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Mental Health Archive 2011

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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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  • Are there any specific recommendations you would make in regards to working with a child with Tourette that would be different than for a child with ADHD?

This question overlaps School Related Medical Issues and Mental Health, so this response is from the DCN behavioral pediatrician and clinical psychologist.

Question:

I am a speech therapist in the Oakland school district. And I have a kindergarten student whose father has Tourette Syndrome.  My student has pretty significant articulation and expressive language delays, and also has a hard time focusing on one task long enough to see it through to completion. I have seen other children with more severe deficits and therefore am reluctant to say he has ADHD.  I am wondering what I should be looking for and when to become concerned that he has inherited the disorder.  I have not noticed any “tics” per se.  Also, are there any specific recommendations you would make in regards to working with a child with Tourette that would be different than for a child with ADHD?


Answer:

It appears that your student has delays in expressive language and articulation difficulties; and that you are concerned that he may have other, possibly inherited, conditions.  In the event that he has made minimal progress in meeting his language goals in the classroom, you might be understandably worried that his limited progress may be due in part to his having possibly inherited Tourette syndrome (TS),  attention-deficit/hyperactivity disorder (ADHD), or both from his father.  Although these are reasonable possibilities to consider, a comprehensive evaluation will be needed to accurately determine his diagnoses. Once he has been thoroughly evaluated and diagnoses have been established, then we would be in a better position to advise you about specific symptoms to watch for and particular strategies which have been effective in the past for students having the same diagnoses.

Genetic factors appear to play a significant role in the transmission of both TS and ADHD. Although only about 7% of the children diagnosed with ADHD will also meet the diagnostic criteria for TS, somewhere between 60-90% of the individuals who have TS will meet the diagnostic criteria for ADHD.  If your student’s father indeed has TS, then it is quite possible that he meets the diagnostic criteria for ADHD as well. If so, his son has an increased probability, relative to the general population, of having TS (inheritable), ADHD (inheritable), or both conditions simultaneously.

Tourette’s Syndrome

In order to be diagnosed with TS, there must have been multiple motor tics along with at least one vocal tic occurring several times nearly every day for more than one year. The onset of the tics must have occurred prior to 18 years of age, there can never have been a “tic-free” period of 3 months or longer, and the individual cannot be taking a medication or have another medical condition which could better account for the tics.

Tics are sudden, purposeless, involuntary muscle movements or vocal sounds. Some common motor tics include head jerking, twitching, squinting or grimacing. Common vocal tics include tongue-clicking, throat clearing, yelping, or whistling. These movements and sounds are not dangerous or harmful, but are often embarrassing. Tics usually show up during childhood or early adolescence, most commonly around 5-7 years of age and occur more frequently in males than in females. Transient tic disorder of childhood (a period of time with occasional tics) is not uncommon and is not the same thing as TS. 

ADHD


When a student’s excessive distractibility, inattentiveness, impulsivity and hyperactivity seem to interfere significantly with their success in school, this student might very well meet the diagnostic criteria for ADHD (see DSM IV TR). If you have such concerns, then it is reasonable to communicate your concerns to the child’s parents. You might explain that you have observed that he appears to be struggling and is not performing at the level you feel he may be capable of performing. You might suggest that this is not due to lack of motivation or effort and suggest that there could indeed be a neurobiological condition which is responsible for the gap you perceive between their child’s potential and productivity. The parents might then consider referral to a clinician who is knowledgeable about and experienced in diagnosing children with such symptoms.

Obtaining Accurate Diagnoses

The first step for the clinician typically involves obtaining a thorough history, including records from the school and other involved professionals. A physical exam and occasionally laboratory testing can help rule out other medical conditions that could cause the child’s symptoms. Once all of the relevant information has been gathered and analyzed, the clinician should be able to ascertain which diagnosis or diagnoses best fit the student.

In the event that a student is determined to meet the diagnostic criteria for both TS and ADHD, it is generally desirable to consider which disorder is causing the most severe impairment for the child. In most cases, the ADHD will be more pervasive and would therefore be addressed first. However, there are certainly instances in which the TS symptoms are particularly severe and disruptive; and in such situations, it would be prudent to address those symptoms first.

Approaches to Treatment

You also asked about treatment recommendations for children with TS and ADHD.  Making an accurate diagnosis or diagnoses is critical, as that will help determine the optimal treatment strategy. Non-pharmacologic interventions are important components of the treatment approach in both conditions. In some cases of TS and in some cases of ADHD, non-pharmacologic strategies may produce sufficient symptom reduction so that medications may not be indicated.
Medications also may be considered as part of the treatment regimen.  One approach  to figuring out optimal medication(s) and dosage(s) is to focus first on a key symptom (or symptom cluster) of the condition felt to be most debilitating. Start with a low dose of a single medication to target the symptom, then titrate the dose upwards gradually until significant symptom reduction is observed. This approach favors the sequential introduction of medications as opposed to beginning two or more medications simultaneously. Although this approach requires some patience, it makes it much easier to identify the medication and dose which are most likely responsible for any deleterious side effects noted during the course of therapy. This strategy also may reduce the incidence of drug-drug interactions, which can be very challenging to identify. After the symptoms responsible for the most severe impairment have been addressed, then a treatment decision can be made about how best to approach any significant symptoms which remain.

School Support

Of course, selection of school accommodations and strategies are determined by an individual student’s needs of a particular child rather than by diagnoses.  Some approaches have been found useful for many children with similar characteristics and these provide a good place to start.
Some general things to keep in mind about TS and ADHD:

  • Both disorders increase the likelihood of disruptive classroom behavior; these disorders involve limited capacities for inhibition, so students may interrupt or blurt things out more frequently than other students do. To some, these behaviors may appear to be willfully defiant, oppositional, and manipulative. However students with these disorders actually have very limited control over many of the behaviors that disrupt instruction. Negative or punitive reactions by staff are ineffective and may lead to negative student attitudes about school.

  • Difficulties with handwriting are commonly associated with ADHD and TS. Students may need extra time to complete work, shorter assignments, or greater assistance.

  • Students with both ADHD and TS are at increased risk of developing anxiety disorders and should be monitored for anxiety symptoms, particularly obsessive-compulsive behaviors (described in a previous Mental Health AAS question).

  • Students with either or both disorders are easily overwhelmed by an ordinary day of school.  “Holding it in” or exerting effort to stay under control all day leads to an accumulation of stress, frustration, and/or fatigue; creating a strong need for restorative time. Some students may shut down or become hyper-irritable or explosive toward the end of the school day or when they arrive home from school. 
     
  • When a student has both disorders, keep in mind that TS may magnify the ADHD symptoms. For example, efforts expended to suppress tics may cause further interference with attention and concentration.
  • When students have both disorders, ADHD generally interferes with school performance more than does TS. We recommend that you first try standard ADHD accommodations; such as preferred seating, visual reminders, checklists, and graphic organizers. Help the student with transitions, organization of materials, checking completed work, and getting the completed work actually turned in.
  • TS accommodations should include unobtrusive ways for the student to signal the teacher and take breaks from classroom when necessary.

  • For students with TS, after obtaining permission from their parents, consider arranging for disability awareness training to help classmates understand why the student jerks or growls or displays other tic-related behaviors.

For all students, but especially students with ADHD, TS or both:

  • Help develop and nurture the student’s strengths and interests;

  • Maximize the student’s emotional connections to the material being learned by utilizing the student’s favorite topics to illustrate concepts;

  • Provide a calm, supportive, and structured, yet flexible, classroom environment with clear expectations and predictable routines;

  • Alter types of activities throughout the day and include sufficient breaks and opportunities for movement; and

  •  Accommodate the child’s need to fidget, as long as the fidgeting is not disruptive to the teacher or other students.

Thank you for your question. We hope that our discussion and suggestions are helpful.

John L. Digges, M.D., Ph.D., Behavioral Pediatrician
Marji Stivers, Ph.D., Clinical Psychologist


  • Information about OCD diagnosis and the proper treatment.

Question:

I would like information about OCD diagnosis and the proper treatment.

What do you recommend?

Judith Spicker


Answer:

Thank you for your question. Many people are acquainted with the term OCD (for obsessive-compulsive disorder) and some use it informally to describe other people whose behaviors they find excessive and irritating (e.g., “…she’s just being so OCD again about…”). Yet even those who are familiar with the term generally know little about the actual disorder and how it is diagnosed and treated, especially in children. The observable symptoms shown by students with OCD look nearly identical to the symptoms of several other child and adolescent disorders. This can easily lead to misinterpretation, incorrect assumptions, and ineffective approaches to treatment.  

About Obsessive-Compulsive Disorder

OCD is an anxiety disorder characterized by intrusive, recurrent obsessions and/or compulsions.  Children and adolescents nearly always experience both.  The thoughts and behaviors associated with OCD are time-consuming and interfere with daily life at home, at school, or in the community or cause significant distress. Although this disorder is generally diagnosed during adolescence or early adulthood, it is sometimes identified in younger children. Estimates range from about 1 in 100 to 1 in 200 for the school-age population.

Obsessions:

Obsessions are persistent, repetitious thoughts, impulses, or images. The thoughts are unwanted and recognized as irrational, even by the person who experiences them (although there is some leeway in this requirement for younger children). Many obsessive thoughts involve profound fears, such as being contaminated by touching everyday objects or harmed by intruders who break in through doors left unlocked.  Some children become excessively anxious about disorder.  Obsessions also can take the form of violent, sexual, or “blasphemous” thoughts, especially on the part of someone raised to be and invested in being peaceful, moral, or religious. The anxieties inherent in obsessive thoughts do not appear to be strongly related to any real-life problems the child is experiencing.

Compulsions:

Compulsions are repetitive behaviors that the child feels compelled to perform to reduce anxiety and counteract obsessive thoughts. Although they “know better,” they often feel that performing the compulsive behaviors is the only way they can prevent the dreaded outcomes with which they are obsessed. Some compulsions take the form of overt behaviors, such as repetitive hand-washing, checking locks every few minutes, or constantly re-arranging items to keep everything “just right.” Other compulsions can be either overt or covert, depending on whether or not words are spoken aloud. These include praying, ritualized counting, or reciting a particular phrase over and over. 

The compulsions that characterize OCD are extremely time consuming and irrational or excessive, e.g., washing hands for several hours/day or checking every few minutes that an action has been completed (e.g., door locked, burner turned off, alarm turned on). Some compulsive behaviors can be irritating to others, such as constant requests for reassurance or arranging and re-arranging of items every time anything gets moved.

Compulsive acts are not performed for pleasure or gratification. The person behaving compulsively feels “driven” by anxiety and performing the compulsive behavior alleviates the stress. However once dispelled, distress builds up again rapidly and the person feels “driven” to repeat the compulsion. Compulsive mental or behavioral rituals are often accompanied by shame or a fear of “going crazy,” so a child or teenager may be secretive or sneaky about symptoms. Even overt behaviors may not be immediately apparent to others. 

Clues That a Student May be Struggling With Obsessions and Compulsions:

  • Frequent disappearances or long periods of time unaccounted for (e.g. prolonged trips to the bathroom to wash hands).
  • Secretive behavior; vague or ambiguous responses to routine questions about what he or she is or has been doing.
  • Decreased attention, concentration; the student may seem preoccupied or “consumed’ by thoughts.
  • Decline in school performance and productivity.
  • Withdrawal from friends and previously-enjoyed social activities.
  • Distress over small things (e.g. someone moves an object, disrupting the child’s arrangement).
  • Arguments or tantrums precipitated by requests that interrupt or interfere with the child’s rituals.
  • Defensiveness; lack of willingness to acknowledge or discuss observed symptoms.

Diagnosis and the Relationship with Other Disorders:

OCD is complex and should be diagnosed and treated by a mental health professional, such as a child psychiatrist or psychologist.  Accurate diagnosis can require extensive time, information, and analysis. 

One diagnostic complication is that many of the OCD symptoms listed above overlap with common characteristics associated with other disorders. For example, agitation when someone moves an object, disturbing the child’s careful arrangement, is a typical feature of the autism spectrum disorders. Increased self-isolation and withdrawal from friends and activities are frequently signs of depression. Throwing tantrums when a sequence of activities is interrupted or insistence on doing everything just the way the child thinks it should be done can lead to the child being labeled oppositional, defiant, or spoiled. These similarities to other disorders make it easy for a child’s behavior to be mislabeled and OCD to be missed. 

There is a further complication posed by the possibility that a child with OCD may have additional disorders, or co-occurring conditions. For example, a child with OCD may also have an attention deficit, depression, or another disorder. Diagnosis of co-occurring conditions can be tricky.  For instance, it is important to remember that obsessive-compulsive thinking disrupts attention and concentration, so it is necessary to obtain a complete history before making an additional diagnosis of attention-deficit/hyperactivity disorder (AD/HD).

Students diagnosed with OCD during the elementary school years are predominantly boys and the most likely co-occurring conditions are AD/HD and Tourette’s Disorder (a tic disorder). By the time students approach the high school years, girls are at least equally likely to be diagnosed. At this age, the more common co-occurring conditions include other anxiety disorders, such as social anxiety and panic disorder, or mood disorders. Other potential co-occurring conditions for students include learning disabilities, eating disorders, or thought disorders. Because co-occurring conditions are fairly common, it is important not to automatically attribute all difficulties in school to the student’s OCD.

The Recommended Approach to Treatment

OCD is considered a neuropsychiatric condition, not a response to intra-psychic conflicts or poor parenting. Psychodynamic or other “talk” therapies which focus on exploring the meaning of the symptoms are unlikely to help and may increase obsessions. The recommended approach to treatment includes cognitive-behavioral therapy, medication, or a combination. This combination appears considerably more effective than therapy or medication alone. If untreated, OCD symptoms may worsen and increasingly jeopardize adjustment at home and school. 

The class of medications recommended to treat children and adolescents with OCD are SSRI’s (selective serotonin reuptake inhibitors), which are commonly prescribed for depression and anxiety in children and adults. Medication may work alone, but often appears to enhance the effectiveness of behavioral therapy. Once treatment goals are reached, medication may no longer be needed. However, it may need to be discontinued gradually rather than stopped abruptly and the prescribing physician will advise on this.

A highly structured therapeutic approach called “cognitive behavior therapy with exposure and response prevention” is considered best practice. The treatment initially targets compulsive behaviors, but many report a decrease in obsessions as well. The therapeutic goal is not to cure OCD (this may not be realistic), but to drastically minimize or eliminate interference with daily life. Treatment will likely require only 10-20 sessions and must be conducted by therapist trained in this method. Medication is generally recommended in conjunction with behavioral therapy and appears to enhance the rate and effectiveness of therapy. 

Cognitive-behavioral therapy with response prevention generally follows the following sequence:

  • Education -- Provide information on OCD and treatment to student and family

Education should help anxiety or embarrassment on the part of the student and family and clear up misinterpretations about the student’s behaviors.  Another purpose is to help them prepare for treatment and enlist their cooperation by describing each step and explaining the rationale.

  • Goal-setting -- Selection of target behavior and goal.

Target only one or, at most, two behaviors. Individuals who are successful in reducing at least one compulsive behavior generally report a decrease in other compulsions as well as fewer obsessions as well as a reduction in anxiety.

  • Anxiety Management Training – Support the student in developing coping skills and techniques for managing anxiety. 

This training increases a student’s sense of mastery and helps provide confidence that can be crucial when a student is asked to face his or her fears.

  • Exposure With Response Prevention – Arrange gradual exposure to fears that trigger compulsions along with prevention of the compulsive response. 

This is the time coping skills are put to the test.  Start with minimal discomfort; exposure can be imagined at first, if necessary.  When the compulsion is prevented (physical prevention of hand-washing or checking, distraction and instruction to avoid repeating phrases), anxiety will build. Then it will gradually diminish as the child habituates to the situation and feared outcomes do not occur.

  • Continue with exposure and response prevention until goals are reached.