loses things needed for tasks or activities
• Is distracted by extraneous stimuli
• Is often forgetful in daily activities (e.g.,
  chores, errands)

Source American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC Author.
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Attention-Deficit/Hyperactivity Disorder
Essential Features

• The individual displays a level of inattention
  and/or hyperactivity-impulsivity that interferes
  with functioning
• Hyperactivity/Impulsivity Six or more symptoms
  over the past six months to a marked degree that
  impacts social/academic functioning
• Fidgets or taps hands or feet or squirms in seat
• Leaves seat when expected to remain seated
• Runs around or climbs in situations when the
  behavior is not appropriate
• Is unable to play or take part in a leisure
  activity quietly
• Seems on the go as if driven by a motor
• Talks incessantly
• Blurts out an answer before a question has been
  fully asked
• Interrupts others

Source American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC Author.
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Attention-Deficit/Hyperactivity Disorder
Prevalence

• It is estimated that perhaps 5 of children may
  meet criteria for ADHD (APA, 2013).
• However, the percentage of children diagnosed
  with ADHD in America has grown substantially over
  time
• 2003 7.8 ADHD
• 2007 9.5 ADHD
• 2011 11.0 ADHD

Sources American Psychiatric Association.
(2013). Diagnostic and statistical manual of
mental disorders (5th ed.). Washington, DC
Author. Centers for Disease Control and
Prevention. (n.d.) ADHD Data statistics.
Retrieved from http//www.cdc.gov/ncbddd/adhd/data
.html
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Disruptive Mood Dysregulation Disorder Essential
Features

• DMDD is one of the Depressive Disorders.
• The individual experiences severe outbursts of
  temper with underlying persistent angry or
  irritable mood.
• Temper outbursts occur 3 times or more per week,
  across at least 2 settingswith severe symptoms
  in at least 1 setting.
• This pattern of outbursts and underlying anger
  has been evident for at least 12 months.
• The condition can be diagnosed between ages 6 and
  18-but onset must be observed before age 10.
• DMDD cannot coexist with ODD, intermittent
  explosive disorder, or bipolar disorder.

Source American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC Author.
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Disruptive Mood Dysregulation Disorder Prevalence

• The prevalence of DMDD is unknown.
• It is estimated that perhaps 2-5 of children and
  adolescents may have the disorder (during a
  6-month to 12-month prevalence period) and that
  rates are likely to be higher among
  pre-adolescents and boys (APA, 2013).

Source American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC Author.
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Disruptive Mood Dysregulation Disorder Issues

• DDMD replaces Bipolar NOS, a diagnosis used in
  DSM-IV to classify children who met some, but not
  all, of the symptoms for bipolar.
• During the use of Bipolar NOS, there was a
  40-fold increase in office visits between 1994
  and 2003 (Hilt, 2012).
• Although bipolar is considered to be a life-long
  condition, both the treatment and progression of
  childhood bipolar were found to differ from the
  adult version of the disorder.
• DDMD was designed as a diagnostic category in DSM
  5 to give these children a diagnostic home and
  ensure they get the care they need. (APA, May,
  2013).

Sources Hilt, R. (2012). Childhood depression
and bipolar disorders What we know now.
University of Washington/Seattle, WA Author.
Retrieved from http//www.nami.org/contentmanageme
nt/contentdisplay.cfm?contentfileid167527 America
n Psychiatric Association. (May, 2013).
Disruptive mode dysregulation disorder Finding a
home in DSM. Washington, DC Author.
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Disruptive Mood Dysregulation Disorder Issues
(Cont.)

• DMDD Limited Diagnostic Utility? One recent
  study found that, in a clinical sample, DMDD
  could not be delimited from oppositional defiant
  disorder and conduct disorder, had limited
  diagnostic stability, and was not associated with
  current, future-onset, or parental history of
  mood or anxiety disorders. These findings raise
  concerns about the diagnostic utility of DMDD in
  clinical populations. (Axelson et al., 2012 p.
  1342).

Source Axelson, D., Findling, R. L., Fristad, M.
A., Kowatch, R. A., Youngstrom, E. A., Horwitz,
S. M. , Arnold, L. E., Frazier, T. W., Ryan, N.,
Demeter, C., Gill, M. K., Hauser-Harrington, J.
C., Depew, J., Kennedy, S. M., Gron, B. A.,
Rowles, B. M. Birmaher, B. (2012). Examining the
proposed Disruptive Mood Dysregulation Disorder
diagnosis in children in the longitudinal
assessment of manic symptoms study. Journal of
Clinical Psychiatry, 73, 1342-1350.
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Oppositional Defiant Disorder Essential Features

• ODD is one of the Disruptive, Impulse-Control,
  and Conduct Disorders.
• The individual shows a pattern of oppositional
  behavior lasting at least 6 months that includes
  elevated levels of at least 4 of the following
• Often loses temper
• Often argues with adults
• Often defies or refuses to comply with adults'
  requests or rules
• Often purposely annoys people
• Often blames others for his or her mistakes or
  misbehavior
• Is often touchy or easily annoyed by others
• Is often angry and resentful
• Is often spiteful or vindictive
• The individual displays these oppositional
  behaviors significantly more frequently than
  typical age-peers.

Source American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC Author.
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Oppositional Defiant Disorder Prevalence

• The prevalence of oppositional defiant disorder
  ranges from 1 to 11, with an average prevalence
  estimate of around 3.3. (APA, 2013 p. 464).

Source American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC Author.
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Generalized Anxiety Disorder Essential Features

• GAD is one of the Anxiety Disorders.
• The individual experiences excessive anxiety and
  worry about a variety of topics, events, or
  activities over a period of at least 6 months.
  Worry occurs on the majority of days. It is
  difficult for the individual to control the
  anxiety/worry.
• The worry is associated with at least 3 of these
  6 symptoms
• Restlessness.
• Becoming fatigued easily
• Difficulty concentrating
• Irritability
• Muscle tension
• Sleep disturbance
• The individual experiences 'clinically
  significant' distress/impairment in one or more
  areas of functioning (e.g., at work, in social
  situations, at school).
• The worry or anxiety cannot be better explained
  by physical causes or another psychiatric
  disorder.

Source American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC Author.
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Normative Anxieties/Fears in Childhood Adolescence Normative Anxieties/Fears in Childhood Adolescence
Stage/Age Anxieties/Fears About
Later Infancy6-8 months Strangers
Toddler 12 months-2 years Separation from parents Thunder, animals
Early Childhood 4-5 years Death, dead people, ghosts
Elementary 5-7 years Germs, natural disasters, specific traumatic events School performance
Adolescence 12-18 years Peer rejection
Source Beesdo, K., Knappe, S. Pine, D. S.
(2009). Anxiety and anxiety disorders in children
and adolescents Developmental issues and
implications for DSM-V. Psychiatric Clinics of
North America, 32(3), 483-524. http//www.ncbi.nlm
.nih.gov/pmc/articles/PMC3018839/
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Generalized Anxiety Disorder Prevalence

• The 12-month prevalence of GAD among adolescents
  is estimated to be 0.9 while among adults the
  rate is 2.9.

Source American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC Author.
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Psychiatric Disorders of Childhood Adolescence Adjusted Comorbidity Psychiatric Disorders of Childhood Adolescence Adjusted Comorbidity Psychiatric Disorders of Childhood Adolescence Adjusted Comorbidity Psychiatric Disorders of Childhood Adolescence Adjusted Comorbidity Psychiatric Disorders of Childhood Adolescence Adjusted Comorbidity Psychiatric Disorders of Childhood Adolescence Adjusted Comorbidity Psychiatric Disorders of Childhood Adolescence Adjusted Comorbidity
Conduct Disorder Oppositional Defiant Disorder ADHD Depressive Disorders Generalized Anxiety Disorder Social Phobia
Oppositional Defiant Disorder 11.5 -- -- -- -- --
ADHD 2.4 6.1 -- -- -- --
Depressive Disorders 2.5 10.9 -- -- -- --
Generalized Anxiety Disorder -- -- -- 37.9 -- --
Social Phobia -- -- 3.4 9.9 -- --
Separation Anxiety Disorders 2.2 3.3 8.1 5.1
Source Copeland, W. E., Shanahan, L., Erkanli,
A., Costello, E. J., Angold, A. (2013).
Indirect comorbidity in childhood and
adolescence. Frontiers in Psychiatry, 4(144),
1-8. doi10.3389/fpsyt.2013.00144
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Problems are an unacceptable discrepancy between
what is expected and what is observed. A problem
solution is defined as one or more changes to the
instruction, curriculum, or environment that
function(s) to reduce or eliminate a problem.
-Ted Christ


Source Christ, T. (2008). Best practices in
problem analysis. In A. Thomas J. Grimes
(Eds.), Best Practices in School Psychology V
(pp. 159-176). Bethesda, MD National Association
of School Psychologists.
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RTI Identifying EBD Students Through
Intervention, Not Psychometric Eligibility

• RTI is based on the logic that if a student's
  behavioral excesses and/or deficits continue at
  unacceptable levels subsequent to an
  evidence-based intervention implemented with
  integrity, then the student can and should be
  eligible for ED i.e., Special Education
  services. RTI is based on the best practices of
  prereferral intervention and gives school
  personnel the latitude to function within an
  intervention framework rather than a psychometric
  eligibility framework.

Source Gresham, F. M. (2005). Response to
intervention An alternative means of identifying
students as emotionally disturbed. Education and
Treatment of Children, 28(4), 328-344.
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Factors Influencing the Decision to Classify as
BD (Gresham, 1992)

• Four factors strongly influence the likelihood
  that a student will be classified as Behaviorally
  Disordered
• Severity Frequency and intensity of the problem
  behavior(s).
• Chronicity Length of time that the problem
  behavior(s) have been displayed.
• Generalization Degree to which the student
  displays the problem behavior(s) across settings
  or situations.
• Tolerance Degree to which the students problem
  behavior(s) are accepted in that students
  current social setting.

Source Gresham, F. M. (1992). Conceptualizing
behavior disorders in terms of resistance to
intervention. School Psychology Review, 20, 23-37.
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School Pathways to Student Mental-Health Support
A Source of Potential Confusion

• A student with a diagnosis of ADHD and some
  oppositional classroom behaviors could go down
  any of several pathways of identification and
  support
• Emotionally Disturbed. The school may find that
  the student meets criteria for ED and provides an
  IEP.
• Other Health Impairment. The students ADHD
  diagnosis is treated as a medical condition and
  an IEP is granted.
• Section 504. The attentional and/or behavioral
  symptoms of ADHD may be identified as comprising
  a major life impairment that requires a
  Section 504 plan.
• No support. The student remains in general
  education with no additional support.

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Schools Psychiatric Disorders Building Capacity

• Promote the expectation whenever possible that
  students with behavioral or social-emotional
  difficultieseven those with psychiatric
  diagnoseswill go through the RTI problem-solving
  process as a starting point. RTI will
  demonstrate whether the student needs more
  support than general education offers
  (resistance to intervention) and will reveal
  what intervention elements actually work.

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Activity Psychiatric Disorders RTI

• Schools Psychiatric Disorders Building
  Capacity
• Promote the expectation whenever possible that
  students with behavioral or social-emotional
  difficultieseven those with psychiatric
  diagnoseswill go through the RTI problem-solving
  process as a starting point.
• RTI will demonstrate whether the student needs
  more support than general education offers
  (resistance to intervention) and will reveal
  what intervention elements actually work.

• Review the several ways that a student with a
  psychiatric diagnosis might currently be handled
  by your district (e.g., Section 504, Special
  Education, etc.).
• Discuss how an RTI model might bring some
  rationality and order to this process.