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Mental Health Archive 2009

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Margaret L. Stivers, Ph.D.
Clinical Psychologist

Margaret is a clinical and social psychologist trained at the University of Kansas and the University of Miami. She has taught psychology at four major universities and directed mental health, residential, and nonpublic school programs for children and adolescents. Her experience includes 30 years of consultation and collaboration with educational programs throughout the country, including schools in urban and rural areas and on Indian reservation.

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  • How can we bring her out of this desperation? (Part 1)

Question:

I have a student who was doing well in her studies till 12th grade. She was a competitive child who was many times (though she may have not realized it) insecure about her relationships with others, sometimes making her act dominating and aggressive. Unfortunately, she failed in 12th grade and failed to get admission to any college. She was not able to take the trauma and tried to commit suicide twice.

My question is how can we bring her out of this desperation? Her suicide attempts occurred despite several talks with a psychologist, parents, friends and others, a change in her surroundings, and other attempts to give support.

Isn't so much pressure – by parents, peers, society -- too much for children to handle?

From “Worried in the East Bay”


Answer:

Dear Worried,

Thank you for writing and for bringing up some difficult, but important, topics. Your letter contains two questions, paraphrased below, about problems that require different levels of analysis and intervention:

  • On the level of individual intervention: 
    What kinds of support are most likely to be helpful to the young woman in your letter who has attempted suicide twice?
  • On a broader social scale, or level of prevention: 
    Are the many pressures on today’s students placing them under too much stress?

Because both questions are worthy of thoughtful responses, I have decided to address them separately in order to respond more fully to each of them. This month’s letter will focus on the first question and next month’s letter will focus on the second.

Advice on supporting the young woman who attempted suicide:

It appears that this young woman has a support network of people who are concerned about her and that all of you have been working to remind her that you care. Even when she does not appear to be responding and your support does not seem to be making any difference, please keep it up! Whether or not she can express appreciation or you can see any results of your efforts, your support is probably helping a great deal. Try not to get discouraged. If she feels that others are “giving up” on her, this may reinforce her sense of hopelessness or worthlessness and intensify her despair.

I do not have enough information about the particular individual and her situation to offer detailed recommendations which are specifically tailored to her individual needs. Instead, I’ll describe types of support, in order of priority, that are likely to help most individuals at risk of suicide. The final recommendation is especially appropriate for those who became suicidal in response to a “failure” experience.

  1. Develop a safety plan 

    The young woman at risk of suicide and key members of her support group can work together to develop a set of agreements that are designed to maximize her safety. Having a plan is also likely to help everybody cope with this difficult, highly stressful situation. The most crucial component is an emergency procedure with a specific set of steps she is willing to commit to following if she experiences another strong urge to commit suicide. Her commitment may be expressed as a spoken promise to the group as well as a written and signed agreement. The emergency plan should include a list of people she promises to contact (along with their phone numbers) should the situation arise. Once she reaches the first person, they talk it through and make necessary arrangements, such as finding someone to stay with her. They may agree that she does not need to contact anyone else. However, if the first person is unavailable, she needs to continue down the list until she finds someone who is available to help.

Safety plans may also include a plan for others (one or more, possibly rotating, members of the support group) to check in with her regularly. Check-ins may be very brief, but, at least at first, should be regular and frequent. The group may think of other areas in which it would be useful to have systematic procedures for responding to events that may arise. It is useful to record and date the set of agreements that make up the safety plan. The group can agree to add, subtract, or revise items as situations and priorities change.

  1. Encourage her to find a compatible therapist and commit to participate for a specified length of time (e.g. two-to-six months, then re-evaluate)

Therapy can be helpful in decreasing suicidal feelings or symptoms of depression. Unfortunately, the results tend not to be immediately apparent, so it can be difficult to determine whether the process is “working” before taking part in several sessions. Although much more research is needed in this area, the results available so far suggest some guidelines for finding the right therapist and form of therapy.

The effectiveness of therapy appears to relate more strongly than to anything else to the “therapeutic alliance,” or strength of the working relationship between the client and therapist. This suggests that the client is likely to gain by when she feels trust and confidence in her therapist.

Many forms (theories and practices derived from those theories) of therapy are available and relatively little is known about matching therapies to particular problems. However, some forms of therapy have been found useful for particular problems across several well-conducted studies,. The young woman you write about sounds like an excellent candidate for cognitive-behavioral therapy (CBT). This therapy is based on the idea that our thoughts strongly influence our feelings, so that the ways we characteristically think about our lives influence our well-being. A well-trained cognitive-behavioral therapist can help this young woman re-examine the assumptions and thoughts that may contribute to her feelings of despair and low self-worth, then help her replace them with more optimistic, yet realistic, ways of thinking about herself and her future.

The therapist may also suggest additional forms of therapy. Family therapy has been shown to be useful for some adolescents and young adults with depression. The therapist might also suggest an evaluation by a psychiatrist to help determine whether she might benefit from taking an anti-depressant or other medication. Although medication cannot teach new ways of thinking about problems or more effective coping skills or patterns of behavior, it can sometimes help a person more receptive and available to benefit from the forms of therapy that focus on developing these skills.

  1. Encourage her to re-focus and re-engage in life

Help this former student find a new activity or project or group she is willing to join. She might “try out’ two or three settings, based on her interests. Urge her to choose one and commit to regular participation for a specified period of time (maybe three months). A paid job or volunteer position with responsibility for helping people, working with animals, or improving the environment is likely to help divert her mental focus away from her own problems. Her commitment to showing up regularly will be strengthened by her knowledge that others need her and expect her to be there for them.

  1. Encourage her to re-visit her long-term goals

Your student’s previous goals may have been well-suited to her strengths, challenges, and interests. In this case, she faces the task of coping, just as she is getting started, with an unexpected need to change her plans and timelines for accomplishing her goals. She will need support in identifying alternative pathways, getting back on track, and accepting and adjusting to these changes.

Alternately, her goals may not have been well-thought out and her unhappy circumstances may represent an important opportunity for self-reflection and re-evaluation. With support, she may take advantage of these chances to further define her values, expand her awareness and interests, and identify a greater range of activities and goals that can for her inspire caring and commitment. Because re-evaluation of long-term goals requires substantial self-reflection as well as exploration of a vast array of opportunities to prepare for work that reflects personal interests and values, it is a difficult and time-consuming process. A counselor from your student’s previous school may be available to help with her exploration of different fields and career paths. A career counselor should also be able to help explore educational options (e.g. complete courses for high school diploma, GED, try out a course at community college).

You mentioned in your letter that this young woman tends to be competitive. A career counselor, her therapist, and those who support her can try to help her understand that self-exploration is a long-term process, help her recognize her progress, and frequently, but gently, remind her that this is not a race. Her goal is to find an individual path leading to productivity and personal fulfillment.

Again, thank you for your letter and good luck to you and the young woman who inspired your letter. Next month’s entry will be focused on the topic of stress resulting from pressures on students.

Resource:

NREPP (National Registry of Evidence-based Programs and Practices), maintained by SAMHSA (Substance Abuse and Mental Health Services Administration), U. S. Department of Health and Human Services - http://www.nrepp.samhsa.gov/


  • ADHD or bipolar disorder?

Question:

I’ve been a fifth grade teacher for many years and I’ve certainly had at least my share of intense, unpredictable kids with non-stop energy – the kind you have to keep an eye on every moment because you never know what they’ll do next. Each time I get another one in my class, I try to meet with his parents as early as possible in the school year to discuss my concerns. I always suggest that they follow up with their pediatrician or another child development professional. When the families do follow through, their children are almost always diagnosed with AD/HD.

Yesterday was a little different. The mother of one of my difficult students told me that her son had just been diagnosed with bipolar disorder. In my classroom, her son seems just like any of my other active, high-maintenance students, past or present. I know that AD/HD and bipolar disorder are different conditions and that children are usually placed on different types of medication depending on which diagnosis they are given. I’m wondering whether there are any actual differences in their behavior that can be observed at school if you know what to look for?


Answer:

Good question!

You are absolutely right; children diagnosed with attention-deficit/hyperactivity disorder (AD/HD) and those diagnosed with juvenile bipolar disorder (JBPD) display many, very similar behaviors. In addition to highly active, unpredictable behaviors, some other characteristics commonly associated with both diagnoses are impulsivity, restlessness, and frequent mood changes. Children with either disorder are also far more likely to engage in intense emotional outbursts, or temper tantrums, than are children with neither disorder. As you point out, these students tend to need a great deal of extra supervision. Coping with the behaviors of a student who has either diagnosis can be a major challenge, especially in a classroom setting with many other students who also need your attention and help.

Despite the high number of overlapping symptoms and characteristics, there tend to be some differences between the characteristic patterns of behavior observed in the two groups. Many of these distinctions revolve around the emotional outbursts, or temper tantrums. If you have a student in your class with AD/HD and one with JPBD, you might observe some of the following differences:

  • Children with AD/HD are most likely to have outbursts of explosive behavior when they are overly stimulated or excited, such as in complex or novel social situations. Children with JBPD are more likely to be “set off” in response to limits (especially being told “no”) or demands placed by people in authority. While a child with AD/HD might briefly become angry when asked to make a transition, this anger seems to arise from the child’s difficulties in shifting focus and organizing himself around a new activity. In the same situation, the child with JBPD is more likely to become infuriated about being told what to do.
  • The behavioral meltdowns of children with JBPD are generally far more intense and longer lasting than those of children with AD/HD. Children with JBPD can remain intensely angry, out of control, and “unreachable” for many hours. During these outbursts, they may reach levels of emotional intensity in which their language and thinking become disorganized, may temporarily lose touch with reality, and may remember little of the episode once it’s over. In contrast, children with AD/HD often calm down within half an hour. They can occasionally be distracted, soothed, or cajoled through humor, which can speed up the process.
  • Some children with JBPD can be aggressive and physically destructive and these behaviors often appear to express anger or hostility (e.g. tearing up others’ papers or artwork, defacing personal property). If a child with AD/HD harms someone, it is more likely to reflect impulsivity (e.g. being unable to stop and think before lashing out and hitting someone, sometimes leading to immediate regret) or carelessness (running into people because of failure to pay attention). Destruction of objects can arise from careless, inattentive behavior.
  • Both children with AD/HD and those with JBPD go through frequent mood changes. When they are not “wound up,” children with AD/HD often express feelings of frustration and boredom. Children with JBPD may go through periods of sadness, inertia, or withdrawal. Children in both groups are often highly irritable, but children with JBPD are more likely to go through periods of hostility.
  • Both groups of children are somewhat injury-prone. Children with AD/HD are more likely to get hurt accidently due to careless, impulsive behavior or to a lack of awareness of the potential dangers in their environments. Children with JBPD are more likely to get hurt from seeking out dangerous situations and engaging in thrill-seeking behaviors. They may ignore potential dangers in their environments due to feelings of invincibility.

There are other distinctions, but these are the primary behavioral differences you might observe in your students at school. The similarities are great and only a few of the potential differences may be apparent in any specific children with these labels. Consequently, experts in child psychiatry and psychology often disagree about the best diagnosis for a particular child.

I hope that this answers your question. Good luck in your work with your students!


  • Signs of stress and depression in preschool-age children.

Question:

Many years back, when I took psychology in college, depression was considered an adult disorder. Since then, I’ve been glad to see a lot more people become concerned about depression and other mental health problems in children. The school where I work ranges from preschool through the early elementary grades. Lately I’ve been hearing more and more concerns from teachers and parents about signs of stress and depression in preschool-age children. I’d like to learn more about whether children this young can actually have symptoms of depression.


Answer:

Just as you were, I was originally taught to think of depression as an adult disorder. But over the past 20-30 years, childhood depression has gradually come to be recognized and taken seriously. There has still been very little acknowledgement or attention paid to depression in children under 6, but this too may be starting to change. An international study published this month in the Journal of Child Psychology and Psychiatry indicates that depression and anxiety may affect up to 15 percent of preschoolers. The authors note that some children show indicators as early as one year of age. These findings seem less surprising when we recall that even babies and very young children display depression-like states, such as failure to thrive or attachment disorders marked by severe withdrawal and apathy.

For anyone interested in learning more about depression and other mental health problems in very young children, the following resource is a good place to start:

Resources to Support the Mental Health Needs of Young Children,

National Child Care and Technical Assistance Center http://nccic.acf.hhs.gov/poptopics/ecmhealth.html.


  • What is “Explosive Behavioral Disorder?”

Question:

I have a student who was just diagnosed with yet another disorder. This one is “Explosive Behavioral Disorder.” I was unable to find any information in the DSM IV. Can you clarify this or do you have a reference for my use?

Humboldt County


Answer:

Eruptions of out-of-control behavior not only prevent a child from participating successfully at home, school, and in the community, but also place major stress on everyone around the child, especially those who must attempt to manage the child’s behavior while also managing a busy household or classroom. Whatever label you use to describe it, explosive behavior is hard to cope with; it is nearly always frustrating and aggravating, and can sometimes be frightening. So thank you for giving me the opportunity to write about some of the dilemmas involved in diagnosing, understanding, and managing these difficult behaviors. First, I will address diagnostic issues, then discuss a system I have found helpful in analyzing the reasons a particular child engages in explosive behavior at particular times and developing a plan to help that child learn to function more adaptively (references included).

Diagnostic Issues

The clinician who diagnosed your student may have taken some liberty with terminology. As you pointed out, “Explosive Behavioral Disorder” is not a standard diagnosis found in the current edition of the Diagnostic and Statistical Manual (DSM-IV), so I assume that the label was not accompanied by an official numeric code. However, the DSM-IV does contain some fairly similar diagnoses. The section titled “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” includes a diagnosis called Disruptive Behavior Disorder, Not Otherwise Specified (NOS). This disorder is characterized by a pattern of behavior that is oppositional-defiant (e.g. being touchy and easily annoyed, losing temper) or violates the rights of others (e.g. starting fights) but does not meet the specific criteria for either Oppositional Defiant Disorder or Conduct Disorder.

The DSM-IV section titled “Impulse Control Disorders Not Elsewhere Classified” includes two diagnoses, Intermittent Explosive Disorder and Impulse Control Disorder – NOS, which are usually assigned to adults, but can be applied to children and adolescents. Intermittent Explosive Disorder refers to recurrent, discrete episodes of failure to resist aggressive impulses resulting in assaultive behavior or serious property destruction. Impulse Control Disorder – NOS is, as it sounds, used to describe any disorder of impulse control that is not covered by another diagnosis.

All three of the diagnoses mentioned above have ICD-10 (International Classification of Diseases, 10 th Edition) codes as well as DSM-IV codes. They provide diagnostic options for a clinician to document a serious problem with volatile behavior when no other diagnosis seems to fit. As catch-all diagnoses, the three DSM-IV diagnostic labels, as well as the less conventional label applied to your student, describe the behavioral problem, but offer no hints about potential underlying factors. Descriptive diagnoses such as these have limited usefulness when it comes to helping teachers, parents, or clinicians understand the problem and find ways to help the child learn more adaptive behavior. Other, more specific, diagnoses, which may contribute to our understanding of the underlying reasons for the behavior, are always considered preferable if they can be applied. For instance, the DSM-IV section on differential diagnosis for impulse control disorders states, “Aggressive behavior can occur in the context of many other mental health disorders. A diagnosis of Intermittent Explosive Disorder should be considered only after all other disorders that are associated with aggressive impulses or behaviors have been ruled out.”

The diagnostic picture is complicated and ruling out other diagnoses can be a major undertaking because explosive behavior can be associated with so many conditions. Explosive behavior occurs in children with: attention-deficit/hyperactivity disorder, language disorders, learning disabilities, cognitive deficits, anxiety disorders, and mood disorders. Limited understanding of social situations and poor social skills can also increase the chances of explosive behavior in children who are temperamentally irritable or prone to emotional extremes. Emergence of explosive episodes in older children may be associated with substance abuse or signal the onset of a thought disorder (psychosis). Episodes of explosive behavior also occur in children and adolescents who face significant challenges across several of these areas, but may not qualify for any specific mental health diagnosis or educational handicapping condition.

Ways to Understand Explosive Behaviors and Help Students Behave More Adaptively

Despite the many diagnostic dilemmas associated with explosive behavior, just about all of us know it when we see it. Most of us usually agree on what it looks like and at what point to consider it a problem, taking into account children’s developmental levels and other individual differences. For instance, we expect occasional melt downs, complete with crying, shrieking, and flailing limbs, in very young children. But we certainly suspect there is a problem when we observe a similar episode in a school-age child. As kids get older, explosive behavior can take a wider range of forms, including verbal outbursts (e.g. insults, curses), physical aggression (e.g. kicking, punching), self-harm (e.g. banging fists or head against hard surfaces), property destruction (e.g. throwing or ripping up items), and dangerous behavior (e.g. running “blindly” into people or onto the street).

Working with children who have any kind of social, emotional, or learning difficulties can be stressful, but dealing with explosive behavior can be particularly distressing for teachers, parents, and professionals. Rages or behavioral outbursts often feel “predictably unpredictable;” we have distressing memories of past behavioral meltdowns and know that similar episodes will occur in the future, but we do not know when. Keeping ourselves alert and ready to cope at all times can keep us “on edge” and raise our levels of chronic stress. Spending regular time with a child who may explode at any moment can feel like hiking down a trail dotted with land mines. We might sometimes feel worn out and discouraged or frustrated and angry. Eventually, we may start to doubt our own competence in working with children.

Another source of stress in working with these children is the fact that the typical tools we rely on to manage difficult behavior are often ineffective with explosive behavior. Some teachers and parents try to ignore outbursts and reinforce positive behaviors. They often find that explosive behavior can escalate very quickly to the point when it is too disruptive or dangerous to ignore. Other parents and teachers try to solve the problem through confrontation and when their efforts don’t meet with success, they go to greater and greater lengths to assert control. However, confrontation comes with a significant danger of triggering more frequent and intense outbursts, thereby establishing explosive behavior even more firmly as the child’s habitual response to situations that feel overwhelming.

Some adults end up going to great lengths to avoid explosiveness. Often, without a conscious decision, they start to “walk on eggshells,” afraid to make any requests or demands that might set the student off. This may succeed in reducing explosive episodes, but it can also result in having the child “in charge” of his or her program, with insufficient expectations and challenges to promote learning and growth. It can be frightening for a child to be in charge and difficult for school staff to think of sending a student on to the next grade level without developing further skills to adapt to a classroom environment.

If you are looking for ways to better understand children with explosive behaviors and intervene more effectively, I recommend that you consider incorporating an approach developed by Ross W. Greene, Ph.D., associate clinical professor of psychiatry at Harvard Medical School and founding director of the Collaborative Problem Solving Institute, a group dedicated to clinical support and research on children and adolescents with explosive behaviors. His assumptions are that “kids do well if they can” and that explosive behavior signals an unsolved problem (trigger) encountered by a child who has not yet developed the necessary skills to respond adaptively.

Unsolved problems involve situations in which there is a poor fit between the demands of the environment and the extent to which the child has developed the behavioral skills to handle those demands. Acquisition of necessary skills to respond adaptively to complex social environments is dependent on development in many areas, including cognitive, language, self-regulation, and social abilities. As we know, not all children progress at same rates in all areas. Some children have trouble processing language and are often confused about what is expected of them, some struggle with formulating language to express their thoughts and feelings, and others may communicate competently, but lag behind in higher-order skills such as the use of “internal” speech to regulate behavior. Some children learn faster than others how to manage their emotions or soothe themselves when they feel frustrated or overwhelmed, so that their thinking is not short circuited by their feelings. Some are slower to develop cognitive flexibility, which helps them adapt to change, or higher-order cognitive abilities which would enable them to solve novel problems by generating and evaluating options based on hindsight (lessons from past experiences) and foresight (projected outcomes). Children also differ in developing the social understanding they need to interpret and learn from social feedback and mesh their behavior with the expectations of social environment. Deficits in any of these areas may underlie a child’s difficulties with behavioral control. Recall the number and variety of diagnostic labels for children with which explosive behavior may be associated.

Young children, who have not yet developed very far in any of these areas, typically have occasional tantrums or meltdowns. As they get older and increase their behavioral repertoires, most children gradually develop the skills they need to respond more adaptively to the social environment. However, some lag behind in critical skill areas. Their volatile behavior persists, or even worsens, as they get older and face increasing social expectations which they cannot meet. Changing a pattern of explosive behavior requires identifying the problem and the necessary skill set that the child has not yet developed. Then, ideally, the concerned adults form a partnership with the child to collaborate on a plan and support the child in learning more adaptive behaviors to meet his or her needs.

A lot of the critical information required to develop an effective individualized Collaborative Problem Solving (CPS) plan is already systematically gathered on special education students with tools we commonly use in schools. Formal or informal functional assessment of behavior helps identify the environmental factors that maintain the behavior and develop hypotheses about the needs served by the behavior. This information, in conjunction with the results of a psychoeducational assessment , can help identify important skills that the child has not yet mastered to solve problems more adaptively. However, we do not always need a full psychoeducational evaluation to identify delays or gaps in a child’s development of cognitive, social, or emotional skills or need a functional assessment of behavior to identify problem situations in which perceived demands surpass the child’s coping skills. Thinking in terms of these variables and pooling knowledge among those who know the child well can yield valuable hypotheses about factors underlying behavior and when team in agreement can be basis for developing interventions to test. If pooling combined knowledge does not result in identification or agreement on factors, then more formal assessment is appropriate.

Greene differs from behavior analysts about the effectiveness of reinforcement systems because he does not feel that explosive behavior is usually a problem of motivation. He points out that when a child lacks the necessary skills to behave in a more adaptive manner, incentives and negative consequences just add to frustration. Greene also takes a broader view than do behavior analysts when thinking about the function or underlying reasons for a behavior. His system incorporates exploration of multiple developmental pathways to identify critical areas of lagging skill development. This concept allows for an integration of findings from psychoeducational evaluation and functional analysis by taking into account relative strengths and weaknesses in domains such as cognition, executive functioning, language, and social-emotional development in determining the focus of behavior support plans. Finally, the CPS approach promotes greater partnership and a less adversarial relationship between the student and adults who work with that student as well as increased student ownership of the problem and the solution.

Good luck! If you try this system, please let me know whether you found it helpful.

Resources on CPS:

Greene, Ross W. The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, “Chronically Inflexible” Children. New York: Harper Collins, 1998.

Greene, Ross W., and J. Stuart Ablon. Treating Explosive kids: the Collaborative Problem-Solving Approach. New York: Guillford Press, 2006.

Greene, Ross W. Lost at School: Why Our Kids with Behavioral Challenges Are Falling Through the Cracks and How We Can Help Them. New York: Scribner, 2008.


  • We aren't seeing any improvement in memory or comprehension. Any ideas on what we are missing?

Question:

My daughter was adopted from Russia at 3 1/2 we know that her first two years were very bad. She was born from a mother who used drugs and alcohol, but she did not have any signs of fetal alcohol syndrome. She does have scars on her body from abuse, one on her head. When we brought her home she was very small and didn't speak much. We have been thru counseling to help with the abuse, she had her adenoids removed due to constant infections causing hearing problems, she has seen a Neurologist and hearing specialists, and is now on Vyvanse for ADD. Now fast forward to her turning 9 in January and competing at State level two years in a row in gymnastics.

I still think she is not diagnosed correctly and is not getting the specific help she needs. She is very forgetful, just last night she said, "I have "radish" on my fingers" as she was clearing her plate. We weren't eating radishes. What she was trying to say is that she had "dressing" on her fingers but could not come up with the word and had no idea what a radish was, and that is just one example. She also does things like walk away and leaving the faucet running after washing her hands. She is always forgetting where she puts things. She struggles in school but they have always said "it was because of her first 3 1/2 years knowing another language" and have put her in reading programs. She can read just fine, but can't recall what she just read. Her current doctor said it is ADD, and she is unable to focus, therefor she isn't able to recall things. But I'm still not convinced because we aren't seeing any improvement in memory or comprehension.

Any ideas on what are we missing and how I help my girl?

Thank you.


Answer:

The above submitted question was answered jointly by Dr. Stivers (clinical psychologist) and Dr. Digges (behavioral pediatrician). It will appear in both the Mental Health and School Related Medical Issues sections of Ask A Specialist for April, 2009.

Thank you for writing. It appears that your daughter is doing far better than are most of the children we see with similar backgrounds. Many of them function well below age level in many areas, have extreme difficulty with interpersonal relationships, and engage in explosive, out-of-control behavior. Evidently your daughter is a resilient individual who had the amazingly good fortune to find a dedicated parent with the skills and persistence to consistently provide a supportive and enriching environment. You should be very proud of her and we hope that you also take pride in your role in supporting her success.

Despite having overcome the odds for someone with her early history and having developed areas of competence, such as gymnastics, your daughter still seems to struggle to master some of the skills she needs. Your concern is that her ADD* diagnosis is insufficient to explain her current problems. We concur. Even though “she did not have any signs of fetal alcohol syndrome,” we cannot conclude that she was unaffected by prenatal exposure to alcohol. Recent literature suggests that alcohol exposure needs to occur sometime between day 21 and day 24 of development (i.e. before mother knows she is pregnant) in order for the classic facial features of fetal alcohol syndrome to be manifested. The implication of this research is that we now realize that children can be exposed to large amounts of alcohol over an extended portion of their fetal development, and still “look normal.” Unfortunately, their brains may have suffered significant damage as a result of the neurotoxic effects of alcohol. Children whose brains have been injured by prenatal exposure to alcohol but who appear normal can be diagnosed with ARND or alcohol related neurodevelopmental disorder.

An additional risk factor for her stems from the potential negative impact on the development of her brain as a result of the abuse to which she was subjected. Recent literature in this field indicates that the essential processes of synaptogenesis (brain growth) and synaptic “pruning” (trimming back of unused pathways) can be impaired by limitations in the quality or number of unconditionally supportive relationships with caring adults in the early years of development.

As you might suspect, children with ARND and a history of abuse often have sustained significant injury to broad regions of the brain, so they may experience a wide range of consequences. These can include a negative impact on:

  • executive functioning (mental control over attention, thinking, and behavior)
  • learning and memory (assimilating, storing, and retrieving information)
  • language (understanding language and/or self-expression)
  • visual processing (includes pattern recognition, visual discrimination)
  • sensory processing and modulation (tendency to over- or under-react to sensations such as touch or sound and experience chronic discomfort)
  • motor development (fine, gross motor coordination, visual-motor integration)
  • social development (social insight and skills for developing relationships)
  • higher-order reasoning, abstract thinking, and problem-solving

Your daughter appears to have challenges in the first area, executive functioning. Executive functions include the abilities to resist distractions and focus on what we need to do, organize and keep track of materials, find effective strategies to accomplish tasks, and develop and follow through on plans. Difficulties with executive functioning are highly characteristic of AD/HD. The absent-minded behaviors you described, such as forgetting to turn water off and where she put things, are part of her your daughter’s AD/HD. Have these behaviors improved since she started taking medication? Children with AD/HD typically have trouble focusing on what they’re doing unless extremely interested in the activity itself or in being with the individuals who are performing the activity. Gymnastics may qualify, but not the water running in the sink. The brains of children with AD/HD tend to function best when they are participating in an activity with which they are emotionally connected (novel, related to interests….). It is very likely that her AD/HD also contributes to her lack of reading comprehension (she decodes the words automatically but doesn’t pay continuous attention to content), although there may be other factors involved.

Interventions can help improve the functioning of children with AD/HD. These interventions generally consist of environmental modifications and instruction to increase critical skills. “To-do” lists and visual charts or checklists for daily routines can help remind her to follow steps in the proper sequence, even though they may “slip her mind.” Labeling where things go with words and/or pictures may also be helpful. To the extent possible, making mundane activites appear novel or connecting boring tasks with desirable rewards may help to establish the emotional connection which is believed to contribute to normalizing the brain function of children with AD/HD.

Your daughter may remain “absent-minded,” but it will be less disruptive to the flow of her day. Often, especially as they progress to higher grades in school, students with AD/HD also need ongoing help with study skills, organization of time and materials, and project planning. You and the staff at her school can collaborate to support her organizational, planning, and study skills.

Your letter also suggested that your daughter may have some challenges in the area of verbal learning and memory. The radish-dressing word substitution incident indicates that she may sometimes have word-finding problems based on inefficient storage (mental organization) and/or retrieval of verbal material. Many of us experience word-finding problems at times and it can be quite frustrating. From your letter, it is unclear to us how significant a problem this poses in her life. Does it occur every 10 minutes or once or twice a week? Does she seem distressed about it? Is it interfering with her learning in school or social interactions?

There are several strategies for helping children successfully manage word retrieval difficulties. You may wish to consult with the staff at your daughter’s school, especially the speech and language therapist. For further suggestions about executive functioning and word retrieval, google: “CHADD” and “All Kinds of Minds.”

Overall, AD/HD appears to be an accurate diagnosis for your daughter in that it describes several of the difficulties that significantly impact her functioning. However, you are probably correct in pointing out that it does not encompass all of the areas in which she experiences difficulty. The diagnoses of ARND (alcohol related neurodevelopmental disorder) and mixed neurodevelopmental disorder may also be appropriate. Post Traumatic Stress Disorder (PTSD) is seen in some children with a history of abuse, but we do not have enough history to know whether this may have applied to your daughter.

Medically, the use of pharmaceuticals can often help normalize abnormal brain physiology. The goal is to achieve an acceptable balance between symptom resolution and side effects, and this delicate balance can best be obtained by working closely with her physician.

Educationally, no matter what her medical diagnoses, interventions may be warranted in areas where she is having difficulty acquiring the skills she needs. It is not clear from your letter how severe her difficulties are with word retrieval or reading comprehension. Do these difficulties interfere significantly with learning, resulting in below grade level skills? If so, and if it has not already been done, you may request that the school district conduct a psychoeducational assessment. This should result in a more thorough understanding of her learning strengths and weaknesses and lead to either formal or informal plans to remediate any identified learning or language weaknesses.

We hope this information is helpful. Thank you for writing, and we wish you and your daughter continued success.

Marji Stivers, PhD, Clinical Psychologist 
John L. Digges, MD, PhD, Behavioral Pediatrician

*ADD or ADD without hyperactivity were terms that were replaced in the 1994 DSM IV (Diagnostic and Statistical Manual, 4 th Edition) with “AD/HD Predominantly Inattentive Type.” We suspect from your letter that this is your daughter’s diagnosis. Children with this subtype often respond to lower potency and lower doses of stimulant preparations than do children with hyperactivity.


  • Learning disability and "social phobia."

Question:

Have you had any students referred who are diagnosed with a learning disability and “social phobia?” We seem to see an increasing number of early adolescents with this profile and I am not sure we are doing everything to meet their needs.

This is from the program specialist in Sacramento whom you recently helped clarify a student’s needs.


Answer:

Thank you for calling attention to a group of students who, because of their dual challenges, can easily be misunderstood and have needs that get overlooked. At the Diagnostic Center, we have seen a few students with both a learning disability and social phobia. As far as I can recall, none of these students had both conditions identified when they were referred to us, so our assessments resulted in one, or both, of the diagnoses. We suspect that there that there are many more students like them out there struggling in school. You and your district are strongly commended for your recognition of the dual challenges faced by these students and your commitment to addressing their needs.

Students with learning disabilities and social phobia are indeed challenging to serve. Each diagnosis has separate dynamics and the problems must be understood and addressed separately as well as together. First, for those who are not familiar with these disabilities, a brief description of each disability is provided below.

Learning Disabilities

Students with learning disabilities (LD) have the overall intelligence to learn grade-level material, but show major differences in the ways they learn. Without intervention, their learning differences result in academic progress that is significantly below grade level and below their abilities. Learning differences are associated with highly uneven profiles of cognitive ability. For students with LD, areas of strength are accompanied by one or more areas of weakness in the ways they perceive, process, store and retrieve, or communicate information . These cognitive “glitches” can impede students’ progress in reading, writing, or math, or can interfere with their capacity to complete assignments or demonstrate their knowledge. In response to standard academic instruction, their learning disabilities prevent them from learning the same amount of material at the same rate as most other students with similar levels of intellectual ability. To have equal access to opportunities to learn the material and acquire the skills in the school curriculum, students with LD need specialized instructional techniques and/or adaptations designed to meet their individual learning needs.

Though LD is often diagnosed during the first half of elementary school, it can become apparent later on. Sometimes during the early grades, when the curriculum is less demanding, a bright student is able to use his/her strengths to compensate for weaknesses, but as the demands increase, the student shows increasing difficulties. Sometimes a student’s weakness in cognitive functioning may involve higher order linguistic processes or abstract reasoning and these difficulties may not affect mastery of curriculum until close to middle school when there is a steep increase in the complexity of academic demands.

Social Phobia/ Social Anxiety Disorder

Educators and parents are less familiar with social phobia than with learning disabilities, so it will be described and discussed in greater detail. Social phobia, currently more often referred to as social anxiety disorder (SAD), is characterized by persistent fears, extreme anxiety, and acute self-consciousness during situations when the student feels that his/her social or academic performance may be observed, scrutinized, or evaluated by others. Social anxiety can take a variety of forms in different individuals and can also vary in degree.

Some socially anxious students fear only a limited number of social situations, such as speaking in front of a class or other large group. Others may be able to deliver a prepared speech, but fear spontaneous conversation, especially with unfamiliar people, and experience severe anxiety during unstructured social settings, such as lunch or free time. Still others may be prone to panic about situations in which their knowledge, ideas, or skills are exposed to others, such as responding to questions when called on in class, taking tests, or turning in written work to be graded. Individuals with social anxiety can be extremely vigilant about looking for clues about the ways other people respond to them and highly sensitive to criticism. Feeling pressure to perform can provoke such intense fears that they either shut down as though “frozen” with fright or feel compelled to escape.

Students with social anxiety can be quite similar to others in their age group when they are at home with familiar people and feel safe. They are very different and far more inhibited at school, where they are expected to perform while surrounded by a large and fluctuating group of peers and adults, many whom they do not know well. Although SAD can emerge at any time from early childhood to adulthood, social anxiety often develops shortly before early adolescence, because this is the time in life when most people develop heightened awareness and self-consciousness about being observed, and perhaps judged, by others. Many adults who have or had SAD report that high school was the most difficult time for them and that their symptoms peaked then and later improved.

It is important to note that it is entirely normal, shortly before and during adolescence, to experience periods of increased self-consciousness and to be easily embarrassed and worried about what others think. These characteristics are usually transitory. Symptoms of social anxiety are not labeled as a disorder unless these symptoms are intense and interfere significantly with an important area of life, such as school functioning, on a consistent basis for a substantial period of time.

Learning Disabilities Combined with Social Anxiety

Both LD and SAD are often associated with underachievement in school. Even with intensive, specialized instruction, learning can require more effort and be more frustrating and exhausting for students with LD and they often fall behind their peers. For students with social anxiety, poor grades may result from lack of participation in class discussions, failure to ask questions or seek clarification, and from shutting down or avoiding situations, such as tests and graded assignments, in which student work is exposed to evaluation. Extreme fear of taking risks, such as trying new skills or sharing ideas while being open to observation and feedback, can limit the student’s intellectual and personal development.

The combined force of the two diagnoses can undermine school success beyond the sum of problems produced by each condition. This is because the diagnoses not only combine, but also interact; each condition is likely to exacerbate the other and make it more disabling. A learning disability can foster insecurity that contributes to social phobia and social phobia can lead to avoidance of academic work, compounding the effects of a learning disability.

While many students with learning disabilities do not experience mental health problems, school can be quite stressful for these students and they are at increased risk of developing social and emotional difficulties. They may experience years of putting out strenuous effort and feel disappointed with themselves, or worried that they have disappointed others, because of their slow academic progress. Many students with LD are acutely aware that they have fallen behind their peers. Some feel stigmatized about needing “extra help” such as accommodations or resource program support. These experiences can cause embarrassment or self-consciousness which, in a child vulnerable to anxiety, can contribute to the development of SAD.

For students with LD, learning is already a challenge and SAD can lead to self-handicapping behaviors that make LD more difficult to overcome. SAD may also keep students from getting necessary help. Extreme social anxiety can even lead to school avoidance.

What Can be Done to Help?

Students with both LD and SAD need interventions and services that specifically target each disorder while taking the other disorder into account. LD is usually addressed primarily through specialized instruction that supplements or replaces standard instruction. This may be accompanied by accommodations, such as the use of calculators in math or extra time for taking tests, and/or modifications in materials or assignments. Special education teachers, and some general education teachers, are relatively experienced in designing interventions and supports for students with learning problems. However implementation can be far more difficult when the student also suffers from social anxiety. One student we worked with was terribly anxious about her friends seeing her entering or sitting in the resource classroom for one period each day. Negotiations were made with the resource teacher to allow the student to arrive once the hallways were empty, just after class was scheduled to start, and to have an assigned seat where she could not be seen from the doorway. Flexibility is a major advantage in working with students with dual diagnoses.

While LD is a relatively stable condition, anxiety can shift dramatically over time and across environments. The good news is that effective treatments for anxiety disorders generally lead to significant improvement. On the other hand, anxiety disorders can increase quite suddenly and rapidly. In working with students with SAD, the first focus of intervention should be on establishing school and classroom practices that help the student feel comfortable and safe. It is essential to start where the student is, and to respect the limits set by the student, because social anxiety can escalate quickly and become so severe that the student becomes overwhelmed by anxiety and cannot remain in class or school. While the long-term goal of intervention is increased participation, it is necessary to start by stabilizing the student in school.

  • Mental Health Support

Though school staff can identify and minimize sources of anxiety and stress at school, treatment for anxiety disorders, including social anxiety, should have a strong component of mental health (and sometimes medical) support. Mental health services would generally involve cognitive-behavioral therapy, development of emotional coping strategies, and systematic desensitization. Collaboration between the mental health provider, family, and school team can be very helpful in helping the student explore new ways of thinking about situations and develop stronger coping skills. The mental health provider can let the team know the skills being worked on in therapy. Then team members can facilitate practice of those skills in everyday environments through modeling the skills, cuing the student when to use them, and reinforcing the student’s efforts.

A therapeutic treatment with demonstrated success in treating social anxiety is systematic desensitization. This calls for starting where the student is comfortable and very gradually and systematically adding small elements that trigger anxiety, while helping the student remain relaxed. the gradual, systematic desensitization to feared situations in program. For instance, the student might relax and do something pleasant with a familiar individual. One other person is introduced who, at first, sits across the room and engages in another activity. The second person gradually moves closer, then begins to observe the activity, and eventually joins in. One at a time, in a similar manner, more people are gradually introduced. A desensitization plan is highly collaborative, implementation requires cooperation, and the plan is ideally developed through teamwork between the mental health support person, school personnel, family, and student.

  • When the student is on medication:

Sometimes students are prescribed medications such as specific serotonin re-uptake inhibitors (SSRIs) to address extreme social anxiety. These medications often have less noticeable impact at home than at school, because these students generally show far less anxiety to begin with at home. It is ideal for the instructional team, parents, and physician maintain close, consistent contact to share observations and comments on the effects of his medication so that reliable information is available for evaluating the medication’s effectiveness and making decisions about dosage.

Other recommendations:

  • Ensure that everyone involved understands the “whole student” and is aware of individual strengths as well as disabilities. All interventions should be aimed, directly or indirectly, to increase the student’s self-confidence, self-acceptance, and self-advocacy skills.
  • Maximize collaboration and coordination of services among general education teachers, special education teacher, and other service providers (speech, occupational therapy…).
  • In order to avoid exacerbating social anxiety by making the student with LD feel stigmatized, accommodations and modifications should be as inconspicuous as possible and delivered in a low-key manner. Try to avoid or minimize special education supports that make a student stand out from peers. For instance, when a student receives 1:1 push-in support, the support staff should circulate and assist other students as well.
  • Remember that the SAD student does not want to attract attention. Generally, even positive messages of encouragement or praise for accomplishments should be delivered in ways that are not too dramatic or public.
  • Offer alternate assignments to avoid areas of particular difficulty (e.g. a special project to replace a class presentation). When possible, make these options/alternatives available to all students in the class.
  • Some students with social anxiety have one or more close friends with whom they feel more relaxed and less inhibited. For such a student, consider having her work with a close friend as a study partner or carry out project in a small group of peers with whom student is familiar and comfortable. Members of team assigned roles in project based on strengths. When carefully designed, group work/projects can dramatically decrease performance anxiety.

 

Some of them constantly compare their work unfavorably with that of their peers and feel ashamed or “dumb.” Feelings of helplessness, hopelessness, and worthlessness can evolve into anxiety and/or depression and years of disappointment or humiliation about academic performance can lead to school-related anxiety disorders.