DEVELOPMENTAL AND BEHAVIOURAL PROBLEMS
This Section contains information on the following topics-
Introduction
Period 1: DSM-1V, DSM-1V-TR
Disorders First Diagnosed in Infancy, Childhood and Adolescence
Pervasive Developmental Disorders
Autism Spectrum Disorders
Attention-Deficit and Disruptive Behaviour Disorder
Other
Period 2: DSM-5
Neurodevelopmental Disorders
Resources
References
Disruptive, Impulsive-Control and Conduct Disorders
Disorders relevant to this Section include-
Selected Emotional Disorders in Children and Adolescents-
Identification and Management
DSM-1V-TR
DSM-5
DSM-1V-TR
DSM-5
Psychological Treatment of Disorders
Stress and Anxiety in Adults-Identification and Management
References
Resources
INTRODUCTION
This Section explores issues central to the identification and management of developmental and behavioural disorders found in children and adolescents. Some attention is also given to adults suffering with stress, anxiety and depression.
Classification of Disorders
To assist psychologists and other professionals recognise and manage children and adolescents with developmental and behavioural/emotional problems, the classificatory systems of the Diagnostic and Statistical Manual of Mental Disorders-(DSM-1V- DSM-1V TR- 2005), the International Statistical Classification of Diseases and Related Health Problems (ICD-10-2007), Managing Mental Disorders, WHO (2004), and the DSM-5 (2013), provide excellent direction and guidance. Other sources include the DET classification and selected texts.
From these and other sources, details are provided on the following topics-
The main classificatory systems, while basically identifying similar disorders, vary slightly in terminology and definitions. From the total list of disorders, those considered more common and hence most likely to come to the attention of psychologists and teachers will be studied.
In keeping with the tradition I have established on this website, I have chosen to preserve earlier developments that give the reader a sense of chronological and historical perspective in the field of disabilities and disorders.
Hence, in the domain of developmental disorders there are two periods-
This means that relevant Period 1 details are retained to show important changes in definitions and diagnostic criteria over time.
PERIOD 1: DSM-1V, DSM-1V-TR
Disorders First Diagnosed in Infancy, Childhood and Adolescence
Pervasive Developmental Disorders
The Pervasive Developmental Disorders discussed are as follows-
Autism Spectrum Disorders
Attention-Deficit and Disruptive Behaviour Disorders
Autism Spectrum Disorders
These disorders are characterised by severe deficits and pervasive impairment in multiple areas of development. These include impairment in reciprocal social interaction, impairment in communication and the presence of stereotyped behaviour, interests and activities. The conditions are difficult to treat and require ongoing intensive work to achieve even small gains.
Autism
Is characterised by qualitative impairment in the development of reciprocal social interaction, in the development of verbal and non-verbal communication and in imaginary activity. (DSM-1V-TR, 2005).
Characteristics
Asperger’s Syndrome
A severe and sustained impairment in social interaction and the development of restricted, repetitive patterns of behaviour, interests, and activities. The disturbance must cause clinically significant impairment in social, occupational or other important areas of functioning. There are no clinically significant delays in language and cognitive development, although this does not imply that there are no problems with communication. (DSM-1V-TR, 2005).
Characteristics
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Because the DSM-1V-TR (2005) indicated the need to consider very recent developments in regard to Asperger’s Syndrome, substantial details are provided above and additional information is summarised below.
In the revision, specific examples of typical manifestations of the impairment in reciprocal social interactions and in restricted, repetitive behaviour and interests are provided in order to better differentiate those individuals from those with Autism Disorder. In addition, the text has been extended to clarify the point that the requirement for no clinically significant delays in language does not imply that individuals with Asperger’s Syndrome have no problem with communication.
I have been asked by parents, teachers and psychologists to develop an easy to use preliminary screening checklist that can be helpful in identifying common characteristics frequently observed in children and adolescents with Asperger’s Syndrome. If several, positive signs are noted in more than two of the four domains, the student should be referred to a team of specialists including a paediatrician, a psychologist and a speech pathologist for comprehensive diagnostic assessments.
The following screening checklist draws on the valuable contributions of the following-
In addition, the author’s several decades of clinical observations are also used to identify defining characteristics.
The following is a checklist of the characteristics that I use and share with parents and teachers to tentatively identify children with possible Asperger’s Syndrome and to decide whether or not to conduct a formal diagnosis.
This checklist can be used to identify the presence (Yes) or absence (No) of relevant characteristics.
The presence of Age Appropriate or Positive Attributes in cognitive, language and often academic areas, are important requirements while a range of Developmental Delays or Negative Attributes are defining characteristics.
The common symptoms of Asperger’s Syndrome are arranged in four domains-
This checklist can be used to identify the presence (Yes) or absence (No) of relevant characteristics.
The presence of Age Appropriate or Positive Attributes in cognitive, language and often academic areas, are important requirements while a range of Developmental Delays or Negative Attributes are defining characteristics.
The common symptoms of Asperger’s Syndrome are arranged in four domains-
ASPERGER’S SYNDROME CHECKLIST
CHARACTERISTICS
Age Appropriate or Positive Attributes- | Yes √ | No X |
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Developmental Delays or Negative Attributes- | ||
Social Impairment | ||
Solitary Activities | ||
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Impaired Social Interaction | ||
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Language and Communication Problems | ||
Verbal | ||
Speech | ||
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Language | ||
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Non-verbal | ||
Failure to use the following to regulate social interaction | ||
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Motor Clumsiness | ||
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Restrictive and Intense Interests | ||
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If several impairments are registered in more than two of the four domains-
then further investigation is recommended.
It must be stressed that children with Asperger’s Syndrome are not a homogeneous group and do not display the same clinical profile. Each individual will reveal a unique pattern of characteristics. However, within the unique profile there will be a set of common characteristics that indicate a positive diagnosis.
Adapted by Stewart Sykes (2011)
This checklist is also presented in Section- FAQs where the topic of Asperger’s Syndrome is discussed further.
Rett’s Syndrome
A condition of unknown cause, to date reported only in girls, which has been differentiated on the basis of a characteristic onset, course, and pattern of symptoms. Typically apparently normal or near normal early development is following by partial or complete loss of acquired hand skills, together with deceleration in head growth, usually with an onset between 7 and 24 months of age. Hand-wringing, loss of purposive hand movements and hyperventilation are particularly characteristic. Problems develop in the coordination of gait and trunk movements. Social and play development are arrested in the first 2 or 3 years, but social interest tends to be maintained. The condition is typically associated with severe or profound intellectual disability and severe impairment in receptive and expressive language development.
Pervasive Developmental Disorder Not Otherwise Specified (Including Atypical Autism)
Severe and pervasive developmental disorder that differs from autism in terms either of age of onset or of failure to fulfil all three sets of diagnostic criteria. Thus abnormal and/or impaired development becomes manifest for the first time only after age of 3 years and/or there are insufficient demonstrable abnormalities in one or two of the three areas of psychopathology required for the diagnosis of autism (namely, reciprocal social interactions, communication and restrictive, stereotyped, repetitive behaviour) in spite of characteristic abnormalities in the other area(s). Atypical autism arises most often in profoundly retarded individuals whose very low level of functioning provides little scope for exhibition of the specific deviant behaviours required for the diagnosis of autism; it also occurs in individuals with severe specific developmental disorder of receptive language.
Attention-Deficit and Disruptive Behaviour Disorders
Attention-Deficit Disorders
The DSM-1V-TR (2005) provides a very detailed account of this disorder and the three subtypes.
The central feature of ADHD is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development. There must be clear evidence of interference with developmentally appropriate social, academic or occupational functioning.
Inattention may be manifest in academic, occupational or social situations. Individuals with this disorder may fail to give close attention to details or may make careless mistakes with schoolwork or other tasks. Work is often messy and performed carelessly and without considered thought. Individuals often have difficulty sustaining attention to tasks or play activities and find it hard to persist with tasks until completion. They often appear as if their mind is elsewhere or as if they are not listening or did not hear what has just been said. They often do not follow through on requests or instructions and fail to complete schoolwork, chores or other duties.
Hyperactivity may be manifested by fidgeting or squirming in one’s seat, by not remaining seated when expected to do so, by excessive running or climbing in situations where it is inappropriate, by having difficulty playing or engaging quietly in leisure activities, by appearing to be often “on the go” or as if “driven by a motor” or by talking excessively.
Impulsivity manifests itself as impatience, difficulty in delaying responses, blurting out answers before questions have been completed, difficulty awaiting one’s turn and frequently interrupting or intruding on others to the point of causing difficulties in social, academic or occupational settings. Individuals with this disorder typically make comments out of turn, fail to listen to directions, initiate conversations at inappropriate times, interrupt others excessively, intrude on others, grab objects from others, touch things they are not supposed to touch and clown around. Impulsivity may lead to accidents and to engage in potentially dangerous activities without consideration of possible consequences. Behavioural manifestations usually appear in multiple contexts, including home, school and social situations.
In 2005, earlier estimates of prevalence rates (3-5%) were revised upward reflecting increased prevalence due to the inclusion of the predominantly Hyperactive-Impulsive and Predominantly Inattentive Types.
Although many individuals present with symptoms of both inattention and hyperactivity-impulsivity, there are individuals in whom one or the other pattern is predominant. The appropriate subtypes should be indicated-
AD/HD, Combined and AD/HD Predominantly Hyperactive-Impulsive Type
Children with these conditions display significant and developmentally inappropriate inattention, impulsivity and overactivity from an early age (before 7 years).
Also difficulty concentrating, are restless, squirm and fidget, easily distracted, loud and noisy. Comorbidity with conduct problems and learning difficulties is common.
These behaviours are typically present across situations (home, school, clinic) and produce substantial impairment in functioning. Children with this problem are typically rejected by their peers and show a variety of difficulties with social relationships.
AD/HD, Predominantly Inattentive Type
Children with this condition have significant difficulties focussing and sustaining attention. They are easily distracted and find concentrating on tasks extremely difficult.
Such children do not display hyperactivity or impulsivity which characterises the other subtypes.
Disruptive Behaviour Disorders
Conduct Disorder
Young people with Conduct Disorder display a pattern of behaviour characterised by breaking rules, deceit and lack of respect for the rights of others. These children and adolescents are constantly in conflict with parents, teachers, peers and society as a whole.
Conduct Disorder is characterised by a repetitive and persistent pattern of dissocial, aggressive or defiant conduct. Such behaviour should amount to major violations of age-appropriate social expectations; it should therefore be more severe than ordinary childish mischief or adolescent rebelliousness and should imply an enduring pattern of behaviour (six months or longer). Features of Conduct Disorder can also be symptomatic of other psychiatric conditions, in which case the underlying diagnosis should be preferred. Examples of the behaviours on which the diagnosis is based include excessive levels of fighting or bullying, cruelty to other people or animals, severe destructiveness to property, fire-setting, stealing, repeated lying, truancy from school and running away from home, unusually frequent and severe temper tantrums and disobedience. Any one of these behaviours, if marked, is sufficient for a diagnosis, but isolated dissocial acts are not.
Oppositional Defiant Disorder
This type of Conduct Disorder is usually seen in children below the age of 9 or 10 years. It is defined by the presence of markedly defiant, disobedient, provocative behaviour and by the absence of more severe dissocial or aggressive acts that violate the law or the rights of others. Severely mischievous or naughty behaviour is not, in itself, sufficient for a diagnosis. Many authorities consider that oppositional defiant patterns of behaviour represent a less severe type of Conduct Disorder, rather than a qualitatively distinct type. Research evidence is lacking on whether the distinction is qualitative or quantitative.
Caution should be taken in using this category, especially in the case of older children. Clinically significant conduct disorders in older children are usually accompanied by dissocial or aggressive behaviour that goes beyond defiance, disobedience or disruptiveness, although not infrequently they are preceded by an Oppositional Defiant Disorder at an earlier age.
The essential feature of this disorder is a pattern of persistently negativistic, hostile, defiant, provocative and disruptive behaviour, which is clearly outside the normal range of behaviour for a child of the same age and which does not include the more serious violations of the right of others.
Children with this disorder frequently and actively defy adult requests or rules and deliberately annoy other people. Usually they tend to be angry, resentful and easily annoyed by other people whom they blame for their own mistakes or difficulties. They generally have a low frustration tolerance and readily lose their temper. Typically, their defiance has a provocative quality, so that they initiate confrontations and generally exhibit excessive levels of rudeness, uncooperativeness and resistance to authority. Frequently this behaviour is most evident in interactions with adults or peers whom the child knows well. Signs of the disorder may not be evident during a clinical interview.
Disruptive Behaviour Disorder (NOS)
This category is for disorders characterised by conduct or oppositional defiant behaviours that do not meet the criteria for Conduct Disorder or Oppositional Defiant Disorder. For example, it includes clinical presentations that do not meet full criteria for these disorders but in which there is clinically significant impairment.
Period 2: DSM-5
Neurodevelopmental Disorders
In 2013, the DSM-5 deleted Pervasive Developmental Disorders and introduced the term Neurodevelopmental Disorders which encompasses the following categories-
Intellectual Disabilities*
Intellectual Disability (Intellectual Developmental Disorder)
Autism Spectrum Disorder
Autism Spectrum Disorder
Specific Learning Disorder*
Specific Learning Disorder
Attention-Deficit/Hyperactivity Disorder
Attention-Deficit/Hyperactivity Disorder
Other Specified Attention-Deficit/Hyperactivity Disorder
Unspecified Attention-Deficit/Hyperactivity Disorder
Communication Disorders
Language Disorder
Speech Sound Disorder (Previously Phonological Disorder)
Childhood-Onset Fluency Disorder (Stuttering)
Social (Pragmatic) Communication Disorder
Unspecified Communication Disorder
Motor Disorders
Developmental Coordination Disorder
Stereotypic Movement Disorder
Tourette's Disorder
* Information on these two Disorders is provided in detail in the Section-Exceptionality.
Detailed information on the following two disorders is provided below-
In addition, information on Disruptive Mood Dysregulation Disorder, a new addition to the Depressive Disorders, has been included. This has been added as a disorder to diagnose children who exhibit persistent irritability and frequent episodes of behaviour outbursts three or more times a week for more than a year. The diagnosis is intended to address concerns about potential overdiagnosis and overtreatment of bipolar disorder in children.
This new disorder will be discussed in detail below under Depressive Disorders.
DSM-5 and Autism Spectrum Disorder
The descriptors recently used to diagnose Autism have been in place since 2000 (DSM-1V-TR) and include behaviours across the well known 'Triad of Impairments': social interaction, communication and restricted interests/repetitive behaviours.
For a diagnosis of Autism, individuals needed to display at least 6 of the described behaviours across the areas, with at least 2 behaviours in the social domain and at least 1 from each of communication and restrictive interests/repetitive behaviours.
A diagnosis of Asperger's Syndrome required at least 2 of the social interaction criteria and 1 criterion from the repetitive and restricted behaviours domain along with no language delay and average or above intellectual functioning.
A diagnosis of Pervasive Developmental Disorder (Not Otherwise Specified) is less prescriptive, requiring severe social impairment with neither communication difficulties or restrictive/repetitive behaviours.
The Fifth Edition of the Manual, DSM-5, sees wide ranging changes throughout the manual. Autism is one of the conditions which looks quite different under the DSM-5 and there is significant consequences for the diagnosis of Autism and the way Autism Spectrum Disorder is described and understood.
The Changes in Brief
The only diagnostic category is Autism Spectrum Disorder, which replaces the previous categories of Autistic Disorder (Autism), Asperger's Disorder and Pervasive Developmental Disorder not Otherwise Specified.
The three domains currently used to make a diagnosis-Social Interaction, Communication and Repetitive Behaviours/Restricted Interests) are now reduced to two domains-Social Communication and Restricted and Repetitive Patterns of Behaviour, Interests and Activities.
Individuals must display all 3 criteria in the Social Communication domain and at least 2 of the 4 criteria in the Restricted and Repetitive Behaviours domain, a total of 5 out of 7 criteria.
The new version provides greater scope across age ranges with descriptors that cover the range of presentations across the spectrum.
DSM-5 also requires that a severity rating be applied for each individual diagnosed with an Autism Spectrum Disorder. There is a severity rating applied for each individual diagnosed with an Autism Spectrum Disorder. There is a severity rating for both domains of impairment ranging from
Level 1-requiring support to Level 3-requiring very substantial support.
In addition, clinicians will be able to add specifiers (with or without Intellectual Disability) and comorbidities (such as ADHD, Anxiety Disorder, Specific Language Disorder) to allow for a more comprehensive description of an individual's presentation.
DSM-5 states that "Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life)”. (p.50)
There is a greater acknowledgement of the role of social demands.
Sensory behaviours are recognised under the Restricted and Repetitive Patterns of Behaviour Interests and Activities domain.
AUTISM SPECTRUM DISORDER: DIAGNOSTIC CRITERIA
A. Persistent deficits in social communication and social interaction across contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive; see text):
1. Deficits in social-emotional reciprocity; ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions or affect; to failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviours used for social interaction; ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding relationships, ranging from, for example, from difficulties adjusting behaviour to suit various social contexts; to difficulties sharing imaginative play or in making friends; to absence of interest in peers.
Specify current severity:
Severity is based on the social communication impairments and restricted, repetitive patterns of behaviour.
B. Restricted, repetitive patterns of behaviour, interests, or activities, as manifested by at least two of the following, currently or by history ( examples are illustrative, not exhaustive; see text):
1. Stereotyped or repetitive motor movements, use of objects or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behaviour (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus; (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
4. Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movements).
Specify current severity:
Severity is based on the social communication impairments and restricted, repetitive patterns of behaviour.
C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).
D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
E. These disturbances are no better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disorder, social communication should be below that expected for general developmental level.
Note: Individuals with a well-established DSM-1V diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.
A new addition to DSM-5 is a Table of severity descriptors for both the Social Communication domain and the Restrictive Interests and Repetitive Behaviours domain.
Severity Level for ASD
Level 3
Requiring Very Substantial Support
Social Communication
Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning; very limited initiation of social interactions and minimal response to social overtures from others.
Restricted Interests and Repetitive Behaviours
Inflexibility of behaviour, extreme difficulty coping with change, or other restricted/repetitive behaviour markedly interfere with functioning in all spheres. Great distress/difficulty changing focus or action.
Level 2
Requiring Substantial Support
Social Communication
Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions; and reduced or abnormal response to social overtures from others.
Restricted Interests and Repetitive Behaviours
Inflexibility of behaviour, difficulty coping with change, or other restricted/repetitive behaviours appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or difficulty changing focus or action.
Level 1
Requiring Support
Social Communication
Without supports in place, deficits in social communication cause noticeable impairments. Difficulties initiating social interactions, and clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions.
Restricted Interests and Repetitive Behaviours
Inflexibility of behaviour causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence.
I have decided to develop a new checklist with information obtained from DSM-5. The heading will be Autism Spectrum Disorder. See below.
AUTISM SPECTRUM DISORDER CHECKLIST
CHARACTERISTICS
Developmental Delays or Deficits | Yes √ | No X |
A. Social Communication and Social Interaction | ||
1.Deficits in Social-Emotional Reciprocity | ||
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2.Deficits in Nonverbal Communication | ||
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3.Deficits in Developing, Maintaining and Understanding Relationships | ||
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B. Restricted, Repetitive Patterns of Behaviour, Interests or Activities | ||
1.Stereotyped/ repetitive motor movements, use of objects or speech | ||
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2.Insistence on sameness | ||
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3.Highly restricted, fixed interests | ||
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4.Over or under reaction to sensory input | ||
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If impairments are registered in the following two domains-
then further investigation is recommended.
It must be stressed that children with Autism Spectrum Disorder are not a homogeneous group and do not display the same clinical profile. Each individual will reveal a unique pattern of characteristics. However, within the unique profile there will be a set of common characteristics that indicate a positive diagnosis.
Adapted from DSM-5 by Stewart Sykes (2013)
Management of Children with Autism Spectrum Disorder
Children with ASD share common behavioural and cognitive characteristics, however, there are important differences in terms of severity and pervasiveness of characteristics.
Where appropriate, I have kept the terms “Autism” and “Asperger’s Syndrome” in a few places in the discussion below.
Children with Autism are defined as having more extreme and extensive disorders than children with Asperger’s Syndrome. For instance, many Autistic children have below average intellectual abilities while most children with Asperger’s Syndrome have intellectual abilities within at least the average range with some possessing superior cognitive abilities. Most children with Asperger’s Syndrome attend regular schools with many successfully completing their secondary education. However, most Autistic children attend special schools and settings where their needs can receive intensive multidisciplinary care.
Programs usually have four main components. The aims are to increase appropriate behaviour and reduce inappropriate behaviour. Hence, activities focus on developing skills that will address disorders in-
In addition, attention is given to developing basic functional academic skills such as reading, writing and social mathematics.
Typically interventions are based on behavioural strategies. Learning techniques are used to demonstrate and increase desirable behaviours and to decrease undesirable behaviours. Interventions also concentrate on improving a child’s social and emotional coping skills.
The overall emphasis is on increasing basic social and behavioural skills and communication competencies to enable the child to participate in family life and also in society.
The management of autistic children usually requires the coordinated efforts of a team of professions including, special education teachers, psychologists, speech therapists, occupational therapists and physiotherapists. Parents and carers have a central role in the management plan.
Children with Asperger’s Syndrome also require programs that focus on their areas of need which include the same components as mentioned above. However, while special support from psychologists, speech therapists, occupational therapist and others is very important, essentially their needs are well met in regular schools. Usually the same curriculum is undertaken with modifications where necessary- often in areas such as language and communication skills and handwriting. For most children with Asperger’s Syndrome, their social and emotional needs require constant attention.
Some common situations and management suggestions-
Children with Autism Spectrum Disorders often present as being stubborn and wanting to follow their own agenda regardless of pressures to conform. The issue that they have with rules of social interaction is that they are unwritten, subtle and constantly changing in everyday life. These children tend to be very logical and willingly follow rules that are clearly explained. Clear and careful explanation and demonstration of appropriate behaviour are the best teaching strategies.
These children find the social world unpredictable and confusing. They often fail to see patterns in the daily events of every-day life so they need a framework to identify the order of regularly occurring events. They require a structured, organised program to give them a feeling of safety, security and confidence. They have considerable problems anticipating future events. They live almost entirely in the present and have less ability to learn from past events and have great difficulty anticipating the future. They sometimes rely on routines and obsessions to provide structure to an ever changing and variable world. These children need to be provided with as much information about upcoming events as possible. A visual wall chart with stickers, drawings, etc, can assist in anticipating imminent events.
Repetitive visual activities such as DVDs, computer games, board games, drawing, model building, visual exploration tasks such as Where’s Wally?, using a magnifying glass, a microscope, etc, are often successful in developing concentration, provide a calming and relaxing environment and help reduce anxiety.
These youngsters need time to complete tasks as they usually have a slower output tempo and frequently have handwriting difficulties. It is advisable to use tangible rewards for compliance or tasks well done such as stickers or stamps. They often derive little intrinsic reward from verbal compliments like “good job” or “well done” or from a friendly pat on the back.
Identifying strengths and interests provide ways to increase motivation for learning. Often these children possess intense interests in certain objects/topics-planes, trains, cars, trucks, toys, cards, animals, cartoon characters, etc. These can be used to personalise learning and hence increase task commitment, motivation and enjoyment.
These children are rarely deliberately rude, naughty or unkind. Their socially inappropriate or unacceptable behaviour often arises from their lack of understanding of other people and social situations. Limited understanding of non-verbal communication is also a major problem and can result in significant confusion. A firm but gentle and calm response is the most appropriate way to handle the situation. Try to avoid angry responses as they simply confuse them.
Some Important Developments and Issues
Overview
For a superb and comprehensive review of the literature and research the following article is highly recommended-
Meng-Chuan, L., Lombardo, M and Baron-Cohen, S. (2014). Autism. The Lancet. 383, 9920, 896-910.
Changing Concepts and Definitions
Zander and Bolte (2015) investigated the implications of changes to the DSM-5 definition of ASD. Below is a summary of their comprehensive article.
Their findings indicate that a strict application of the new DSM-5 impairment criteria might prejudice early diagnosis of ASD. They postulated that a strict application of the new impairment criterion would compromise the possibility for very young children to get an ASD diagnosis despite exhibiting the defining symptomatology. As a consequence, the ongoing development towards earlier detection and intervention of ASD may be challenged.
In the DSM-5 the significance of impairment has been further strengthened and now has the form of a mandatory defining feature. From being basically a threshold criteria in DSM-111 and DSM-1V, and conceptually intermingled with symptomatology, an explicit effort has been made in DSM-5 to separate the two dimensions from each other, even though impairment is still acknowledged as a necessary threshold criterion for many diagnoses.
In mental disorders, it is predominantly the impairment dimension that is linked to the need and/or eligibility for treatment or service. DSM-5 does not provide an explicit definition of impairment.
There is an ongoing debate on how the new DSM-5 criteria for ASD will affect the diagnosis rates. The most frequently expressed hypothesis is that the application of DSM-5 will reduce diagnostic rates for ASD-up to a third compared to DSM-1V-TR and even more at the higher functioning end of the spectrum.
Mehling et al., (2016) discussed the concept of severity of impairment of ASD in the DSM-5 definition. Their report is summarised below.
Since the first inclusion in DSM-111 (1980) severity has not been specified as part of an autism diagnosis.
To date autism severity has been informally conceptualized on the basis of language deficits, cognitive impairment, adaptive behaviour impairments and the presence of challenging behaviour such as aggression. These characteristics have been used to both stratify individuals with ASD for research and to offer information regarding prognosis to parents, caseworkers and educators.
The concept of ASD severity represents a major paradigm shift from a focus on level of impairment based on the amount of ASD symptomatology to a focus on intensity of needed support.
Clinicians will likely need to rely upon a battery of standardized measures (e.g., ADOS-2, CARS-2, RBS-R, Social Responsiveness Scale, 2nd Edition, Vineland Adaptive Behavior Scales-11) and sources of information as well as their clinical judgement to arrive at an ASD severity determination.
The DSM-5 offers the opportunity to distinguish between various subsets of children with ASD by assigning "severity ratings" based on the "severity of support needs" separately from both social communication and restrictive/repetitive behaviour symptom categories respectively.
Diagnosis of ASD
Constantino and Charman (2016) provided the following statement-
"The past decade has witnessed an explosion in scientific discovery of the causes of autism. Although so far, neither a laboratory test nor a neural signature that can reliably establish the presence of a non-syndromic ASD is available a rapidly increasing proportion of all cases-approaching the majority-can be attributed to the influence of deleterious genetic variants of combination of variants, and it is expected that understanding of the genetics of autism will play a major part in revolutionising diagnosis". (p.288).
The authors identify some key refinements that they would like to see to the diagnosis of ASD with implications for research, clinical practice, public health and policy.
Autism Spectrum Australia (2017). Fact Sheet. Is autism genetically inherited?
An excellent review of the topic with up-to-date references.
The Australian Scene
Parner et al., (2011) reported that the prevalence rate of childhood autism in Western Australia was 51.0 per 10,000 children while the diagnosis of childhood autism was 39.3 per 10,000 children.
Taylor et al., (2016) contended that there is no agreed Australian standard currently for the diagnosis of ASD despite the availability of special diagnostic services. They suspect that inconsistency in the diagnostic practices of health professionals in Australia play a causal role. Their study aimed to assess these practices across Australia by surveying all relevant professional groups.
It was concluded that the reported practice of some professionals in Australia many not be consistent with international best practice guidelines for ASD diagnosis. These findings highlight the need for a minimum national standard for ASD diagnosis throughout the country that ensures best practice regardless of the type of setting in which the service is provided.
The Overseas Scene
UK
Taylor et al., (2013) estimated the annual prevalence rates of autism for each year from 2004 -2010 were steady at approximately 3.8 per 1,000 boys and 0.8 per 1000 girls. Annual incidence rates each year were also steady at about 1.2 per 1,000 boys and 0.2 per 1,000 girls. Following a fivefold increase in the annual incidence rates of autism during the 1990s in the UK, the incidence and prevalence rates in 8-year-old children reached a plateau in the 2000s and remained steady through to 2010.
USA
A report in the Science Daily (2018) based on a study conducted at the Johns Hopkins University of Bloomberg School of Public Health, found that the prevalence of ASD is one in 59 among children aged 8 years in 2014 (or 1.7%). The gender ratio was about 5 boys to every girl. This marks a 15% increase from the most recent report two years ago and the highest prevalence since the US Centre for Disease Control and Prevention began tracking ASD in 2000. The bulk of the increase is considered to stem from a growing awareness of autism and changes to the condition's diagnostic criteria.
Denmark
Parner et al., (2011) declared that the prevalence rate of childhood autism was 68.5 per 10, 000 children while the diagnosis was 21.8. per 10,000 children.
RESOURCES
A selection of resources on ASD
Links
https://autism.ahpa.com.au
Autism Awareness Australia www.autismawareness.co.au
Resources for Teachers https://autismcrc.com.au
Tools for Professionals https://autismspeaks.org
Classroom Materials https://www.nationalautismresources.com
Autism Resource Centre www.autism.org.sg/
Autism Speaks https://www.autismspeaks.org/
National Autistic Society-UK https://www.autism.org.uk/
Autism Society of America www.autism-society.org/
Other materials
APS-Tipsheets
REFERENCES
There has been an enormous amount of research in the field of Developmental and Behavioural Problems, especially Autism Spectrum Disorder, in recent times. A sample is provided below.
Wing, L. (2005). Reflections on opening Pandora’s box. Journal of Autism and Developmental Disorders. Vol.35, No.2, April, 197-203.
Woodbury-Smith, M. (2005). Asperger’s Syndrome: A comparison of clinical diagnoses and those made according to the ICD-10 and DSM-1V. Journal of Autism and Developmental Disorders. Vol. 35, No.2, 235-240.
Kamil, M.l. (Ed.). (2006). Students with autism spectrum disorder : Effective instructional practices.
Macintosh, K. et al, (2006). Social skills and problem behaviours in school aged children with high-functioning Autism and Asperger’s Disorder. Journal of Autism and Developmental Disorders. 36: 1065-1076.
White, S.W. et al, (2007). Social skills development in children with Autism Spectrum Disorders: A review of the intervention research. Journal of Autism and Developmental Disorders. 37:1858-1868.
Assouline, S.G. et al, (2008). The paradox of giftedness and Autism. Packet of Information for Professionals. (PIP) Revised.
Bishop, D. (2008). Forty years on: Uta Frith's contribution to research on Autism and Dyslexia, 1966-2006. The Quarterly Journal of Experimental Psychology. 61, 1, 16-26.
Cederlund, M. et al, (2008). Asperger Syndrome and Autism: A comparative longitudinal follow-up study more than 5 years after original diagnosis. Journal of Autism and Developmental Disorders. 38:72-85.
Ingeborg, S et al, (2008). Asperger’s coming out of our ears: Making sense of a modern epidemic. Australian & New Zealand Journal of Family Therapy, Vol. 29, Number 1, 1-9.
Lasser, J. (2008). Constructing normalcy: A qualitative study of parenting children with Asperger’s Disorder. Educational Psychology in Practice. Vol.24, No.4, December, 335-346.
Allred, S. (2009). Reframing Asperger Syndrome: Lessons from other challenges to the Diagnostic and Statistical Manual and ICIDH approaches. Disability and Society. Vol. 24, No.3, May, 343-355.
Phetrasuwan, S. et al, (2009). Defining Autism Spectrum Disorders. Journal for Specialists in Pediatric Nursing. Vol. 14, No. 3, July. 206-209.
Reilly, C. et al, (2009). Screening for Asperger Syndrome in school-age children: Issues and instruments. Educational Psychology in Practice. Vol. 25, No.1, 37-52.
Rosenberg, R. et al, (2009). Trends in Autism Spectrum Disorder diagnoses:1994-2007. Journal of Autism & Developmental Disorders. 39:1099-1111.
Woodbury, M et al, (2009). Asperger Syndrome. European Child and Adolescent Psychiatry.18: 2-11.
Ghaziuddin, M. (2010). Brief Report: Should the DSM 5 drop Asperger Syndrome? Journal of Autism and Developmental Disorders, Sep. Vol.40, Issue 9, 1146-1148.
Kamp-Becker, I. et al, (2010). Categorical and dimensional structure of Autism Spectrum Disorders: The nosologic validity of Asperger Syndrome. Journal of Autism and Developmental Disorders. Aug. Vol.40. Issue, 8, 921-929.
Muller, R. (2010). Will you play with me? Improving social skills for children with Asperger’s Syndrome. International Journal of Disability, Development and Education. Vol. 57, Issue, 3 331-334.
Parner, R. et al., (2011). A comparison of Autism prevalence trends in Denmark and Western Australia. Journal of Autism and Developmental Disorders. 41, 12, 1601-1608.
Dunlop, G., Wilson, K., Strain, P. & Lee, J. (2013). Prevent-Teach-Reinforce for Young Children. Paul Brooks Publishers.
Rutter, M. (2013). Changing concepts and findings on Autism. Journal of Autism and Developmental Disorders. 43, 8, August. 1749-1757.
Dillenburger, K et al., (2014). Multidisciplinary teamwork in Australia: Can one size fit all? The Australian Educational and Developmental Psychologist. 31, 2, 97-112.
Meng-Chuan, L., Lombardo, M and Baron-Cohen, S. (2014). Autism. The Lancet, 383, 9920, March, 896-910.
Wheeler, J.J. (2014). Methods for Teaching Students with Autism Spectrum Disorder. Evidence Based Practices. Amazon. Kindle Edition.
Young, R. L. et al., (2014). Redefining Autism Spectrum Disorder Using DSM-5: The Implications of the Proposed DSM-5 Criteria for Autism Spectrum Disorders. Journal of Autism and Developmental Disorders. 44, 4, April. 758-765.
Sacrey, L, et al. (2015). Early Infant Development and Intervention for Autism Spectrum Disorder. Journal of Child Neurology. 30:14, 1921-1929.
Self, T. L. et al., (2015). Autism Spectrum Disorder Early Screening Practices. Communication Disorders Quarterly. 36, 4, August, 195-207.
Smith, I.C. et al., (2015). The Effects of DSM-5 Criteria on Number of Individuals Diagnosed with Autism Spectrum Disorder: A Systematic Review. Journal of Autism and Developmental Disorders. 45, 8, August, 2541-2552.
Van Schalkwyk, G. et al., (2015). Autism Spectrum Disorder: In Theory and Practice. The Psychoanalytic Study of the Child. 69, 219-241.
Zander, E., & Bolte, S. (2015). The New DSM-5 Impairment Criterion. A Challenge to Early Autism Spectrum Disorder diagnosis? Journal of Autism and Developmental Disorders. 45:11, 3634-3643.
Boroson, B.L. (2016). Autism Spectrum Disorder in the Inclusive Classroom: How to Reach and Teach Students with Autism Spectrum Disorder. Scholastic.
Constantino, J.N. et al., (2016). Diagnosis of Autism Spectrum Disorder: Reconciling the Syndrome, its Diverse Origins and Variation in Expression. The Lancet Neurology, 15, 3, March, 279-291.
Mehling, M.H. et al., (2016). Severity of Autism Spectrum Disorders: Current Conceptualization and Transition to DSM-5. Journal of Autism and Developmental Disorders. 46, 6, June, 2000-2016.
Taylor, L. et al., (2016). Diagnostic Evaluation for Autism Spectrum Disorder: A Survey of Health Professionals in Australia. British Medical Journal. 6, 9.
Hall, L.J. (2017). Autism Spectrum Disorder: From Theory to Practice. Pearson.
Postorino, V. et al., (2017). A Systematic Review and Meta-analysis of Parent Training for Disruptive Behavior in Children with Autism Spectrum Disorder. Psychology Review. 20, 4, December, 391-402.
Smith, D. (2017). Autism Spectrum Disorder. (Custom Edition). (2e). Flinders University. Pearson Australia
Stokes, M.A. et al., ( 2017). Principals' and Teachers' Reports of Successful Teaching Strategies with Children with High-Functioning Autism Spectrum Disorder. Canadian Journal of School Psychology. 32, 3-4, September, 192-208.
Carnahan, C.R. (2018). Facilitating Evidence-Based Practice for Students with Autism Spectrum Disorder: A Classroom Observation Tool for Building Quality Education.
Howes, O. D. et al., (2018). Autism Spectrum Disorder: Consensus Guidelines on Assessment, Treatment and Research from the British Association of Psychopharmocology. Journal of Psychopharmocology. 32, 1, January, 3-29.
Kaluzna-Czaplinskia, J. et al., (2018). Focus on aspects of autism. Journal of Autism and Developmental Disorders. 48, 5, 1861-1867.
Lord, C. et al., (2018). Autism Spectrum Disorder. The Lancet. 392,10146, 508-520.
Robinson, J. E. (2018). What is Autism? Psychology Today. 51,5, 48-50.
Soriano, M.F. (2018). Autism:Hard to switch from details to the whole. Journal of Abnormal Child Psychology. 46, 6, 1359-1371.
Additional information is contained in the Section-Exceptionality. While the emphasis in that Section is on students with special educational needs, relevant information is provided on the definition, identification and diagnosis of certain pervasive developmental and behavioural problems and types of anxiety. Hence, readers are advised to consult that Section.
Information on basic management skills recommended for children and adolescents is also available in the Section-Parenting.
DSM-5: Attention-Deficit/Hyperactivity Disorders
As mentioned in the Section-Exceptionality, the DSM-5 has updated information on ADHD. The new details are provided below
Diagnostic Criteria
Note: The symptoms are not solely a manifestation of oppositional behaviour, defiance, hostility or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
Note: The symptoms are not solely a manifestation of oppositional behaviour, defiance, hostility or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
Specify whether:
314.00 (F90.2) Combined presentation: If both Criterion A1 (Inattention) and Criterion A2 (Hyperactivity) are met for the past 6 months.
314.00 (F90.0) Predominantly Inattentive presentation: If Criterion A1 (Inattention) is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months.
314.01 (F90.1) Predominantly Hyperactive/Impulsivity presentation: If Criterion A2 (hyperactivity-impulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months.
Specify if:
In partial remission: When full criteria were previously met, fewer than the full criteria have been met for the past 6 months and the symptoms still result in impairment in social, academic, or occupational functioning.
Specify current severity:
Mild: Few, if any, symptoms result in no more than minor impairments in social or occupational functioning.
Moderate: Symptoms or functional impairment between “mild” and “severe” are present.
Severe: Many symptoms in excess of those required to make the diagnosis or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.
Management of Attention-Deficit Disorders
A multidisciplinary approach is essential in the management of these disorders. Medication on its own is considered not to be a sufficient treatment and psychological treatments such as behaviour therapy, family therapy and classroom management are recommended in all instances.
Psychological treatment is extremely important. The role of parents and teachers is central as they are primarily responsible for implementing the treatment program.
The main aims of psychological management are:
In the home, parents need to-
At school, teachers are advised to expect problems with attention, concentration, distractibility and therefore set short tasks that the child can handle.
Parents and teachers should find the information on child management in the Parenting Section helpful.
Some Important Developments and Issues
An Excellent Overview Article
Thapar and Cooper's report in the Lancet (2016) is a superb overview of key aspects of ADHD and research findings. It is a highly recommended source of important information.
This article provides a thorough overview of the following topics-
Definitions
Epidemiology
Early Co-morbidity
Risk Factors
Genetics
Environmental and gene-environment interplay
Pathophysiology
Biology
Cognition
Imaging
Clinical Assessment
Treatment
Prognosis
Further Research and Clinical Directions
Australia
Ghosh et al., (2017) examined cross-cultural variations in psychostimulant use for ADHD in Western Australia. They estimated that stimulant prescribing rate for ADHD rose 72% between 2000 and 2011 despite a significant community concern that ADHD is over- diagnosed and over-treated.
The authors identified significant country of birth variations as well as gender, regional and socioeconomic disparities in stimulant use for ADHD in WA. Individuals born in Africa, Asia, Middle East and South America were least likely to have stimulant treatment than individuals born in Australia, New Zealand or North America. A greater likelihood of stimulant treatment among boys, individuals living in regional areas and living with socioeconomic disadvantage was also observed. The finding highlighted the need for tailoring ADHD diagnosis, treatment and service delivery appropriate to children and adolescents from diverse cultures.
Sawyer et al., (2017) reported that between 2009 and 2012 in Australia there was a 26.7% increase in dispensing of stimulant medication for 3-to 9-year olds and 14.2% increase for 10- to 14-year olds.
Four key findings were presented-
Only a small proportion of children and adolescents in the general community were using stimulant medication and current use varied little from that reported in the first Australian National Child and Adolescent Mental Health Survey- 2002. First survey-stimulant use- 1.8%; current survey-stimulant use- 1.3%.
A minority of 4-to 17-year olds with symptoms meeting the criteria for ADHD were being treated with stimulant medication and antidepressants. Furthermore, the percentage of those with ADHD being treated with stimulant medication in 2013-2014 differed little from that identified in 1998 in Australia.
The results suggest that at a population level, the use of stimulant medication to treat children and adolescents with ADHD in Australia has not increased. The percentage of children with ADHD using stimulants in the present study is consistent with those reported in studies conducted in the US.
The majority of children and adolescents in the present survey who were using stimulant medication did not have the symptoms required to meet the criteria for a diagnosis of ADHD. However, many of the children had a high level of emotional and behavioural problems comparable to that reported for children whose symptoms met the diagnostic criteria
The Overseas Scene
UK
Beau-Lejdstrom et al., (2016) investigated trends in ADHD drug prescribing patterns in the UK. In their study, 14,748 children under 16 (85%boys) received at least one prescription of an ADHD drug between January 1992 and December 2013. Methylphenidate is by far the most used drug in children with ADHD in the UK accounting for 94% of prescriptions followed by atomoxetine, dexamphetamine and modafinil.
Among other countries such as the USA, the Netherlands and Germany, the UK shows one of the lowest estimates in ADHD drug prescribing rates in children. Although the prevalence and incidence of ADHD drug use in children have substantially increased during the past two decades, it seems that it may have reached a plateau recently. Looking at overall persistence in prescribing of ADHD drugs, children in the UK show the highest rates of ADHD drug persistence compared to other European countries and the USA. These findings may suggest that the UK prescribing practice restricts the choices of children receiving drugs ensures a better follow-up of these children.
USA
Olfson et al., (2016) reported that in the US stimulant medications are the dominant treatment for ADHD in school-aged children and adolescents. In 2010, stimulants accounted for 5.9% of all prescriptions to children (2-12 years) and 7.6% of prescriptions to adolescents (12-17 Years). In that year, methylphenidate was the single most widely prescribed medication to adolescents.
The authors claimed that stimulant treatment peaks during late childhood and early adolescence with rates that are almost three times as high for boys as girls. The rate of stimulant treatment markedly declines during late adolescence particularly for males, so that by early adulthood, males and females have comparable rates of treatment. Despite progress in developing effective psychosocial interventions for ADHD, only a small proportion of children, adolescents and young adults who are treated with stimulants receive any psychosocial services. In addition, most stimulant-treated young people in each age group do not receive their prescriptions from psychiatrists. Pediatricians prescribe stimulants to the largest share of children and adolescents with ADHD.
Canada
Hauck et al (2017) studied the prevalence and medication trends in youth with ADHD in Ontario, Canada. From more than 250,000 medical records, a total of 10,000 charts were randomly selected and reviewed. The prevalence of ADHD was 5.4% (7.9% males, 2.7% females). Individuals with ADHD had significant psychiatric comorbidities. The majority (70%) of ADHD patients received prescriptions for stimulant or non-stimulant ADHD medication. Antipsychotic drugs were provided to 11.9% of ADHD patients versus 0.9% of patients without ADHD. Antidepressant prescriptions were given to 19.8% versus 5.4% of patients with or without ADHD, respectively. Predictors of antidepressant prescriptions were increasing age, psychiatric consultation and diagnoses of both anxiety and depression, whereas the only predictor of antipsychotic prescriptions was psychiatric consultation.
Summary of Some Key Research Findings
Medication and Outcomes
While generally well tolerated, methylphenidate has been associated with a range of adverse events/reactions over both the short and medium/long term. The most common include loss of appetite, restricted growth, weight suppression, increased blood pressure and heart rate and sleep disturbances. (Kovshoff, et al., 2016; Sawyer et al., 2017).
Short-term positive effects of drug medication on motivation, attention and cognition are well documented in neuropsychological studies. (Kovshoff, et al., 2016).
While there is evidence that stimulant medication provides short term benefits for ADHD, evidence of longer benefits is weak. (Thomas et al., 2013).
Medication and School Performance
The impairments at school and in academic achievement caused by symptoms are some of the most profound and common difficulties faced by children and adolescents with ADHD (Prasad et al., 2013; Olfson, et al., 2016 ; de Zeeuw, et al., 2017; Mahone and Denkla, 2017).
Children and adolescents with ADHD often struggle both socially and academically even when treated. (Mahone and Denkla, 2017).
In school, children with ADHD are more likely to experience increased learning problems, school absences, and troublesome relationships with peers. (Mahone and Denkla, 2017).
Children with more ADHD symptoms scored lower on educational achievement than controls. (de Zeeuw, et al., 2017).
Positive effects of drug therapy for ADHD improves the school experience for children both in terms of the classroom behaviour and their academic performance (Prasad et al., 2013).
Children with ADHD medication scored significantly higher on the educational achievement test than children with ADHD who did not use medication. (de Zeeuw, et al., 2017).
Results are consistent with a direct causal effect of ADHD and educational achievement. (de Zeeuw, et al., 2017).
Children using methylphenidate still perform less at school compared to their peers. (Jurjen van der, et al., 2017).
No conclusive evidence that stimulants have beneficial effects on major associated outcome parameters, particularly school performance. (Jurjen van der, et al., 2017).
The early start of meth. treatment is associated with lower school performance compared to children starting later with treatment. (Jurjen van der, et al., 2017).
Other Important Findings/Issues
Thapar and Cooper, (2016) reported that-
ADHD is a childhood-onset disorder characterised by developmentally inappropriate and impaired attention, motor hyperactivity, and impulsivity, with difficulties often continuing into adulthood.
The disorder has a prevalence of 1.4-3.0 % with boys outnumbering girls.
Comorbidity with childhood-onset neurodevelopmental disorders and psychiatric disorders is substantial.
ADHD is highly hereditable and multifactorial: multiple genes and non-inherited factors contribute to the disorder. Prenatal and perinatal factors have been implicated as risks, but definite causes remain unknown.
Most treatment guidelines recommend a stepwise approach, beginning with non-drug interventions and then moving to pharmacological treatment in those severely affected.
Short-term benefits of stimulant medication and atomoxeline identified.
Meta-analyses of blinded trials of non-drug treatment have not yet proven efficacious.
Longitudinal studies show heightened risk of multiple mental health and social difficulties as well as premature mortality in adult life.
Resources
Some resources on ADHD
Links
APS-Kidsmatter https://kidsmatter.edu.au.
ADHD Australia https://www.adhdaustralia.org.au/
Parents’ Guide https://childmind.org/
Parents’ Guide www.parentsconnect.org.au/
Teachers’ Guide www.education.vic.gov.au/
Teachers’ Guide https://www.adhdchildhood.com/
Teachers’ Guide https://www.adhdkidsrock.com/
Teachers’ Guide https://childmind.org/
Teachers’ Pack-UK https://www.dronfield.derbyshire.sch.uk./
ADHD UK-Resources adhdkids.org.uk/
US Department of Ed. https://www2.ed.gov/
Other Material
APS-Tips Sheets
ADHD: Understanding and Managing Attention Deficit Hyperactivity Disorder (ADHD) in Children
Murdock Children’s Research Institute -The Children’s Attention Project (CAP)
Tips for managing ADHD in the classroom.
The Australian Parenting Website (raisingchildren.net.au)
Managing ADHD in children 5-11.
REFERENCES
A selection of ADHD references
Prasad, V. et al., (2013). How effective are drug treatments for children with ADHD at improving on-task and academic achievement in the school classroom? A systematic review and meta-analysis. European Child and Adolescent Psychiatry. 22, 4, 203-216.
Thomas, R. et al., (2013). Attention-deficit/hyperactivity disorder: Are we helping or harming? BMJ. 347.
Beau-Lejdstrom, R. et al., (2016). Latest trends in ADHD drug prescribing patterns in children in the UK: Prevalence, incidence and persistence. BMJ. 6, 6.
Fowler, M. (2016). The effects of ADHD on academic achievement: A meta-analysis review. ProQuest Dissertations Publishing. 3664560.
Olfson, M. et al., (2016). Stimulant treatment of young people in the United States. Journal of Child and Adolescent Psychopharmacology. 26,6, 520-526.
Thapar, A. et al., (2016). Attention deficit hyperactivity disorder. The Lancet, 387,10024, 1240-1250.
Corcoran, J et al., (2017). Parents of children with Attention Deficit/Hyperactivity Disorder: A meta-synthesis. Part 1. Child and Adolescent Social Work Journal. 34, 4, 281-335.
Corcoran, J et al., (2017). Parents of children with Attention Deficit/Hyperactivity Disorder: A meta-synthesis. Part 11. Child and Adolescent Social Work Journal. 34, 4, 337-348.
de Zeeuw, E. et al., (2017). Attention Deficit Hyperactivity Disorder symptoms and low educational achievement: Evidence supporting a causal hypothesis. Behavior Genetics. 47, 3, 278-289.
Ghosh, M. et al., (2017). Identifying cross-cultural variations in psychostimulant use for attention deficit hyperactivity disorder using linked data. Child and Adolescent Psychiatry and Mental Health. 11, 16.
Mahone, E. and Denckla, M. (2017). Attention-Deficit/Hyperactivity Disorder: An historical neuropsychological perspective. Journal of the International Neuropsychological Society. 23, 9-10, 916-929.
Hauck, T.S. et al., (2017). ADHD treatment in primary care: Demographic factors, medication trends and treatment predictors. Canadian Journal of Psychiatry. 62, 6, 393-402.
Jurjen, van der S. et al., (2017). Methylphenidate use and school performance among primary school children: A descriptive study. BMC Psychiatry. 17.
Leahy, L.G. (2017). Attention-Deficit/Hyperactivity Disorder: A historical review. (1775 to Present). Journal of Psychosocial Nursing and Maternal Health Services. 55, 9, 10-16.
Quinn, P.D. et al., (2017). ADHD medication and substance-related problems. The American Journal of Psychiatry. 174, 9, 877.
Sawyer, M.G. et al., (2017) The prevalence of stimulant and antidepressant use by Australian children and adolescents with attention-deficit/hyperactivity disorder and major depressive disorder. Journal of Child and Adolescent Psychopharmacology. 27, 2, 177-184.
Hales, C.M. et al., (2018). Trends in prescriptive medication use among children and adolescents in the United States, 1999-2014. The Journal of the American Medical Association. 319, 19, 2009.
Harmer, C.J. et al., (2018). How do drugs for psychiatric disorders work? Epidemiology and Psychiatric Science. 27, 2 141-142.
Lambek, R. et al., (2018). Are there distinct cognitive and maturational sub-groups of children with ADHD? Psychological Medicine. 48,10, 1722-1730.
Sarah, P. et al., (2018). Efficacy and safety of drugs for attention deficit disorder in children and adolescents: A network meta-analysis. European Child and Adolescent Psychiatry. 1-11.
Theule, J. et al., (2018). Children's ADHD: Interventions and parenting stress. A meta-analysis. Journal of Child and Family Studies. 27, 9, 2744-2756.
DSM-5
Disruptive, Impulse Control and Conduct Disorders
In the DSM-5, there is a separate Chapter on Disruptive, Impulsive-Control and Conduct Disorders. Disorders relevant to this Section include-
Disruptive, impulse-control and conduct disorders include conditions involving problems in self-control of emotions and behaviours. Problems are manifested in behaviours that violate the rights of others (e.g., aggression, destruction of property) and/or that brings the individual into significant conflict with social norms or authority figures. The underlying causes of the problems in the self-control of emotions and behaviours can vary greatly across the disorders in this chapter and among individuals within a given diagnostic category.
Oppositional Defiant Disorder
A pattern of angry/irritable mood, argumentative/defiant behaviour, or vindictiveness lasting for at least 6 months as evidenced by at least four symptoms from any of the following categories exhibited with at least one individual who is not a sibling.
Angry/Irritable Mood
1.Often loses temper
2.Is often touchy or easily annoyed
3.Is often angry or resentful
Argumentative/Defiant Behaviour
4.Often argues with authority figures or for children and adolescents, with adults
5.Often actively defies or refuses to comply with requests from authority figures or with rules
6.Often deliberately annoys others
7.Often blames others for his or her mistakes or misbehaviour
Vindictiveness
8.Has been spiteful or vindictive at eat twice within the past 6 months
Management of Oppositional-Defiant Disorder
The suggestions provided in the Section-Parenting are appropriate.
Conduct Disorder
The DSM-5 adds a descriptive features specifier to the diagnosis of Conduct Disorder for individuals who meet the full criteria for the disorder and who also present with limited prosocial emotions, such as limited empathy and guilt. The specifier applies to those individuals with a more serious pattern of behaviour characterised by a "callous and unemotional" interpersonal style across multiple settings and relationships. Individuals with conduct disorder who meet the criteria for the specifier have a relatively more severe form of the disorder and a different treatment response.
Management of Conduct Disorder
Many treatments produce short-term relief of symptoms but improvements usually are short-lived.
Individual counselling is difficult and ineffective in most cases because these young people lack remorse and typically believe they have done nothing wrong. Once established the behaviours are very resistance to change.
The more promising treatments are problem solving skills training, parenting skills training, functional family therapy and multisystemic therapy.
A close ongoing working relationship between the family and the therapist offers the best chances of success. Unfortunately for many of these children, if they have a family at all, it is often disorganised, neglectful or abusive.
Placement in a residential setting may be required.
It is clear that prevention is the best way of dealing with Conduct Disorders. Parents and teachers should be assisted to identify the early signs of such behaviour during early childhood and the first years of school and to seek and persist with treatment to address such behaviours. The most useful early intervention at that stage is parenting skills training.
Other Sections also contain material relevant to the identification and treatment of developmental and behavioural disorders in children and adolescents. These include-
Selected Disorders from the Categories-Pervasive Developmental Disorders and Attention-Deficit and Disruptive Behaviour Disorders as well as some prominent Emotional Disorders, will be discussed below.
SELECTED EMOTIONAL DISORDERS IN CHILDREN AND ADOLESCENTS-
IDENTIFICATION AND MANAGEMENT
Some of the major disorders classified in the DSM-1V-TR
Anxiety Disorders
Selected Emotional Disorders
Children with emotional disorders may appear unhappy, sad, frightened or worried. In pre-pubertal children, the prevalence of emotional disorders is approximately equal amongst boys and girls: after puberty, emotional disorders become more common in females. Young people with emotional disorders represent about half of those seen in child and adolescent mental health services.
Anxiety Disorders
Apprehensions and fears are normal and more common during childhood and adolescence. Infants are frightened by loud noises, falling and strangers. Children aged one to two years are scared when separated from their parents. Later on, children are fearful of the dark, animals, storms, strange imaginary beasts and monsters. From the age of 7 or 8 years, children begin to worry about their academic performance and their interpersonal relationships-especially girls. Adolescents are concerned about being accepted, disliked, rejected or criticised by their peers.
The type of fears experienced at each stage of development is largely a reflection of the intellectual and emotional growth of the child at that point in time. An anxiety disorder is likely if fears become intense or pervasive and cause significant impairment in functioning.
Anxiety disorders are frequent in young people. Their onset is often during childhood or adolescence and they can follow a chronic, fluctuating course. All the anxiety disorders occurring in children, adolescents and adults have similar, although not, identical symptoms, with the exception of separation anxiety which is peculiar to children and adolescents. Anxiety disorders are not easily recognised in young people because they know that their fears are often groundless and so try to conceal them.
Traditionally, a differentiation has been made between emotional disorders specific to childhood and adolescence and adult-type neurotic disorders. The majority of children with emotional disorders go on to become normal adults: only a minority show neurotic disorders in adult life. Many emotional disorders in childhood seem to constitute exaggerations of normal developmental trends rather than phenomena that are qualitatively abnormal in themselves. The emotional disorders of childhood are less clearly demarcated into supposedly specific entities such as phobic disorders or obsessional disorders.
Generalised Anxiety Disorder
In line with DSM-1V-TR classification of Anxiety Disorders, the category of Generalised Anxiety Disorder includes Overanxious Disorder in Childhood.
The essential feature is anxiety, which is generalised and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstance (i.e., it is “free-floating”). As in other anxiety disorders, the dominant symptoms are highly variable but complaints of continuous feelings of nervousness, trembling, muscular tension, sweating, light-headedness, palpitations, dizziness are common. Fears that the sufferer will become ill or a parent or relative will shortly become ill or have an accident are often expressed, together with a variety of other worries and forebodings. Its course is variable but tends to be fluctuating and chronic.
The sufferer must have primary symptoms of anxiety most days for at least several weeks at a time, and usually for several months. These symptoms should usually involve elements of:
Apprehensiveness (worries about future misfortunes, feeling “on edge”, difficulty in concentrating, etc.)
Motor tension (restless fidgeting, tension headaches, trembling, inability to relax)
Automatic over-activity (light-headedness, sweating, epigastric discomfort, dizziness, dry mouth etc.)
The intensity, duration or frequency of the anxiety and worry is well out of proportion to the actual likelihood or impact of the feared event. The person finds it difficult to keep worrisome thoughts from interfering with attention to tasks at hand and has difficulty stopping worrying.
In children and adolescents with Generalised Anxiety Disorder, the anxieties and worries often concern the quality of their performance or competence at school or in sporting events even when their performance is not being evaluated by others. There may be excessive concerns about punctuality. They may also worry about catastrophic events such as earthquakes or cyclones etc. Children may be overly conforming, perfectionistic and unsure of themselves and tend to redo tasks because of excessive dissatisfaction with less-than-perfect performance. They are typically overzealous in seeking approval and require excessive reassurance about their performance and their other worries. Recurrent somatic complaints may be prominent.
Separation Anxiety Disorder
It is normal for toddlers and preschool children to show some anxiety over real or threatened separation from people to whom they are attached. Separation Anxiety Disorder should be diagnosed only when fear over separation constitutes the focus of the anxiety and when such anxiety arises during the early years. It is differentiated from normal separation anxiety when it is associated with significant problems in social functioning. In addition, the diagnosis requires that there should be no generalized disturbance of personality development or functioning.
The key diagnostic feature is a focussed excessive anxiety concerning separation from people to whom the child is attached- usually parents or other family members.
The anxiety may take the form of:
An unrealistic, consuming worry about possible harm happening to parents or a fear that they will leave and never return.
An unrealistic, preoccupying worry that some untoward event, such as the child being lost, admitted to hospital or killed, will separate them from parents.
Persistent reluctance or refusal to go to school because of a fear about separation (rather than for other reasons such as fear about events or experiences at school). Becoming physically ill or complaining about some illness in the morning when they are due to leave for school (e.g., headaches, stomach pains, vomiting). Monday mornings and the period immediately following school holidays are usually the worst times for these happenings or complaints.
Excessive difficulty coping with parents going out. If their parents do go out, they may require considerable reassurance and need to know every single detail about the outing.
Persistent reluctance or fear of going to sleep without being near or next to a parent. Difficulty going off to sleep or needing the company and comfort of a parent when going to bed. Some older children and adolescents with separation anxiety still share a bed with their parents.
Reluctance to sleep over at friends’ places or attend school camps.
Persistent, inappropriate fear of being alone.
Excessive, recurrent distress in anticipation of, during, or immediately following separation from a parent.
Separation Anxiety is different from school refusal or school phobia. With school refusal the major problems arise from issues at school-e.g., social stresses such as restricted peer relationships, interpersonal problems, bullying, poor academic achievement, learning problems and low self-esteem as a learner.
Management of Separation Anxiety Disorder
The onset of separation anxiety is often triggered by a worrying or traumatic incident such as an illness or death in the family, a separation or divorce, a change of school or a minor illness that keeps young people at home for a few days. The disorder can also emerge out of the blue. There may be a family history of anxiety problems. It is common for at least one parent of a child with separation anxiety disorder to be highly anxious.
It is important for parents to realise that facing fear or uncertainty, while initially distressing, reduces anxiety, whereas avoidance increases it. Intense anxiety is mainly confined to the time immediately before the parent-child separation- parents going out for the evening, the child going to school, etc.
It helps to have a set routine and to be firm about the separation. Excessive reassurances also need to be avoided as they can reinforce the child’s belief that their concerns for their parents’ welfare are legitimate.
I find Maslow’s Need Hierarchy helpful in explaining the importance of a child feeling safe and secure. The model on pages 52-56 outlines the positive and negative consequences when the need for safety is satisfied and not satisfied. The negative consequences include- instability, insecurity, uncertainty, distress, worry, anxiety, fear, obsession, compulsion.
Phobias
Specific Phobia
The essential feature of Specific Phobia is marked and persistent fear of clearly discernible, circumscribed objects or situations. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response. This response may take the form of a situationally bound or situationally predisposed Panic Attack. Although adolescents and adults with this disorder recognise that their fear is excessive or unreasonable this may not be the case with children. Most often the phobic stimulus is avoided, although it is sometimes endured with dread. The diagnosis is appropriate only if the avoidance, fear or anxious anticipation of encountering the phobic stimulus interferes significantly with the person’s daily routine, occupational functioning or social life. Or if the person is markedly distressed about having the phobia.
Anxiety is almost invariably felt immediately on confronting the phobic stimulus.
In children, the anxiety may be expressed by crying, tantrums, freezing or clinging. Children often do not recognise that the fears are excessive or unreasonable and rarely report distress about having the phobias. Fears of animals, strangers, clowns, storms and other objects in the natural environment are particularly common and are usually transitory in childhood. A diagnosis of Specific Phobia is not warranted unless the fears lead to clinical impairment (e.g., unwillingness to go to school if dark clouds are about and a storm is imminent).
Social Phobia
The essential feature is a marked and persistent fear of social or performance situations in which embarrassment may occur. Exposure to the social or performance situation almost invariably provokes an immediate anxiety response. Although adolescents and adults with this disorder recognise that their fear is excessive or unreasonable, this may not be the case with children.
In children crying, tantrums, freezing, clinging or staying close to a familiar person and inhibited interactions to the point of mutism may be present. Young children may appear excessively timid in unfamiliar social settings, shrink from contact with others, refuse to participate in group play, typically stay on the periphery of social activities, and attempt to remain close to familiar adults. Unlike adults, children with Social Phobia, usually do not have the option of avoiding feared situations altogether and may be unable to identify the nature of their anxiety. There may be a decline in classroom performance, school refusal or avoiding age-appropriate social activities and dating. To make the diagnosis in children there must be evidence of a capacity for social relationships with familiar people and the social anxiety must occur in peer settings, not only in interactions with adults. Social Phobia typically has an onset in the mid-teens, sometimes emerging out of a childhood history of social inhibition or shyness.
Obsessional Compulsive Disorder
According to the DSM-1V-TR, OCD is characterised by recurrent obsessions and/or compulsions that interfere considerably with daily functioning. Obsessions are persistent ideas, thoughts, impulses or images that are experienced as intrusive and inappropriate and cause marked anxiety or distress. The most common obsessions are repeated thoughts about contamination, repeated doubts, a need to have things in a particular order, aggressive or horrific impulses and sexual imagery.
Compulsions are repetitive behaviours or mental acts the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification. The most common compulsions involve washing and cleaning, counting, checking, requesting or demanding assurances, repeating actions and ordering.
Onset is usually in childhood or early adult life.
Presentations of OCD in children are generally similar to those in adulthood. Washing, checking and ordering rituals are particularly common in children. Children generally do not request help; the problem is usually identified by parents. Gradual declines in schoolwork secondary to impaired ability to concentrate have been reported. Like adults, children are more prone to engage in rituals at home than in front of peers, teachers or strangers.
Post-Traumatic Stress Disorder
The essential feature is the development of characteristic symptoms following exposure to an extremely traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury or threat to one’s physical integrity; or witnessing an event that involves death, injury or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate. The person’s response to the event must involve intense fear, helplessness or horror or in children, the response must involve disorganised or agitated behaviour. The disturbance must cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
In younger children, distressing dreams of the event may, within several weeks, change into generalised nightmares of monsters, of rescuing others, or of threats to self or others. Young children usually do not have the sense that they are reliving the past; rather the reliving of the trauma may occur through repetitive play. Children may also exhibit various physical symptoms, such as stomachaches and headaches.
DSM-5 Changes: Anxiety Disorders
The DSM-5 has a separate Chapter on "Anxiety Disorders". These include disorders that share features of excessive fears and anxiety and related behaviour disturbances. Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat. Obviously these two states overlap but they also differ, with fear more often associated with surges of autonomic arousal necessary for fight or flight, thoughts of immediate danger and escape behaviour and anxiety more often associated with muscle tension and vigilance in preparation for future danger and cautious or avoidant behaviours includes-
Anxiety Disorders
It is important to note that Obsessional Compulsive Disorder is not included in the Anxiety Disorders but in a separate Chapter. See below.
Managing Anxiety in Children and Adolescents
The recommendations are taken from the following guides-
Rapee, R.M., Spencer, S.H., Cobham, V., & Wignall, A.M. (2000). Helping Your Anxious Child: A Step-by-Step Guide for Parents. Oakland, CA: New Harbinger.
Spencer, E.D., DuPont, R.L., & DuPont, C.M. (2004). The Anxiety Cure for Kids: A Guide for Parents. New York: Wiley.
Three techniques are mentioned-
1. Progressive Muscle Relaxation (PMR)
This is a technique where a person progressively tenses the muscle groups in the body and then relaxes them. This teaches the difference between feeling tense and feeling relaxed. (Extensive notes on Learning to Relax are available in this Section under Adults with Anxiety-Management).
2. Breathing and Imagery
A person learns how to breathe in an even, gentle manner while picturing a relaxing scene or event to help reduce feelings of anxiety.
(Notes on Slow Breathing exercises are provided in this Section under Adults with Anxiety-Management).
3. The Detective Technique
When a person becomes anxious it is important that they learn ways of coping rather than relying on others to constantly reassure them. This technique helps to problem-solve the situation which is causing anxiety. The anxiety can be understood by asking the following questions-
What am I worried about?
Someone breaking into the house when I am asleep.
What is the evidence?
I have slept through the nights lots of times and no one has ever broken in. Nothing like this has happened before.
What is my calm thought?
I am safe in my house, nothing bad is likely to happen.
Some General Strategies
Praise, compliment and reward courageous, confident, non-anxious behaviour.
Try to minimise giving attention to the anxious behaviour and direct the child into a more productive activity giving praise for the activity without acknowledging the anxiety.
Gentle, positive, encouragement for the child to confront anxiety-inducing situations.
Role-playing and relaxation techniques have proven useful.
Try to deal with the child’s anxious behaviour in a calm, compassionate, empathetic manner.
Demonstrate and model non-anxious behaviour so that the child can learn how to respond appropriately to anxiety inducing situations.
Remember. Often family factors can have an association with the development and maintenance of childhood anxiety. These factors include parental anxiety and depression, family conflict, marital discord and parental reinforcement of avoidance coping strategies, negative feedback and parental restrictions. Young people can learn both effective and ineffective ways of coping with anxiety by observing family members managing their own anxiety.
DSM-5 Changes: Obsessive-Compulsive Disorders
The DSM-5 includes a new Chapter on Obsessive-Compulsive and Related Disorders. Disorders grouped in this Chapter have features in common such as an obsessive preoccupation and repetitive behaviours. The disorders in this new Chapter include obsessive-compulsive disorder, body dysmorphic disorder and trichotillomania (hair-pulling disorder, as well as two new disorders: hoarding disorder and excoriation (skin picking) disorder.
Obsessive-Compulsive and Related Disorders include several disorders, the most relevant for my website being Obsessive -Compulsive Disorder (OCD). OCD is characterised by the presence of obsessions and/or compulsion. Obsessions are recurrent and persistent thoughts, urges or images that are experienced as intrusive and unwanted, whereas compulsions are repetitive behaviours or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
DSM-1V-TR: Mood Disorders: Depressive Disorders
Major Depressive Episode and Major Depressive Disorder
Depression is a mood state that is characterised by significantly lowered mood and loss of interest or pleasure in activities that are normally enjoyable. Such depressed mood is a common and normal experience. However, a major depressive episode can be distinguished from this “normal” depression by its severity, persistence, duration and the presence of characteristic symptoms (e.g., sleep disturbance).
Diagnostic Criteria
Depressed mood and/or loss of interest or pleasure in life activities for at least 2 weeks and at least five of the following symptoms that causes clinical signs of impairment in social, work or other important areas of functioning almost every day.
The most common emotional, behavioural and physical symptoms of a major depressive episode are listed below-
The overall depressed mood is relatively constant from one day to the next, although the mood may vary somewhat during the course of the day. A pattern is often present in which mood becomes better as the day progresses.
According to ICD-10, a major depression can be coded according to severity and the presence of psychotic features or somatic (melancholic) features. The severity of the disorder can be classified as mild, moderate or severe depending on the level of functional impairment-everyday activities, occupational or social functioning.
DSM-1V-TR considers that the core symptoms of a Major Depressive Episode (lasting at least two weeks) are the same for children and adolescents, although it is suggested that the prominence of characteristic symptoms may change with age. Certain symptoms such as somatic complaints, irritability and social withdrawal are particularly common in children, whereas psychomotor retardation, hypersomnia and delusions are less common in prepuberty than adolescence and adulthood. In prepubertal children, Major Depressive episodes occur more frequently in conjunction with other mental disorders (especially Disruptive Behaviour Disorders, Attention-Deficit Disorders and Anxiety Disorders) than in isolation. In adolescence, Major Depressive Episodes are frequently associated with Disruptive Behaviour Disorders, Attention-Deficit Disorders, Anxiety Disorders, Substance Abuse Disorders and Eating Disorders.
Dysthymic Disorder
Bipolar Episode and Bipolar Disorder
DSM-5 Changes: Depressive Disorders
The DSM-5 Chapter on Depressive Disorders includes Disruptive Mood Dysregulation Disorder (DMDD), major depressive disorder (including major depressive episode) persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, substance/medication induced depression, depressive disorder due to another medical condition, other specified depressive disorder and unspecified disorder. Unlike in DSM-1V, this Chapter "Depressive Disorders", has been separated from the previous Chapter, "Bipolar and Related Disorders". The common feature of all of these disorders is the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive change that significantly affect the individual's capacity to function. What differs among them are issues of duration, timing or presumed etiology.
As indicated above, the DSM-5 has included Disruptive Mood Dysregulation Disorder as a Depressive Disorder. The core feature of disruptive mood dysregulation disorder is chronic, severe persistent irritability. The severe irritability has two prominent clinical features, the first of which is frequent temper outbursts. These outbursts typically occur in response to frustration and can be verbal or behavioural (the latter in the form of aggression against property, self or others). They must occur frequently (i.e., on average, three or more times per week).
DIAGNOSTIC CRITERIA
Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event of its anticipation, should not be considered as a symptom of mania or hypomania.
Comment: As mentioned elsewhere, the DSM-5 has been attacked for expanding the range of mental health issues that are classified as disorders. For example, considerable controversy has surrounded the inclusion of Disruptive Mood Dysregulation Disorder, which it is claimed essentially makes children’s temper tantrums a mental illness.
Psychological Treatment of Disorders
Nathan and Gorman (2002, 2007) provide a helpful classification of treatments. The main types of psychological interventions that have been used with children and adolescents with developmental and behavioural disorders include the following-
Cognitive-Behavioural Therapy (CBT)
CBT is well established as an effective treatment for a range of disorders. This approach utilises a combination of cognitive and behavioural techniques to target an individual’s symptoms. The focus is on teaching a person how to control their symptoms, correct faulty thinking patterns and manage their own disorder. Ideally, at the end of treatment a client should be able to use the strategies they have been taught to deal with any future problems and possible return of symptoms.
Cognitive Interventions
These treatments are predicated on the proposition that the way a person interprets or appraises a situation is based on their past experiences and that this focus influences how they think and subsequently feel. This approach contends that modifying the way a person thinks will change the way they interpret a situation which should then lead to a subsequent change in behaviour. For example, a person with depression will often have a number of negative thoughts which are a classic “cognitive symptom”. Although treating some of the symptoms of depression using behavioural techniques (e.g., activity scheduling) will be effective, it is also important to focus directly on this cognitive symptom.
The A-B-C model developed by Ellis (1975) is often used to explain the influence on the way we think, on the way we feel and behave.
Activating Event (A) Belief or Reaction to Event (B) Emotional Consequences (C)
It is commonly assumed that (A) leads directly to (C). However, in most cases, it is a person’s reaction or thoughts in response to an event (B) that influences how they feel.
Beliefs and what we say to ourselves (i.e., “self-talk”) have a very strong influence on how we feel. Thus, the aim of cognitive therapy is to teach a client how to modify their beliefs (B) about an event in order to change their emotional reaction (C). The next step, often referred to as (D) in this model, is when the client learns to challenge their negative thoughts and substitute these with more rational beliefs. The end result is (E), a new emotional effect or consequence.
Care needs to be taken when using these approaches with children and adolescents as their effectiveness is very dependent on their ability to think and reason. Hence, factors such as the level of intellectual, language and communication skills must be taken into consideration.
Behavioural Interventions
These techniques are used to decrease dysfunctional or problem behaviour or to increase or learn desirable or functional behaviour. It is particularly effective in treating externalising disorders and for developing prosocial and basic living skills in children and adolescents.
Behaviour modification commences with a thorough behavioural analysis which involves specifying and measuring the behaviours to be altered and identifying the antecedents and consequences controlling these behaviours. This analysis is followed by a systematic program which may include altering the stimulus triggering the unwanted behaviour, shaping up new adaptive (competing) behaviour and contingency management (using reinforcers for increasing desirable and consequences to decrease the unwanted/dysfunctional behaviour).
After changing particular behaviours, techniques for generalisation and maintenance are discussed along with relapse prevention.
Exposure Techniques
Exposure techniques are used for all the anxiety disorders, particularly the phobias. Essentially, exposure involves confronting the feared situation/event/ activity so that the fear decreases or ideally is extinguished.
Graded exposure is the most commonly used technique. It involves identifying a client’s fears and constructing a hierarchy of the least to the most feared situations. A graded approach is necessary because of the fear it provokes and few individuals would be willing to confront this immediately and directly when commencing treatment.
Hence the individual enters the anxiety provoking situations in graded steps so that anxiety is evoked but not overwhelmingly so. The person is then instructed to remain in the situation until their anxiety decreases. By staying in the situation until the fear subsides, the person learns that their fear is groundless.
Systematic desensitisation is similar in that it involves exposure to a hierarchy of feared objects or situations (often in imagination) while using slow breathing and/ or relaxation techniques and cognitive coping self-statements to cope with the anxiety experienced.
Activity Scheduling
This technique is mainly used to assist clients with depression. Activity scheduling is a useful strategy for clients who have lost interest in doing things that they enjoy and who find it difficulty to undertake basic daily tasks. It is particularly important to increase pleasurable activities when people feel depressed, as they feel less inclined to engage in activities that are a source of pleasure and satisfaction. Similarly, when people are not involving themselves in activities that they consider pleasant, this can make them feel depressed. This creates a vicious cycle and in order to break this pattern of inactivity clients need to learn how to keep active when they feel down. Activity scheduling is a behavioural technique designed to mobilise the client and to increase the range and frequency of pleasant activities in which they are engaged. The overall aim is to teach clients how to increase their activities in a structured and organised manner, thereby improving their mood. Activity is the key and mastery of tasks, pleasant activities or exercise, should be reinforced.
Psychoeducation
This approach involves explaining the disorder to the client and answering the client’s questions about the disorder. Typically, the information is provided at the appropriate level and this includes education about how common is their disorder, what symptoms they have, any complications or other problems, what causes it, what will happen in the long term, what treatments work and what are the potential positive and negative consequences of those treatments. It is also useful to supplement this discussion with a handout that the client can read and refer to as needed. While helpful with some children and adolescents, care must be taken in determining how much information they can meaningfully assimilate and understand. With young people, their parents are usually actively involved in their management and treatment programs and hence an understanding of their youngster’s condition is vitally important.
Social Skills Training (SST)
SST uses the principles of behaviour therapy to teach social skills, communication skills and independent living skills. Skills are broken down into several discrete steps. After reviewing the steps of the skill, the therapist usually models the skill by demonstrating a role-play. The client then does a role-play to learn and practise the skill. The therapist provides constructive feedback after each role-play and the client is given the opportunity to practise the skill several times. Repeated practice and “overlearning” of skills are important aspects of SST. Duration, frequency and exact content of SST interventions depend on the needs of the client.
The rationale for SST is based on the belief that people with certain disorders including Autism Spectrum Disorder, Conduct Disorder, Oppositional Defiant Disorder are deficient in social and/or communication skills and that these need immediate attention if their condition is to improve.
Parent Management Training
The work of Alfred Adler has been used to inspire the development and use of parenting programs for many years. The STEP (Systematic Training for Effective Parenting) program and the numerous “derivations” have been extremely popular with both parents and teachers. While these programs focus on the management of the behaviour of children and adolescents generally, they also are extremely helpful in managing behavioural and developmental disorders in young people. Details of such programs are provided in the Parenting Section.
Relaxation Techniques
Such techniques often supplement the main thrust of treatment. For further details see below on pages 63-68.
Other Sections also contain material relevant to the identification and treatment of developmental and behavioural disorders in children and adolescents. These include-
STRESS AND ANXIETY IN ADULTS:
IDENTIFICATION AND MANAGEMENT
Defining Stress
Maslow’s Hierarchy of Needs
A Model of Stress
Management of Stress
Defining Anxiety
Management of Anxiety
Defining Stress
Stress is a part of everyone’s life and a source of difficulty for many.
Basically, STRESS refers to the application of some force or pressure to something. Some force is needed to get moving, whether it is a basic need such as hunger or thirst or a more complex human need or desire such as belonging, self-esteem or understanding or creating.
A useful paradigm to understand human needs and the consequences of unfulfilment and stress is provided in Maslow’s Hierarchy of Needs. (See details below).
There is a relationship between the level of drive, need or arousal, ranging from low to high and performance and wellbeing, ranging from high to low. At very low levels of need or arousal, an individual is under-stimulated and undermotivated. More stimulation may be needed. Both quality of performance and wellbeing are low. Examples of this are people in boring, monotonous, unfulfilled, repetitive jobs, with little or no control over what they do or how they do it.
People in these situations will show all of the usual signs of too much stress and often try to cope by avoiding work, or smoking, eating, drinking excessively.
At very high levels of need or arousal, a person can become over-stimulated and typically subjected to conflicting motivations and demands. An excess of stimulation usually results in a declension in both performance and wellbeing. Examples of this situation are people who have high-performance occupations which make too many, often competing demands on them but who have little control over what they do or how they do it.
This is typically the case of many professions. Often it occurs as a result of ever-commitment, resulting from a basic inability to refuse unreasonable requests. People in this state of over-arousal show the usual signs of too much stress:
They may try to cope with it through health threatening or reducing behaviours. Smoking, eating or drinking too much and excessive use of other drugs, prescribed or not. These are the indirect attacks of stress on physical health.
Effective stress management is aimed at helping a person control or at least minimising their stress, as much as it is possible and using the stress positively to perform and feel at their best. Obviously, stress can not be eliminated from life; at best it can be minimised.
To maximise wellbeing, satisfaction and enjoyment, a middle position between too much and too little stress is considered appropriate. Achieving the right balance between beneficial, helpful and positive arousal and unpleasant, harmful, negative arousal is the challenge.
FIVE COMPONENTS OF THE STRESS PROCESS
THOUGHTS BEHAVIOUR
STRESSORS
PHYSIOLOGICAL SIGNS FEELINGS
This conceptual paradigm identifies five components of STRESS: the stressors and the four symptoms of stress.
Stressors
These are the sources of the stress that place demands on an individual’s coping skills. They can stem from an increase or decrease in demands, events and situations, e.g.,
Real
Imagined
Thoughts
An event or situation only becomes a stressor because of our thoughts. While some thoughts are realistic or rational, some thoughts are unrealistic or irrational. Unrealistic, exaggerated and distorted thinking plays a major role in stress. Thoughts will determine whether the situation becomes “good” stress or “bad” stress. The constructive power of positive thoughts is challenged by the destructive power of negative thoughts.
Physiological Responses
Our body reacts to a stressor with basically a constant set of physiological changes called the General Adaptation Syndrome (GAS). These are the body’s attempts to adapt to the increased load of coping with the stressor and include changes in-
Basically, our body is preparing itself to either “fight” or “flee” the stressor.
Feelings
Emotional response to the stressor can be either good or bad.
“Good” stress or positive feelings include-
“Bad” stress or negative feelings include-
Because most people believe that there is something wrong with feeling “bad”, these feelings themselves can act as stressors. When people get upset with themselves for feeling upset, their stress is increased. Many people attempt to eliminate their bad feelings by smoking, over-drinking, taking drugs, over-eating or by denying that they feel bad. This accounts for much stress related illness.
Behaviour
When discussing stress, behaviour can be classified in terms of “fight” or “flight”.
Fight behaviours include positive and constructive attempts to cope with a stressor and to solve any resulting problems. They can also include aggressive verbal or physical responses. Aggression can be passive, too, like sulking, ignoring people or refusing reasonable requests.
Flight or Flee behaviours can literally mean escaping from the situation, by walking out; or by deliberately avoiding a situation. Both escape and avoidance can reduce stress in the short-term and may sometimes be appropriate choices. But sometimes they result in such major restrictions that they cause even greater stress in the long-term.
Some people try to escape from their stress biochemically by taking their favourite “drug”. Unfortunately, these health-threatening substances are sometimes openly marketed as being stress-reducing.
Stress is an Interaction
The five components of the stress process interact with and influence each other. For instance-
If you are already in a bad mood, you are more likely to see an event as a stressor.
If you are run down physically, you are less likely to expect to cope with a new demand.
If you see yourself handling a situation well, you are more likely to expect to cope.
If you react aggressively to a stressful situation, you may influence others in the situation to be aggressive towards you, increasing the demands on you.
If you know that you have habitually avoided a particular situation in the past, you are unlikely to expect to cope with it next time.
Maslow’s Hierarchy of Needs
I have found the work of Maslow (1962, 1968) extremely helpful in explaining some of the behavioural/emotional challenges and problems experienced by children, adolescents and adults.
Maslow (1962) proposed a theory of motivation based on a hierarchy of needs. He argued that the individual progresses through a series of stages/levels. Only when needs are gratified at a particular level is the individual motivated to move on to the next higher level. The progression begins with basic needs and moves towards the higher needs.
The needs are as follows-
Some people are so focussed trying to satisfy the basic needs of, say safety and love, that they have hardly any energy or motivation to reach the higher level needs such as self-esteem and self-actualisation.
What are we doing in our schools and homes to make the attainment of higher- level needs a reality?
For instance, today many children and adolescents do not feel safe and secure in their environment and hence are likely to experience the negative consequences as outlined below. Likewise, for some the social/love needs are not satisfied resulting in the negative consequences of rejection, worthlessness, loneliness and isolation.
Before such children can progress to the important higher self-esteem needs, satisfied through schooling, learning and achievement, the fulfilment of the basic needs must be addressed.
The first table below provides an overview of Maslow’s theory. The second table, while mainly focussing on social/ emotional needs, also identifies our higher-order needs and shows the positive and negative consequences when needs are fulfilled or unfulfilled. It is contended that unfulfilled needs can result in STRESS and ANXIETY and other negative consequences.
MASLOW’S THEORY OF HUMAN MOTIVATION:
A HIERARCHY OF NEEDS
BASIC NEEDS
PHYSIOLOGICAL NEEDS
∙ OXYGEN
∙ FOOD
∙ WATER
∙ WARMTH
∙ SLEEP/REST
SAFETY NEEDS
∙ SHELTER
∙ SECURITY
∙ STABILITY
LOVE NEEDS
∙ ATTENTION
∙ AFFECTION
∙ BELONGING
HIGHER NEEDS
SELF-ESTEEM NEEDS
∙ KNOWLEDGE-UNDERSTANDING
∙ LEARNING-ACHIEVEMENT
∙ CAPABLE
∙ USEFUL
∙ SELF-WORTH
∙ SELF-RESPECT
∙ SELF-CONFIDENCE
SELF-ACTUALISATION NEEDS
∙ SELF-FULFILMENT
∙ BECOMING SELF
∙ FULLY FUNCTIONING
AN OVERVIEW OF CHILD/ADOLESCENT BEHAVIOUR
UNDERSTANDING BASIC SOCIAL/EMOTIONAL NEEDS
DOMAINS | NEEDS | CONSEQUENCES | |
|
| POSITIVES | NEGATIVES |
SOCIAL / EMOTIONAL | SAFETY |
|
|
|
| STABILITY | INSTABILITY |
|
| SECURITY | INSECURITY |
|
| POISE | STRESS |
|
| COMFORT | FEAR |
|
| CALM | OBSESSION |
|
| PREDICTABILITY | COMPULSION |
|
|
|
|
| SOCIAL | IDENTITY | ISOLATION |
|
| AFFILIATION | LONELINESS |
|
| BELONGING | ANXIETY |
|
| DEPRESSION | |
|
|
| |
| LOVE | AFFECTION | ANXIETY |
| ATTENTION | DEPRESSION | |
|
| INTIMACY | OUTSIDER |
|
| REJECTION | |
|
| AGGRESSION | |
|
|
| CONDUCT/ |
|
|
| DISORDERS |
|
|
| WITHDRAWAL |
|
|
| EMPTINESS |
|
|
| |
HIGHER NEEDS | |||
|
|
|
|
SELF-ESTEEM |
|
|
|
| KNOWLEDGE |
|
|
| UNDERSTANDING |
|
|
| LEARNING |
|
|
| ACHIEVEMENT |
|
|
| MASTERY |
|
|
|
| COMPETENT | FAILURE |
|
| CAPABLE | INFERIORITY |
|
| USEFUL | DISCOURAGEMENT |
|
| ENCOURAGED | USELESS |
|
| SELF-WORTH | INCOMPETENT |
|
| SELF-RESPECT | LEARNED/ |
|
| CONFIDENT | HELPLESSNESS |
SELF-ACTUALISATION |
|
|
|
| CURIOSITY |
|
|
| MASTERY |
|
|
| CREATIVE |
|
|
| FULFILMENT |
|
|
|
| REALISING POTENTIAL | ALIENATION |
|
| PEAK EXPERIENCES |
|
|
| CREATIVE LIVING |
|
Management of Stress
Stress can be managed or minimised in various ways.
Changing Your Stressors
Work
Relationships
Life Style
Developing new interests, activities, hobbies or skills.
Changing Thoughts
The challenge is the identification of irrational thoughts and the adoption of rational thoughts.
Some common, irrational thoughts
I must be loved or at least liked and approved by ever significant person I meet.
I must be completely competent, make no mistakes and achieve in every possible way, if I am to be worthwhile.
Some people are bad, wicked or evil and they should be blamed and punished.
It is absolutely dreadful when things aren’t how I would like them to be.
Human happiness, including mine, is caused by factors outside my control, so little can be done about it.
If something might be dangerous, unpleasant or frightening, I should worry about it excessively.
It is easier to put off something difficult or unpleasant than it is to face up to it.
I need someone stronger than myself to depend on.
My problem(s) were caused by event(s) in my past and that is why I have my problem(s) now.
I should be very concerned and upset by other people’s problems and difficulties.
Some common, rational thoughts
I want to be liked or loved by some of the people in my life, and I known I may feel disappointed or lonely when that doesn’t happen, but I can cope with those feelings and I can take constructive steps to make and keep better relationships.
I want to do some things well most of the time but, like everybody else, I will occasionally fail or make mistakes. Then I may feel bad but I can handle that and I can take constructive steps to do better next time.
It is sad that most of us do some bad things from time to time and some people do many bad things, but making myself upset won’t change things.
It is disappointing, sometimes very disappointing, when things aren’t how I would like them to be, but I can’t, it doesn’t help to exaggerate my disappointment.
My problem(s) may be influenced by factors outside my control, but my thoughts and actions also influence my problem(s) are they ARE under my control.
Worrying about something that may go wrong won’t stop it from happening: it just makes me unhappy now. I can take constructive steps to prepare for possible problems and that’s as much as anyone can do. So I won’t dwell on the future now.
Facing difficult situations may make me feel bad at the time, but I can cope with that. Putting off problems doesn’t make them any easier-it just gives me longer to worry about them.
It is good to get support and assistance from others when I want it, but the only person I really need to rely on is me.
My problem(s) may have started in some past event(s) but what keeps them going now are my thoughts and actions and they are under my control.
It is sad to see other people in trouble but I won’t help them by making myself miserable; sometimes I can take constructive steps to help others.
Irrational thoughts play a major role in creating stress. Watch out for “silly” thinking and start “clever” thinking.
Changing Physiological Responses
Learn to engage in relaxing activities. See comments below on relaxation techniques.
Increase your physical wellbeing and endurance capacity by regular exercise, healthy eating and good sleeping habits.
Changing Feelings
The aim is to understand your feelings. Use introspection (what is going on?) and positive self-talk. Challenge your irrational belief(s).
Changing Behaviour
Develop new and more appropriate behaviours through such programs as assertiveness training and social skills training.
Sources
Montgomery, R. (1982). Coping with Stress. Melbourne. Pitman.
Montgomery, R., & Evans, L. (1984). You and Stress: A Guide to Successful Living. Melbourne: Nelson.
Anxiety
Understanding and Managing Anxiety in Adults
The DSM-1V-TR and the DSM-5 includes a wide range of disorders under the rubric “Anxiety”. The focus will be on Generalised Anxiety Disorder.
The essential feature is anxiety, which is generalised and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstance (i.e., it is “free-floating”). As in other anxiety disorders, the dominant symptoms are highly variable but complaints of continuous feelings of nervousness, trembling, muscular tension, sweating, light-headedness, palpitations, dizziness are common. Fears that the sufferer will become ill or a parent or relative will shortly become ill or have an accident are often expressed, together with a variety of other worries and forebodings. Its course is variable but tends to be fluctuating and chronic.
The sufferer must have primary symptoms of anxiety most days for at least several weeks at a time, and usually for several months. These symptoms should usually involve elements of:
Apprehensiveness (worries about future misfortunes, feeling “on edge”, difficulty in concentrating, etc.)
Motor tension (restless fidgeting, tension headaches, trembling, inability to relax)
Autonomic overactivity (light-headedness, sweating, epigastric discomfort, dizziness, dry mouth, etc.)
The intensity, duration or frequency of the anxiety and worry is far out of proportion to the actual likelihood or impact of the feared event. The person finds it difficult to keep worrisome thoughts from interfering with attention to tasks at hand and has difficulty stopping worrying.
Management of Anxiety
Some general recommendations include the following-
Activities mentioned above under the heading STRESS are obviously relevant in this section. Stress and worry have both physical and mental effects. Learning skills to reduce the effect of stress and control the worry, will provide the most effective relief.
Some practical steps to take in dealing with anxiety-
Daily relaxation methods greatly help to reduce the physical symptoms or tension.
Plan short-term activities that are relaxing, distracting or pleasant.
Resume enjoyable activities that have been helpful in the past.
Identifying and challenging exaggerated worries can reduce anxiety symptoms.
Identify exaggerated worries or pessimistic thoughts. What are your thoughts when you are anxious? Try to identify specific thought distortions. In cognitive therapy, anxiety is recognised as the result of biases in thinking-
These include
Some Specific Management Strategies
Relaxation Training
Components of Relaxation Training
In order to be more in control of stress, anxiety, emotions and general physical wellbeing, it is important to learn to relax. To do this the individual will need to learn to:
1. Recognise tension.
2. Learn how to relax.
Recognising Tension
The following questions will be useful for examining an individual’s tension level in greater detail:
5. Which external events lead to an increase in tension?
Learning to Relax
Relaxation is useful in reducing physical and mental tension and stress. Relaxation helps people to reduce worry and anxiety, improve sleep and relieve physical symptoms caused by stress (e.g., headaches, stomach pains, diarrhoea or constipation).
Progressive muscle relaxation involves relaxing the muscles in a progressive or step-by-step manner. This form of relaxation is a practical skill which is best learned through instruction from a skilled teacher. In addition, many music stores sell relaxation tapes which guide the individual through the progressive relaxation exercises. Although these tapes are useful, they are recommended as training aids rather than as a substitute for training itself.
How to relax
The two main principles of physical relaxation are to:
A full session of progressive relaxation takes about 20 minutes. The individual will need to sit in a supportive, straight-back chair, with feet flat on the floor, hands resting in the lap, and eyes closed. Lying down is discouraged so as to reduce the likelihood of falling asleep. The room needs to be quiet, dim and free from interruptions.
If you follow the specified steps you will be well on your way to learning how to relax. This exercise should take about 15-20 minutes. However, if you only have 5 minutes to spare, 5 minutes is certainly better than nothing!
1. Find a quiet and relaxing place.
Choose a comfortable chair in a place which is free from noise and interruptions. You may need to explain to your family what you are doing so that they will not disturb you. Telling your family may also reduce any embarrassment you may feel.
2. Clear your mind.
Try to clear your mind of all worries or disturbing thoughts. If these worries or thoughts drift back into your mind while you are relaxing, do not worry, just let them float gently out of your mind without reacting to them. Let your mind be clear and calm.
3. Practise the slow breathing method for one minute.
Breathe in for 3 seconds and breathe out for 3 seconds, thinking the word relax every time you breathe out. Let your breathing flow smoothly. Imagine the tension flowing gently out of your body each time you breathe out.
4. Relax your muscles.
For each of the muscle groups in your body, tense the muscles for 7-10 seconds, then relax for about 10 seconds. Only tense your muscles moderately (not to the point of inducing pain). Tense and relax your muscles in the following order:
Hands-curl your hands into fists, then relax.
Lower arms-bend your hand down at the wrist, as though you were trying to touch the underside of your arm, then relax.
Upper arms-tighten your biceps by bending your arm at the elbow, then relax.
Shoulders-lift your shoulders up as if trying to touch your ears with them, then relax.
Neck-turn your neck gently to the left (touching your left shoulder), then bend it forward, then gently to the right (touching your right shoulder) then to the back in a slow rolling motion, then relax.
Forehead and scalp-raise your eyebrows, then relax.
Eyes-screw up your eyes, then relax.
Jaw-clench your teeth (just to tighten your muscles), then relax.
Tongue-press your tongue against the roof of your mouth, then relax.
Chest-breathe in deeply to inflate your lungs, then relax.
Stomach-push your tummy out to tighten the muscles, then relax.
Upper back-pull your shoulders forward with your arms at your side, then relax.
Lower back-while sitting, lean your head and upper back forward, rolling your back into a smooth arc tensing the lower back, then relax.
Buttocks-tighten your buttocks, then relax.
Thighs-while sitting, push your feet firmly into the floor, then relax.
Calves-lift your toes off the ground towards your shins, then relax.
Feet-gently curl your toes so that they are pressing into the floor, then relax.
5. Enjoy the feeling of relaxation
Sit still for a few minutes enjoying the feeling of total body relaxation.
Normal activities are then resumed in a calm and peaceful manner, thus bringing the feeling of relaxation into the daily routine.
Practise once or twice every day for at least 8 weeks.
During the day, try relaxing specific muscles whenever you notice that they are tense.
Remember, achieving deep levels of relaxation requires patience and practice. However, the effort is worth it as many of my patients have discovered. The more often you practise, the deeper and longer lasting the relation will be and the more quickly anxiety can be reduced.
Once progressive muscle relaxation is sufficiently mastered, you will be able to use this relation technique in most places at most times as the need arises. Whenever an increase in muscle tension is recognised, the relevant muscle group can be targeted for a quick, on the spot relation exercise. By keeping muscle tension levels in check throughout the day, you will be able to maintain more continuous feelings of relation.
Other Relaxation Methods
Although progressive muscle relaxation is the most recognised and documented method of relation, there are other methods that can achieve similar results. It is preferable for individuals to regularly use an effective method that they feel comfortable with and which has been successful in the past, rather than use “no method” at all. Other methods include-
Any of these “methods” can be useful if they reduce tension and are used daily/regularly.
Slow Breathing
When you become anxious your rate of breathing increases. This over-breathing is often referred to as “hyperventilation”. When you over-breathe you breathe out too much carbon dioxide which leads to a decrease in the level of carbon dioxide in the blood. The decrease level of carbon dioxide causes or worsens a number of symptoms such as breathlessness or light-headedness. You may experience these symptoms if you have panic attacks.
To get rid of these symptoms, the level of carbon dioxide in the blood must be steadied. One way of achieving increased levels of carbon dioxide in the blood is to breathe into a paper bag. A large proportion of the air that you breathe out is carbon dioxide, therefore, by re-breathing your old air you are taking higher amounts of carbon dioxide into your lungs.
Although breathing into a paper bag is simple and effective, it may not always be convenient or socially appropriate to pull out your paper bag in public! Additionally, although breathing into a paper bag is effective during a panic attack, this method cannot prevent hyperventilation in the future. An alternative method which is less obvious to other people and more effective in the long run is slow breathing exercise. This method will help you to control your hyperventilation. Also, by learning slow and regular breathing habits you will help to prevent future episode of hyperventilation and other symptoms of panic.
The following exercise is to be practised four times every day for at least five minutes each time AND at the first signs of panic or anxiety. Combining slow breathing with relaxation is particularly helpful.
A Slow Breathing Exercise
(To be practised regularly and at the first signs of anxiety or panic).
It is very important for you to practise the above so that it becomes easy to use any time you feel anxious. It is helpful to time the exercise using the second hand of your watch or nearby clock.
Source: Management of Mental Disorders. Volume 1. (2004) Treatment Protocol. World Health Organization Collaborating Centre. Sydney. (Fourth Edition).
The major sources for the above information are as follows-
Texts
The Australian Psychological Society Publications
Monograph
Evidence-based Psychological Interventions in the Treatment of Mental Disorders.
A Literature Review. (3rd Edition). 2010.
Tip Sheets
Other General Publications
Nathan, P. & Gorman, J. (Eds.) (2002). Evidence-based Psychosocial Treatment of Children and Adolescents.
Management of Mental Disorders. Volumes 1 and 2. (Fourth Edition). (2004). Treatment Protocol Project. World Health Collaborating Centre. Sydney.
Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. (DSM-1VTR). (2005)
International Statistical Classification of Diseases and Related Health Problems. 10th Revision. (ICD-10). (2007)
Nathan, P. & Gorman, J. (Eds.) 3rd Edition (2007). A Guide to Treatments that Work.
Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. (DSM-5). (2013)
Barlow, D.H. (Ed.). (2014). Clinical Handbook of Psychological Disorders. Fifth Edition.
Nathan, P. & Gorman, J. (2014). Management of Mental Disorders. Fifth Edition.
RESOURCES
APS-KidsMatter Resources
Links
Some valuable general resources on Managing Children from the ACER (www.acerpress.com.au)
Links-Parenting
Additional information is contained in the Section-Exceptionality. While the emphasis in that Section is on students with special educational needs, relevant information is provided on the definition, identification and diagnosis of certain pervasive developmental and behavioural problems and types of anxiety. Hence, readers are advised to consult that Section.
Information on basic management skills recommended for children and adolescents is also available in the Section-Parenting.
This resource has been prepared by Dr. Stewart C. Sykes - Psychologist. MAPS.
Former Associate Professor of Psychology and Special Education and Director of the Krongold Centre for Exceptional Children.
Monash University, Australia.
Copyright © Dr. Stewart C. Sykes. All rights reserved.
Copyright Dr. Stewart Sykes