Behavioral Health Services

ADHD


What Is ADHD? ADHD stands for attention deficit hyperactivity disorder. It is a medical condition. A person with ADHD has differences in brain development and brain activity that affect attention, the ability to sit still, and self-control. ADHD can affect a child at school, at home, and in friendships. What Are the Signs of ADHD? All kids struggle at times to pay attention, listen and follow directions, sit still, or wait their turn. But for kids with ADHD, the struggles are harder and happen more often. Kids with ADHD may have signs from one, two, or all three of these categories:

  • Inattentive. Kids who are inattentive (easily distracted) have trouble focusing their attention, concentrating, and staying on task. They may not listen well to directions, may miss important details, and may not finish what they start. They may daydream or dawdle too much. They may seem absent-minded or forgetful, and lose track of their things.
  • Hyperactive. Kids who are hyperactive are fidgety, restless, and easily bored. They may have trouble sitting still, or staying quiet when needed. They may rush through things and make careless mistakes. They may climb, jump, or roughhouse when they shouldn't. Without meaning to, they may act in ways that disrupt others.
  • Impulsive. Kids who are impulsive act too quickly before thinking. They often interrupt, might push or grab, and find it hard to wait. They may do things without asking for permission, take things that aren't theirs, or act in ways that are risky. They may have emotional reactions that seem too intense for the situation.
Sometimes parents and teachers notice signs of ADHD when a child is very young. But it's normal for little kids to be distractible, restless, impatient, or impulsive — these things don't always mean that a child has ADHD. Attention, activity, and self-control develop little by little, as children grow. Kids learn these skills with help from parents and teachers. But some kids don't get much better at paying attention, settling down, listening, or waiting. When these things continue and begin to cause problems at school, home, and with friends, it may be ADHD. How Is ADHD Diagnosed? If you think your child has ADHD, make an appointment with one of our providers! He or she will give your child a check-up, including vision and hearing, to be sure something else isn't causing the symptoms. The doctor can refer you to a child psychologist or psychiatrist if needed. To diagnose ADHD, doctors start by asking about a child's health, behavior, and activity. They talk with parents and kids about the things they have noticed. Your doctor might ask you to complete checklists about your child's behavior, and might ask you to give your child's teacher a checklist too. After gathering this information, doctors diagnose ADHD if it's clear that:
  • A child's distractibility, hyperactivity, or impulsivity go beyond what's usual for their age.
  • The behaviors have been going on since the child was young.
  • Distractibility, hyperactivity, and impulsivity affect the child at school and at home.
  • A health check shows that another health or learning issue isn't causing the problems.
Many kids with ADHD also have learning problems, oppositional and defiant behaviors, or mood and anxiety problems. Doctors usually treat these along with the ADHD. How Is ADHD Treated? Treatment for ADHD usually includes:
  • Medicine. This activates the brain's ability to pay attention, slow down, and use more self-control.
  • Behavior therapy. Therapists can help kids develop the social, emotional, and planning skills that are lagging with ADHD.
  • Parent coaching. Through coaching, parents learn the best ways to respond to behavior difficulties that are part of ADHD.
  • School support. Teachers can help kids with ADHD do well and enjoy school more.
  • The right treatment helps ADHD improve. Parents and teachers can teach younger kids to get better at managing their attention, behavior, and emotions. As they grow older, kids should learn to improve their own attention and self-control.
When ADHD is not treated, it can be hard for kids to succeed. This may lead to low self-esteem, depression, oppositional behavior, school failure, risk-taking behavior, or family conflict. What Can Parents Do? If your child is diagnosed with ADHD:
  • Be involved. Learn all you can about ADHD. Follow the treatment your child's health care provider recommends. Keep all recommended appointments for therapy.
  • Give medicines safely. If your child is taking ADHD medicine, always give it at the recommended time and dose. Keep medicines in a safe place.
  • Work with your child's school. Ask teachers if your child should have an IEP. Meet often with teachers to find out how your child is doing. Work together to help your child do well
  • Parent with purpose and warmth. Learn what parenting approaches are best for a child with ADHD — and which can make ADHD worse. Talk openly and supportively about ADHD with your child. Focus on your child's strengths and positive qualities.
  • Connect with others for support and awareness. Join a support organization for ADHD to get updates on treatment and other information.
What Causes ADHD?
  • It's not clear what causes the brain differences of ADHD. There's strong evidence that ADHD is mostly inherited. Many kids who have ADHD have a parent or relative with it.
  • ADHD is not caused by too much screen time, poor parenting, or eating too much sugar.
  • ADHD can improve when kids get treatment, eat healthy food, get enough sleep and exercise, and have supportive parents who know how to respond to ADHD.




Autism


Autism spectrum disorder (ASD) is a neurodevelopmental disability that affects a child's social skills, communication, and behavior. Because most children with ASD will sit, crawl, and walk on time, you may not notice delays in social and communication skills in the first year of life. Looking back, many parents can recall early differences in interaction and communication. ASD symptoms may change as children get older and with intervention. As many children with autism develop, they may likely have other developmental, learning, speech/language, behavioral issues, as well or other medical diagnoses. Other children, while not very common, may improve so much with intervention that they might no longer meet criteria for a a diagnosis of ASD. How common is ASD?

  • ASD affects about 1 in 59 children. Boys are diagnosed with ASD about 4 times more often than girls.
  • The number of children reported to have autism has increased since the early 1990s; the increase could be caused by many factors.
  • Many families are more aware of ASD.
  • Pediatricians are doing more screening for ASD, as recommended by the AAP, and children are identified earlier—which is a good thing.
  • Schools are more aware and children are receiving more appropriate special education services.
There have been many changes in how ASD is defined and diagnosed. Changes in how autism is defined & diagnosed: ​Doctors use the a book called Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to assist in diagnosing autism. In the past, only children with the most severe autism symptoms were diagnosed. But in 2013, the diagnostic criteria for autism spectrum disorder (ASD) changed based on the research literature and clinical experience in the 19 years since the DSM-IV was published in 1994. Now children with milder symptoms are being identified and helped. Several conditions used to be diagnosed separately under the term "pervasive developmental disorders" or "autism spectrum disorders" in the DSM. Those conditions were:
  • Autistic disorder
  • Pervasive developmental disorder—not otherwise specified (PDD-NOS)
  • Asperger syndrome
  • Disintegrative Disorder
With publication of the fifth edition of the DSM in 2013, the terms listed above are no longer used and these conditions are now grouped in the broader category of autism spectrum disorder or ASD. Many people may self-identify as having Asperger Syndrome, but professionals should no longer use this terminology when making a diagnosis. ​The benefits of early identification: Each child with autism has different needs. The sooner autism is identified, the sooner an early intervention program directed at the child's symptoms can begin. The American Academy of Pediatrics (AAP) recommends that all children be screened for ASD at their 18- and 24-month well-child checkups. Research shows that starting an intervention program as soon as possible can improve outcomes for many children with autism. Children with ASD may have other medical problems that may need further evaluation and treatment. These may include seizures, problems with sleep, gastrointestinal problems (feeding problems, abdominal pain, constipation, diarrhea, and behavioral health problems (such as anxiety, ADHD, irritability, and aggression).




Depression


What is adolescent depression? Depression may be present when your teenager has:

  • A sad or irritable mood for most of the day. Your teen may say they feel sad or angry or may look more tearful or cranky.
  • Not enjoying things that used to make your child happy.
  • A marked change in weight or eating, either up or down.
  • Sleeping too little at night or too much during the day.
  • No longer wanting to be with family or friends.
  • A lack of energy or feeling unable to do simple tasks.
  • Feelings of worthlessness or guilt. Low self-esteem.
  • Trouble focusing or making choices. School grades may drop.
  • Not caring about what happens in the future.
  • Aches and pains when nothing is really wrong.
  • Frequent thoughts of death or suicide.
Any of these signs can occur in children who are not depressed, but when seen together, nearly every day, they are red flags for depression. What should I do if I think my teen is depressed?
  • Talk to your child about his/her feelings and the things happening at home and at school that may be bothering him/her.
  • Tell your teen's doctor. Some medical problems can cause depression. Your doctor may recommend psychotherapy (counseling to help with emotions and behavior) or medicine for depression.
  • Your child's doctor may now screen your teen for depression every year from ages 12 through 21, with suicide now a leading cause of death among adolescents. Treat any thoughts of suicide as an emergency.
What can I do to help? Promote health
  • The basics for good mental health include a healthy diet, enough sleep, exercise, and positive connections with other people at home and at school.
  • Limit screen time and encourage physical activity and fun activities with friends or family to help develop positive connections with others.
  • One-on-one time with parents, praise for good behavior, encouragement for seeking care and pointing out strengths build the parent-child bond.
Provide safety and security
  • Talk with your child about bullying. Being the victim of bullying is a major cause of mental health problems.
  • Look for grief or loss issues. Seek help if problems with grief do not get better. If you as a parent are grieving a loss, get help and find additional support for your teen.
  • Reduce stress as most teens have low stress tolerance. Accommodations in schoolwork is critical as well as lowered expectations at home regarding chores and school achievements.
  • Guns, knives, long ropes/cables and medicines (including those you buy without a prescription), and alcohol should be locked up.
Educate others
  • Your teen is not making the symptoms up.
  • What looks like laziness or crankiness can be symptoms of depression.
  • Talk about any family history of depression to increase understanding.
Help your teen learn thinking and coping skills
  • Help your teen relax with physical and creative activities. Focus on the his/her strengths.
  • Talk to and listen to your child with love and support. Encourage teens to share their feelings including thoughts of death or suicide. Reassure them that this is very common with depression.
  • Help your teen look at problems in a different more positive way.
  • Break down problems or tasks into smaller steps so your teen can be successful.
Make a safety plan
  • Follow the treatment plan. Make sure your teen attends therapy and takes any medicine as directed.
  • Treatment works, but it may take a few weeks. The depressed teen may not recognize changes in mood right away and may become discouraged with initial side effects of treatments (such as antidepressants).
  • Develop a list of people to call when feelings get worse.
  • Watch for risk factors for suicide. These include talking about suicide in person or on the internet, giving away belongings, increased thoughts about death, and substance abuse.
  • Locate telephone numbers for your teen's doctor and therapist, and the local mental health crisis response team.
  • The National Suicide Prevention Lifeline can be reached at 1-800-273-8255 or online at www.suicidepreventionlifeline.org.




Anxiety


Anxiety disorders are the most common type of mental health disorder in childhood, affecting approximately 8% of all children and adolescents. There are many types of anxiety disorders that affect youth, the most common being Generalized Anxiety Disorder, Panic Disorder, Separation Anxiety Disorder, and Phobic Disorders. Symptoms
Symptoms of anxiety disorders can include:

  • ​Recurring fears and worries abo​ut routine parts of every day life
  • ​Physical complaints, like stomachache or headache
  • ​Trouble concentrating
  • ​Trouble sleeping
  • ​Fear of social situations
  • Fear of leaving home
  • ​Fear of separation from a loved one
  • Refusing to go to school
  • Co-morbid disorders, in particular ADHD and depression, are not uncommon.

Treatment
Anxiety disorders are treatable! Studies have shown that cognitive behavioral therapies (CBT) and medication treatments are both effective in treating anxiety disorders in youth. Parent involvement in treatment has also been shown to improve outcomes in some children. Early treatment can prevent future difficulties, such as academic or social difficulties and low self-esteem. Understanding Childhood Fears and Anxieties My child seems to be afraid of a lot of things. Should I be worried? From time to time, every child experiences fear. As youngsters explore the world around them, having new experiences and confronting new challenges, anxieties are almost an unavoidable part of growing up. Fears are Common: According to one study, 43% of children between ages 6 and 12 had many fears and concerns. A fear of darkness, particularly being left alone in the dark, is one of the most common fears in this age group. So is a fear of animals, such as large barking dogs. Some children are afraid of fires, high places or thunderstorms. Others, conscious of news reports on TV and in the newspapers, are concerned about burglars, kidnappers or nuclear war. If there has been a recent serious illness or death in the family, they may become anxious about the health of those around them. In middle childhood, fears wax and wane. Most are mild, but even when they intensify, they generally subside on their own after a while. About Phobias: Sometimes fears can become so extreme, persistent and focused that they develop into phobias. Phobias – which are strong and irrational fears – can become persistent and debilitating, significantly influencing and interfering with a child's usual daily activities. For instance, a 6-year-old's phobia about dogs might make him so panicky that he refuses to go outdoors at all because there could be a dog there. A 10-year-old child might become so terrified about news reports of a serial killer that he insists on sleeping with his parents at night. Some children in this age group develop phobias about the people they meet in their everyday lives. This severe shyness can keep them from making friends at school and relating to most adults, especially strangers. They might consciously avoid social situations like birthday parties or Scout meetings, and they often find it difficult to converse comfortably with anyone except their immediate family. Separation anxiety is also common in this age group. Sometimes this fear can intensify when the family moves to a new neighborhood or children are placed in a childcare setting where they feel uncomfortable. These youngsters might become afraid of going to summer camp or even attending school. Their phobias can cause physical symptoms like headaches or stomach pains and eventually lead the children to withdraw into their own world, becoming clinically depressed. At about age 6 or 7, as children develop an understanding about death, another fear can arise. With the recognition that death will eventually affect everyone, and that it is permanent and irreversible, the normal worry about the possible death of family members – or even their own death – can intensify. In some cases, this preoccupation with death can become disabling. Treating Fears & Phobias: Fortunately, most phobias are quite treatable. In general, they are not a sign of serious mental illness requiring many months or years of therapy. However, if your child's anxieties persist and interfere with her enjoyment of day-to-day life, she might benefit from some professional help from a psychiatrist or psychologist who specializes in treating phobias. As part of the treatment plan for phobias, many therapists suggest exposing your child to the source of her anxiety in small, nonthreatening doses. Under a therapist's guidance a child who is afraid of dogs might begin by talking about this fear and by looking at photographs or a videotape of dogs. Next, she might observe a live dog from behind the safety of a window. Then, with a parent or a therapist at her side, she might spend a few minutes in the same room with a friendly, gentle puppy. Eventually she will find himself able to pet the dog, then expose herself to situations with larger, unfamiliar dogs. This gradual process is called desensitization, meaning that your child will become a little less sensitive to the source of her fear each time she confronts it. Ultimately, the child will no longer feel the need to avoid the situation that has been the basis of her phobia. While this process sounds like common sense and easy to carry out, it should be done only under the supervision of a professional. Sometimes psychotherapy can also help children become more self-assured and less fearful. Breathing and relaxation exercises can assist youngsters in stressful circumstances too. Occasionally, your doctor may recommend medications as a component of the treatment program, although never as the sole therapeutic tool. These drugs may include antidepressants, which are designed to ease the anxiety and panic that often underlie these problems. What Parents Can Do: Here are some suggestions that many parents find useful for their children with fears and phobias.
  • Talk with your child about his anxieties, and be sympathetic. Explain to him that many children have fears, but with your support he can learn to put them behind him.
  • Do not belittle or ridicule your child's fears, particularly in front of his peers.
  • Do not try to coerce your youngster into being brave. It will take time for him to confront and gradually overcome his anxieties. You can, however, encourage (but not force) him to progressively come face-to-face with whatever he fears.
Since fears are a normal part of life and often are a response to a real or at least perceived threat in the child's environment, parents should be reassuring and supportive. Talking with their children, parents should acknowledge, though not increase or reinforce, their children's concerns. Point out what is already being done to protect the child, and involve the child in identifying additional steps that could be taken. Such simple, sensitive and straightforward parenting can resolve or at least manage most childhood fears. When realistic reassurances are not successful, the child's fear may be a phobia.




Mood Disorders


Mood Disorders & ADHD The mood disorders most likely to be experienced by children with ADHD include dysthymic disorder, major depressive disorder (MDD), and bipolar disorder. Dysthymic disorder can be characterized as a chronic low-grade depression, persistent irritability, and a state of demoralization, often with low self-esteem. Major depressive disorder is a more extreme form of depression that can occur in children with ADHD and even more frequently among adults with ADHD. Dysthymic disorder and MDD typically develop several years after a child is diagnosed with ADHD and, if left untreated, may worsen over time. Bipolar disorder is a severe mood disorder that has only recently been recognized as occurring in children. Unlike adults who experience distinct periods of elation and significant depression, children with bipolar disorder present a more complex disturbance of extreme emotional instability, behavioral difficulties, and social problems. There is significant overlap with symptoms of ADHD, and many children with bipolar disorder also qualify for a diagnosis of ADHD. What to Look For Every child feels discouraged or acts irritable once in a while. Children with ADHD, who so often must deal with extra challenges at school and with peers, may exhibit these behaviors more than most. If your child claims to be depressed, however, or seems irritable or sad a large portion of each day, more days than not, she may have a coexisting dysthymic disorder. To be diagnosed with dysthymic disorder, a child must also have at least 2 of the following symptoms:

  • Poor appetite or overeating
  • Insomnia or excessive sleeping
  • Low energy or fatigue
  • Low self-esteem
  • Poor concentration or difficulty making decisions
  • Feelings of hopelessness
Before dysthymic disorder can be diagnosed, children must have had these symptoms for a year or longer, although symptoms may have subsided for up to 2 months at a time within that year. The symptoms also must not be caused by another mood disorder, such as MDD or bipolar disorder, a medical condition, substance abuse, or just related to ADHD itself (low self-esteem stemming from poor functioning in school, for example). Finally, the symptoms must be shown to significantly impair your child’s social, academic, or other areas of functioning in daily life. Major depressive disorder is marked by a nearly constant depressed or irritable mood or a marked loss of interest or pleasure in all or nearly all daily activities. In addition to the symptoms listed previously for dysthymic disorder, a child with MDD may cry daily; withdraw from others; become extremely self-critical; talk about dying; or even think about, plan, or carry out a suicide attempt. Unlike the brief outbursts of temper exhibited by a child with ODD who does not get her way, a depressed child’s irritability may be nearly constant and not linked to any clear cause. Her inability to concentrate differs from ADHD-type inattention in that it is accompanied by other symptoms of depression, such as loss of appetite or loss of interest in favorite activities. Finally, the depression itself stems from no apparent cause—as opposed to being demoralized as a result of specific obstacles posed by ADHD or becoming depressed in response to parental divorce or any other stressful situation. (In fact, research has shown that the intactness of a child’s family and its socioeconomic status have little or no effect on whether a child develops MDD.) While children with ADHD/CD alone are not at higher than normal risk for attempting suicide, children with ADHD/CD who also have an MDD and are involved in substance abuse are more likely to make such an attempt and should be carefully watched. Talk of suicide (even if you are not sure whether it is serious), a suicide attempt, self-injury, any violent behavior, or severe withdrawal should be considered an emergency that requires the immediate attention of your child’s pediatrician, psychologist, or local hospital. A depressed child may admit to feeling guilty or sad, or she may deny having any problems. It is important to keep in mind the fact that many depressed children refuse to admit to their feelings, and parents often overlook the subtle behaviors that signal a mood disorder. By keeping in close contact with her teacher, bringing your child to each of her treatment reviews with her pediatrician, and including her in all discussions of her treatment as appropriate to her age, you can improve the chances that her pediatrician or mental health professional will detect any signs of developing depression, and that she will have someone to talk to about her feelings. A child with bipolar disorder and ADHD is prone to explosive outbursts, extreme mood swings (high, low, or mixed mood), and severe behavioral problems. Such a child is often highly impulsive and aggressive, with prolonged outbursts typically “coming out of nowhere” or in response to trivial frustrations. She may have a history of anxiety. She may also have an extremely high energy level and may experience racing thoughts and inflated self-esteem or grandiosity, extreme talkativeness, physical and emotional agitation, overly sexual behavior, and/or a reduced need for sleep. These symptoms can alternate with periods of depression or irritability, during which her behavior resembles that of a child with MDD. A child with ADHD/ bipolar disorder typically has poor social skills. Family relationships are often strained because of the child’s extremely unpredictable, aggressive, or defiant behavior. Early on the symptoms may only occur at home, but often begin to occur in other settings as the child gets older. Bipolar disorder is a serious psychiatric disorder that can sometimes include psychotic symptoms (delusions/hallucinations) or self-injurious behavior such as cutting, suicidal thoughts/impulses, and substance abuse. Many children with bipolar disorder have a family history of bipolar disorder, mood disorder, ADHD, and/or substance abuse. Children with ADHD and bipolar disorder are at higher risk than those with ADHD alone for substance abuse and other serious problems during adolescence. If your child has ADHD with coexisting bipolar disorder, her pediatrician will generally refer her to a child psychiatrist for further assessment, diagnosis, and recommendations for treatment. Treatment As with ADHD with anxiety disorders, treatment of ADHD with depression usually involves a broad approach. Treatment approaches may include a combination of cognitive-behavioral therapy, interpersonal therapy (focusing on areas of grief, interpersonal relationships, disputes, life transitions, and personal difficulties), traditional psychotherapy (to help with self-understanding, identification of feelings, improving self-esteem, changing patterns of behavior, interpersonal interactions, and coping with conflicts), as well as family therapy when needed. Medication management approaches, as with ADHD and other coexisting conditions, include treating the most disabling condition first. If your child’s ADHD-related symptoms are causing most of her functioning problems, or the signs of depression are not completely clear, your child’s pediatrician is likely to start with stimulant medication to treat the ADHD. In cases when the depressive symptoms turn out to stem from poor functioning due to ADHD and not to a depressive disorder, they may diminish as the ADHD symptoms improve. If the ADHD and depressive symptoms improve, your child’s pediatrician will probably maintain stimulant treatment alone. If her ADHD symptoms improve but her depression remains the same, even after a reasonable trial of the type of broad psychotherapeutic approach described previously, her pediatrician may add another medication, most commonly an SSRI—a class of medications including Prozac, Zoloft, Paxil, Luvox, and Celexa. Selective serotonin reuptake inhibitors can make the symptoms of bipolar disorder worse, so a careful evaluation must be completed before starting medication. If this approach is unsuccessful, you may be referred to a developmental/behavioral pediatrician or a psychiatrist, who may try other classes of medications.





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