Month: April 2012

Intellectual Developmental Disorder / Mental Retardation

The term “mental retardation” is an often-misunderstood term and since it is seen as derogatory in the general public we use the term “intellectual disability.”  In general people believe that retardation is only diagnosed on the basis of below-normal intelligence (IQ), and that those with intellectual disabilities are unable to learn or to care for themselves.   This is actually not true.  In order to be diagnosed as a person with intellectual disabilities, the individual has to have both a significantly low IQ and considerable problems in everyday functioning. Most of those with intellectual disabilities can learn a great deal, and in adulthood can lead at least partially independent lives.  The reason for this is like anything else there are degrees of impairment and most individuals with intellectual disabilities have only a mild level of impairment. However, those with intellectual disabilities may also have several different physical and emotional complications.  For instance, they may have difficulty with hearing, sight or speech.

There was a time when parents were advised to institutionalize a child with significant intellectual disabilities. Today, on the other hand, the goal is to help the child with intellectual disabilities stay in the family and take part in community life. This is made easier by the fact that in most states, educational and other services are guaranteed at public expense.

Since every individual is unique in his or her impairments, it is very important that the child has a comprehensive evaluation to find out about his or her strengths and areas of growth needed.  Due to the fact that no specialist has all the necessary skills, many professionals might be involved. General medical tests as well as tests in areas such as neurology (the nervous system), psychiatry, psychology, special education, hearing, speech, vision, and physical therapy are often useful. A pediatrician or a child and adolescent psychiatrist often coordinates these tests.  Serving as a central coordination point for these services, physicians refer the child for the necessary tests and consultations, put together the results, and jointly with the family and the school develop a comprehensive treatment and education plan.

In addition to the intellectual disabilities, emotional and behavioral disorders may be present and may interfere with the child’s progress. Most children with intellectual disabilities recognize that they are behind others of their own age. Some may become frustrated, withdrawn or anxious, or act “bad” to get the attention of other youngsters and adults. Adolescents and young adults with intellectual disabilities may become depressed as they gradually become more aware that they are different.  It is important to keep in mind that since they may not have enough language skills to talk about their feelings, their depression may be shown by new problems, such as in their behavior, eating and sleeping.

Keep in mind that early diagnosis of psychiatric disorders in children with intellectual disabilities leads to early treatment and that medications may be helpful as ONE part of an overall treatment plan in those with intellectual disabilities.  Periodic consultation with a child and adolescent psychiatrist can help the family in setting appropriate expectations, limits, opportunities to succeed, and other measures, which will help their child, handle the stresses of growing up.

Sleep Problems

What Do Sleep Problems Consist Of?

Many people, including children, have sleep problems; in fact they affect about 10 to 40% of the population.  They include such things as:

  • Frequent awakening during the night
  • Talking during sleep
  • Difficulty falling asleep
  • Waking up crying
  • Feeling sleepy during the day
  • Having nightmares
  • Sleep terrors (in children)
  • Bedwetting (in children)
  • Teeth grinding and clenching
  • Waking early
  • Narcolepsy

Many sleep problems are related to poor sleep habits.  Poor sleep habits tend to occur when an individual gets used to doing many things in their bed:  reading, watching TV, playing video games, talking on the phone, eating, etc.  The end result is that the mind and body lose perspective of what a bed is for, because in those individuals it can be anything and everything.  So when it is time to sleep, the body doesn’t have a different feeling than any other time and resists falling asleep.

Additionally some sleep problems may be symptoms of stress.  In children persistent sleep problems may be a symptom of emotional difficulties or a fear about going to bed and falling asleep.  “Separation anxiety” is a developmental landmark for young children. For all young children, bedtime is a time of separation, but some children will do everything they can to prevent a separation at bedtime.  To help minimize common sleep problems, a parent should develop consistent bedtime and regular bedtime and sleep routines for children. Parents often find that feeding and rocking help an infant to get to sleep. However, as the child leaves infancy, parents should encourage the child to sleep without feeding and rocking. Otherwise, the child will have a hard time going to sleep alone.  Simply put, the child will expect whatever they got used to when they first learned to fall asleep.

What Types Of Sleep Problems Are There?

Sleep disorders can be related to problems initiating sleep, maintaining sleep, or resulting in excessive sleep.  They can affect the amount, quality, or timing of sleep and even result in behavioral abnormalities that occur during sleep.

Advanced Sleep Phase Syndrome – is a condition in which a person falls asleep very early in the evening, usually between 6 and 9pm, and then wakes up in the middle of the night before sunrise, sometimes as early as 1 am.

Bedwetting – also known as enuresis, is a condition in which a person (usually a child) urinates on the bed while sleeping.

Bruxism – – is a condition in which a person grinds their teeth or clenches their jaw during sleep.  It is one of the most common sleep disorders affecting up to 40 million Americans. Bruxism can result in serious damage to the teeth so getting treatment is very important.  It can also lead to facial pain and headaches, and in severe and chronic cases, it can lead to deterioration of the temporomandibular joints. Most individuals with Bruxism are not aware of it and 5-10% go on to develop symptoms such as jaw pain and headache. While there is no cure for this disorder, doctors either recommend mouth guards or Botox injections.

Delayed Sleep Phase Syndrome – is a condition in which the person chronically stays up until very late, usually until 3 to 4 am, and then sleeps all morning, getting up at 10 to 11 am.

Hypersomnia – is a condition in which a person sleeps too much, either for prolonged periods at night or during the day.

Insomnia – is a condition in which a person has an inability either to fall asleep or to remain asleep during the course of the night.  Insomnia can be further classified into:  Early insomnia– taking more than 30 minutes to fall asleep, followed by a relatively normal night of sleep.  Middle insomnia– waking up one or more times during the course of the night and taking more than 30 minutes to fall back asleep after each awakening.  Late insomnia– waking up before sunrise and not being able to get back to sleep.

Klein-Levin Syndrome – is a very rare condition in which a person needs excessive amounts of sleep, sometimes for up to 20 hours a day.  This is normally accompanied with excessive food intake (compulsive hyperphagia) and an abnormally uninhibited sexual drive (hypersexuality).  While some researchers speculate that Klein-Levin syndrome has a hereditary cause, others believe the condition may be the result of an autoimmune disorder. There is no definitive treatment for Klein-Levin syndrome. Stimulants and wake-promoting medicines including amphetamines, methylphenidate, and modafinil are used to treat the sleepiness. Because of similarities between Klein-Levin syndrome and certain mood disorders, lithium and carbamazepine may be prescribed.  Responses to treatment have often been limited.

Narcolepsy – is a condition in which a person chronically experiences daytime sleepiness so extreme that they fall asleep at inappropriate times for anywhere from a few seconds to 30 minutes. See Below for Further Information.

Night / Sleep Terror – is a condition in which a sleeping person (usually a child) will scream uncontrollably and appear to be awake, but is confused and can’t communicate.  The sufferer usually has no recollection of the event. Sleep is divided into two categories: rapid eye movement (REM) and non-rapid eye movement (non-REM). Non-REM sleep is further divided into four stages, progressing from stages 1-4. Night terrors occur during the transition from stage 3 non-REM sleep to stage 4 non-REM sleep, beginning approximately 90 minutes after the person (usually a child) falls asleep.  Sleep terrors may be caused by:  stressful life events, fever, sleep deprivation, medications that affect the brain, and recent anesthesia given for surgery.  See Below for Further Information.

Nocturia – is a condition in which a person has a reoccurring need to go to the bathroom and urinate at night

Periodic Limb Movement Disorder – This often coexists with restless legs syndrome and is a condition in which a person has sudden, involuntary, and repetitive leg jerking that occurs at the onset of sleep as well as during the course of sleep.

REM Behavior Disorder – is a condition in which a person loses the whole body paralysis that normally occurs during the Rapid Eye Movement period.  As a result, their body is free to act out their dreams. These behaviors can be violent in nature and in some cases will result in injury to either the patient or their bed partner.  REM Behavior Disorder is a treatable condition. The standard therapy is the anti-convulsant drug Klonopin (clonazepam), and this is generally well tolerated.  While the exact reason for its effectiveness is unknown, it does restore the natural paralyzed state of a person in the REM stage of sleep.

Restless Legs Syndrome – is a condition in which a person feels creeping, crawling, prickling, burning, itching, or tugging sensations in the legs while resting or sitting for extended periods of time. Sometimes the arms and torso may be affected as well.   While this disorder is at its worst during sleep or periods of non-movement it can also affect a person who is awake.   Restless Legs Syndrome is characterized by an irresistible urge to move one’s body to stop uncomfortable or odd sensations by providing temporary relief.  For relief of this disorder, some doctors prescribe anticonvulsants, opioids (such as methadone), or Benzodiazepines.

Rhythmic Movement Disorder – is a condition in which a person has head banging, head rolling, body rocking, body rolling or other repetitive movements during sleep.

Situational Circadian Rhythm Sleep Disorder – also commonly known as jet lag, is a condition in which a person has trouble adjusting to their home time zone and regular sleep schedule.  It also occurs to shift workers who work irregular and often night shifts.

Sleep Apnea – is a condition in which a person momentarily stops breathing during sleep. The most common form of this condition is obstructive sleep apnea, in which the air passages become blocked, causing respiratory distress. Sleep apnea is characterized by pauses in breathing during sleep. Each episode lasts long enough so that one or more breaths are missed, and occurs repeatedly throughout sleep. Clinically significant levels of sleep apnea are defined as five or more episodes per hour. Individuals suffering from this sleep disorder are rarely aware of having difficulty breathing, even upon awakening. It is usually recognized as a problem by others witnessing the individual during episodes or is suspected because of its effects on the body. Symptoms may be present for years, even decades without identification, during which time the sufferer may become conditioned to the daytime sleepiness and fatigue associated with significant levels of sleep disturbance. The most common treatment for sleep apnea is the use of a positive airway pressure (PAP) device. The PAP ‘splints’ the patient’s airway open during sleep by means of a flow of pressurized air into the throat. Other treatments such as surgery and medication also exist.

Sleep Talking / Somniloquy – is a condition in which a person talks aloud in their sleep. It can be quite loud, ranging from simple sounds to long speeches, and can occur many times during sleep. Listeners may or may not be able to understand what the person is saying. Sleep-talking usually occurs when the body does not move smoothly from one stage in non-REM sleep to another, and they become partially aroused from sleep. Further it can also occur during REM sleep at which time it represents a motor breakthrough of dream speech, when words spoken in a dream are spoken out loud.  There are no medical treatments for this, but in order to prevent sleep-talking a mouth guard may be worn.

Sleep Walking / Somnambulism – is a condition in which a person does actions typical of being awake such as walking around, eating or dressing, without conscious knowledge or awareness.  This usually occurs during stage 4 sleep (the deepest stage) and lasts between 5 and 15 minutes. Sleepwalking usually begins between ages 6 and 12.  It runs in families and affect boys more often than girls. Those who sleepwalk may appear to be awake as they move around, but are actually asleep and in danger of hurting themselves.

What is the Difference Between a Nightmare and Night / Sleep Terror?

Nightmares are relatively common during childhood, begin at a variety of ages, and occur throughout life.  Nightmares affect girls more often than boys. Children often remember nightmares, which usually involve major threats to their well being.  For some children nightmares are serious, frequent, and interfere with restful sleep.

Night / Sleep Terrors are different from nightmares. Children with sleep terrors will scream uncontrollably and appear to be awake, but are often confused and can’t communicate. Night / Sleep Terrors usually begin between ages 4 and 12.  Sleep terrors run in families and affect boys more often than girls.

Most often, children with these sleep disorders have single or occasional episodes of the disorder. However, when episodes occur several times a night, or nightly for weeks at a time, or interfere with the child’s daytime behavior, treatment by a child and adolescent psychiatrist may be necessary. A range of treatments is available for sleep disorders.

What are the symptoms of Sleep Terrors?

The symptoms include frequent recurrent episodes of intense crying, fear during sleep, and difficulty arousing the child.  They may also include an increased heart rate, an increased breathing rate and sweating during the episodes.  Unlike nightmares, most children do not recall a dream after a night terror episode, and they usually do not remember the episode the next morning. The typical night terror episode usually begins approximately 90 minutes after falling asleep. The child sits up in bed and screams, appearing awake but is confused, disoriented, and unresponsive to stimuli. Although the child seems to be awake, the child does not seem to be aware of the parents’ presence and usually does not talk. The child may thrash around in bed and does not respond to comforting by the parents. Most episodes last 1-2 minutes, but they may last up to 30 minutes before the child relaxes and returns to normal sleep. If the child does awake during a night terror, only small pieces of the episode may be recalled.

When do you need to seek Medical Care?

Sleep disruption is parents’ most frequent concern during the first years of a child’s life. Half of all children develop a disrupted sleep pattern serious enough to warrant physician assistance.  In children younger than 3 years, the peak frequency of night terrors is at least one episode per week.  In older children, the peak frequency of night terrors drops to one to two episodes per month.

If your child seems to be experiencing night terrors, an evaluation by the child’s pediatrician may be useful. During this evaluation, the pediatrician may also be able to exclude other possible disorders that might cause night terrors. Usually, a complete history and a physical exam are sufficient to diagnose night terrors. If other disorders are suspected, additional tests may be useful to exclude them:

  • An electroencephalogram (EEG), which is a test to measure brain activity, may be performed if a seizure disorder is suspected.
  • A sleep study, known as a Polysomnography (a combination of tests used to check for adequate breathing while asleep) may be done if a breathing disorder is suspected.
  • CT scans and MRIs are usually not necessary.

What is Narcolepsy?

Narcolepsy is a neurological disorder that affects the control of sleep and wakefulness. People with narcolepsy experience excessive daytime sleepiness and intermittent, uncontrollable episodes of falling asleep during the daytime. These sudden sleep attacks may occur during any type of activity at any time of the day.

In a typical sleep cycle, we initially enter the early stages of sleep followed by deeper sleep stages and ultimately (after about 90 minutes) rapid eye movement (REM) sleep. For people suffering from narcolepsy, REM sleep occurs almost immediately in the sleep cycle as well as periodically during the waking hours. It is in REM sleep that we can experience dreams and muscle paralysis, which explains some of the symptoms of narcolepsy.

What Are the Symptoms of Narcolepsy?

Symptoms of narcolepsy include:

Excessive daytime sleepiness (EDS): In general, EDS interferes with normal activities on a daily basis, whether or not a person with narcolepsy has sufficient sleep at night. People with EDS report mental cloudiness, a lack of energy and concentration, memory lapses, a depressed mood, and/or extreme exhaustion.

Hallucinations: Usually, these delusional experiences are vivid and frequently they are frightening. The content is primarily visual, but any of the other senses can be involved. These are called hypnagogic hallucinations when they occur while falling asleep and hypnopompic hallucinations when they occur while waking up.

Cataplexy: This symptom consists of a sudden loss of muscle tone that leads to feelings of weakness and a loss of voluntary muscle control. It can cause symptoms ranging from slurred speech to total body collapse depending on the muscles involved and is often triggered by intense emotion, for example surprise, laughter, or anger.

Sleep paralysis: This symptom involves the temporary inability to move or speak while falling asleep or waking up. These episodes are generally brief lasting a few seconds to several minutes. After episodes end, people rapidly recover their full capacity to move and speak.

What Causes Narcolepsy?

The cause of narcolepsy is not known, but very likely involves multiple factors that interact to cause neurological dysfunction and REM sleep disturbances. However, scientists have made progress toward identifying genes strongly associated with the disorder. These genes control the production of chemicals in the brain that may signal sleep and wake cycles. One such chemical is called hypocretin.   Experts believe a deficiency in the production of this chemical by the brain is responsible for Narcolepsy.  In addition, researchers have discovered abnormalities in various parts of the brain that contribute to symptom development.  These areas are involved in regulating REM sleep.

How Is Narcolepsy Treated?

There is no cure for narcolepsy, but the most disabling symptoms of the disorder can be controlled in most people with medication treatment.  These include excessive daytime sleepiness and symptoms of abnormal REM sleep, such as cataplexy. Sleepiness is treated with stimulants, such as amphetamine (that have wake-promoting properties) and other medications, such as antidepressants, can help treat the symptoms of abnormal REM.

In addition to this, lifestyle changes can be helpful.  These include avoiding caffeine, alcohol, nicotine, and heavy meals.  Regular exercise, regular sleep schedules, small naps (15 min or so) and regular meal schedules may also reduce the symptoms.

Specific Phobia

What is a specific phobia?

A specific phobia, formerly called a simple phobia, is a lasting and unreasonable fear caused by the presence or thought of a specific object or situation that usually poses little or no actual danger. Exposure to the object or situation brings about an immediate reaction, causing the person to endure intense anxiety (nervousness) or to avoid the object or situation entirely. The distress associated with the phobia and/or the need to avoid the object or situation can significantly interfere with the person’s ability to function. Adults with a specific phobia recognize that the fear is excessive or unreasonable, yet are unable to overcome it.   There are different types of specific phobias, based on the object or situation feared, including:

  • Animal phobias: Examples include the fear of dogs, snakes, insects, or mice. Animal phobias are the most common specific phobias.
  • Situational phobias: These involve a fear of specific situations, such as flying, riding in a car or on public transportation, driving, going over bridges or in tunnels, or of being in a closed-in place, like an elevator.
  • Natural environment phobias: Examples include the fear of storms, heights, or water.
  • Blood-injection-injury phobias: These involve a fear of being injured, of seeing blood or of invasive medical procedures, such as blood tests or injections
  • Other phobias: These include a fear of falling down, a fear of loud sounds, and a fear of costumed characters, such as clowns.

 A person can have more than one specific phobia. The fear may not make any sense, but they feel powerless to stop it. People who experience these seemingly excessive and unreasonable fears in the presence of or in anticipation of a specific object, place, or situation have a specific phobia. Having phobias can disrupt daily routines, limit work efficiency, reduce self-esteem, and place a strain on relationships because people will do whatever they can to avoid the uncomfortable and often-terrifying feelings of phobic anxiety. Although people with phobias realize that their fear is irrational, even thinking about it can often cause extreme anxiety.

What Are the Symptoms of Specific Phobias?

Symptoms of specific phobias may include:

  • Excessive or irrational fear of a specific object or situation
  • Avoiding the object or situation, or enduring it with great distress
  • Physical symptoms of anxiety or a panic attack, such as a pounding heart, nausea or diarrhea, sweating, trembling or shaking, numbness or tingling, problems with breathing (shortness of breath), feeling dizzy or lightheaded, feeling like you are choking
  • Anticipatory anxiety, which involves becoming nervous ahead of time about being in certain situations or coming into contact with the object of your phobia (For example, a person with a fear of dogs may become anxious about going for a walk because he or she may see a dog along the way)
  • Children with a specific phobia may express their anxiety by crying, clinging to a parent, or throwing a tantrum

How Common Are Specific Phobias?

The National Institute of Mental Health estimates that about 5%-12% of Americans have phobias. Specific phobias affect an estimated 6.3 million adult Americans. Phobias usually first appear in adolescence and adulthood, but can occur in people of all ages. They are slightly more common in women than in men. Specific phobias in children are common and usually disappear over time. Specific phobias in adults generally start suddenly and are more lasting than childhood phobias. Only about 20% of specific phobias in adults go away on their own (without treatment).

What Causes Specific Phobias?

The exact cause of specific phobias is not known, but most appear to be associated with a traumatic experience or a learned reaction. For example, a person who has a frightening or threatening experience with an animal, such as an attack or being bitten, can develop a specific phobia. Witnessing a traumatic event in which others experience harm or extreme fear can also cause a specific phobia, as can receiving information or repeated warnings about potentially dangerous situations or animals. Fear can be learned from others, as well. A child whose parents react with fear and anxiety to certain objects or situations is likely to also respond to those objects with fear.

How Are Specific Phobias Diagnosed?

If symptoms of a specific phobia are present, the doctor will begin an evaluation by performing a complete medical history and physical exam. Although there are no laboratory tests to specifically diagnose specific phobias, the doctor may use various tests to make sure that a physical illness isn’t the cause of the symptoms.

If no physical illness is found, you may be referred to a psychiatrist or psychologist, mental health professionals who are specially trained to diagnose and treat mental illnesses. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a person for a specific phobia.

The doctor bases his or her diagnosis of specific phobias on reported symptoms, including any problems with functioning caused by the symptoms. A specific phobia is diagnosed if the person’s fear and anxiety are particularly distressing or if they interfere with his or her daily routine, including school, work, social activities, and relationships.

How Are Specific Phobias Treated?

Treatment for specific phobias may include one or a combination of:

  • Cognitive-behavior therapy: Treatment for specific phobias involves a type of cognitive-behavior therapy, either desensitization or exposure, in which patients are gradually exposed to what frightens them until their fear begins to fade.
  • Medication: Tranquilizers (benzodiazepines) such as Ativan, Librium, Valium, and Xanax may be prescribed to help reduce anxiety.
  • Relaxation techniques, such as deep breathing, may also help reduce anxiety symptoms.

Posttraumatic Stress Disorder (PTSD)

What is Posttraumatic Stress Disorder?

Posttraumatic Stress Disorder, or PTSD, once called shell shock or battle fatigue syndrome, is a serious potentially debilitating condition that can occur in people who have experienced or witnessed a natural disaster, serious accident, terrorist incident, sudden death of a loved one, war, violent personal assault such as rape, or other life-threatening events. All children, adolescents and adults experience stressful events that can affect them both emotionally and physically.  Their reactions to stress are usually brief, and they recover without further problems.  However, an adult, child or adolescent who experienced a catastrophic event may develop ongoing difficulties with this disorder. Following the trauma, children may initially show agitated or confused behavior.  Individuals may also show intense fear, helplessness, anger, sadness, horror or denial.  Children who experience repeated trauma may develop a kind of emotional numbing to deaden or block the pain and trauma. This is called dissociation.  Children with Posttraumatic Stress Disorder avoid situations or places that remind them of the trauma.

What Are the Symptoms of Posttraumatic Stress Disorder?

Symptoms of Posttraumatic Stress Disorder most often begin within three months of the event. In some cases, however, they do not begin until years later. The severity and duration of the illness vary. Some people recover within six months, while others suffer much longer.
A person with Posttraumatic Stress Disorder may also re-experience the traumatic event by:

  • Having upsetting and frightening dreams
  • Acting or feeling like the experience is happening again
  • Having frequent memories of the event, or in young children, play in which some or all of the trauma is repeated over and over
  • Developing repeated physical or emotional symptoms when the person is reminded of the event

Those with Posttraumatic Stress Disorder may also show the following symptoms:

  • Losing interest in activities
  • Having problems concentrating
  • Showing irritability or angry outbursts
  • Having problems falling or staying asleep
  • Worry about dying at an early age (in children)
  • Showing increased alertness to the environment
  • Repeating behavior that reminds them of the trauma
  • Showing more sudden and extreme emotional reactions
  • Having physical symptoms such as headaches and stomachaches
  • Acting younger than their age (in children – for example, clingy or whiny behavior, thumb sucking)

People with Posttraumatic Stress Disorder have symptoms for longer than one month and cannot function as well as before the event occurred. The symptoms of Posttraumatic Stress Disorder may last from several months to many years.  Support from parents, school, and peers is important.

Who Gets Posttraumatic Stress Disorder?

Everyone reacts to traumatic events differently. Each person is unique in his or her ability to manage fear and stress, and to cope with the threat posed by a traumatic event or situation. For that reason, not everyone who experiences or witnesses a trauma will develop Posttraumatic Stress Disorder. Posttraumatic Stress Disorder was first brought to the attention of the medical community by war veterans, hence the names shell shock and battle fatigue syndrome. However, Posttraumatic Stress Disorder can occur in anyone who has experienced a traumatic event. People who have been abused as children or who have been repeatedly exposed to life-threatening situations are at greater risk for developing Posttraumatic Stress Disorder. Victims of trauma related to physical and sexual assault face the greatest risk for Posttraumatic Stress Disorder. Women are twice as likely to develop Posttraumatic Stress Disorder as men. Posttraumatic Stress Disorder often occurs with depression, substance abuse, or other anxiety disorders.

How Common Is Posttraumatic Stress Disorder?

About 3.6% of adult Americans, about 5.2 million people, suffer from Posttraumatic Stress Disorder during the course of a year, and an estimated 7.8 million Americans will experience Posttraumatic Stress Disorder at some point in their lives. Posttraumatic Stress Disorder can develop at any age, including childhood. Women are more likely to develop Posttraumatic Stress Disorder than are men. This may be due to the fact that women are more likely to be victims of domestic violence, abuse, and rape.

How Is Posttraumatic Stress Disorder Diagnosed?

If symptoms of Posttraumatic Stress Disorder are present, a medical doctor will begin an evaluation by performing a complete medical history and physical exam. Although there are no laboratory tests to specifically diagnose Posttraumatic Stress Disorder, the doctor may use various tests to rule out physical illness as the cause of the symptoms. If no physical illness is found, you may be referred to a psychiatrist or psychologist, mental health professionals who are specially trained to diagnose and treat mental illnesses. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a person for an anxiety disorder. The doctor bases his or her diagnosis of Posttraumatic Stress Disorder on reported symptoms, including any problems with functioning caused by the symptoms. The doctor then determines if the symptoms and degree of dysfunction indicate Posttraumatic Stress Disorder. Posttraumatic Stress Disorder is diagnosed if the person has symptoms of Posttraumatic Stress Disorder that last for more than one month.

Social Anxiety Disorder

Social Anxiety Disorder, previously called Social Phobia, is an anxiety disorder in which a person has an excessive and unreasonable fear of social situations. People with social anxiety disorder have an intense, persistent, and chronic fear of being watched and judged by others and of doing things that will embarrass them. They can worry for days or weeks before a dreaded situation. This fear may become so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends. Social anxiety disorder usually begins in childhood or adolescence, and children are prone to clinging behavior, tantrums, and even mutism.

A person with social anxiety disorder is afraid that he or she will make mistakes and be embarrassed or humiliated in front of others. The fear may be made worse by a lack of social skills or experience in social situations. The anxiety can build into a panic attack. As a result of the fear, the person endures certain social situations in extreme distress or may avoid them altogether. In addition, people with social anxiety disorder often suffer “anticipatory” anxiety, the fear of a situation before it even happens, for days or weeks before the event. In many cases, the person is aware that the fear is unreasonable, yet is unable to overcome it. People with social anxiety disorder may be afraid of a specific situation, such as speaking in public. However, most people with social anxiety disorder fear more than one social situation.

Other situations that commonly provoke anxiety include:

• Eating or drinking in front of others (such as in a restaurant)

• Writing or working in front of others (such as in a classroom or at an office meeting)

• Being the center of attention

• Interacting with people, including dating or going to parties

• Asking questions or giving reports in groups

• Using public toilets

• Talking on the telephone

What are the Symptoms of Social Anxiety Disorder?

Social anxiety disorder can be limited to one situation (such as talking to people, eating or drinking, or talking in front of a group) or may be so broad (such as in generalized social anxiety disorder) that the person experiences anxiety around almost anyone other than the family. Physical symptoms that often accompany social anxiety disorder include blushing, profuse sweating, trembling, nausea, and difficulty talking. When these symptoms occur, people with social anxiety disorder feel as though everyone is looking at them and observing their every move. Symptoms may be so extreme that they disrupt daily life. People with this disorder may have few or no social or romantic relationships, making them feel powerless, alone, or even ashamed. Many people with social anxiety disorder feel that there is “something wrong,” but don’t recognize their feeling as a sign of illness. Symptoms of social anxiety disorder can include:

• Intense anxiety in social situations

• Avoidance of social situations

• Physical symptoms of anxiety, including confusion, pounding heart, sweating, shaking, blushing, muscle tension, upset stomach, and diarrhea

• Children with this disorder may express their anxiety by crying, clinging to a parent, or throwing a tantrum

How Common is Social Anxiety Disorder?

Social anxiety disorder affects about 15 million American adults. Women and men are equally likely to develop the disorder, which usually begins in childhood or early adolescence. The typical age of onset is 13 years old. 36 percent of people with social anxiety disorder report symptoms for 10 or more years before seeking help.

What Causes Social Anxiety Disorder?

There is no single known cause of social anxiety disorder, but research suggests that biological, psychological, and environmental factors may play a role in its development.

Biologically: Social anxiety disorder may be related to an imbalance of the neurotransmitter serotonin. Neurotransmitters are special chemical messengers that help move information from nerve cell to nerve cell in the brain. If the neurotransmitters are out of balance, messages cannot get through the brain properly. This can alter the way the brain reacts to stressful situations, leading to anxiety. In addition, social anxiety disorder appears to run in families. This means that the disorder may be passed on in families through genes, the material that contains instructions for the function of each cell in the body.

Psychologically: The development of social anxiety disorder may stem from an embarrassing or humiliating experience at a social event in the past.

Environmentally: People with social anxiety disorder may develop their fear from observing the behavior of others or seeing what happened to someone else as the result of their behavior (such as being laughed at or made fun of). Further, children who are sheltered or overprotected by their parents may not learn good social skills as part of their normal development.

How is Social Anxiety Disorder Diagnosed?

Social anxiety disorder is diagnosed when people become overwhelmingly anxious and excessively self-conscious in everyday social situations. Social anxiety disorder may be linked to other mental illnesses, such as panic disorder, obsessive-compulsive disorder, and depression. In fact, many people with social anxiety disorder initially see the doctor with complaints related to these disorders, not because of social anxiety symptoms. If symptoms of social anxiety disorder are present, the doctor will begin an evaluation by asking questions about your medical history and performing a physical exam.

Although there are no laboratory tests to specifically diagnose social anxiety disorder, a medically-trained doctor, such as a psychiatrist, may use various tests to make sure that a physical illness isn’t the cause of the symptoms. In addition to this, psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a person for an anxiety disorder. The doctor bases his or her diagnosis of social anxiety disorder on reports of the intensity and duration of symptoms, including any problems with functioning caused by the symptoms. The doctor then determines if the symptoms and degree of dysfunction indicate social anxiety disorder.

How is Social Anxiety Disorder Treated?

People with social anxiety disorder suffer from distorted thinking, including false beliefs about social situations and the negative opinions of others. Without treatment, social anxiety disorder can negatively interfere with the person’s normal daily routine, including school, work, social activities, and relationships. Social anxiety disorder can be successfully treated with certain kinds of psychotherapy or medications.

The most effective treatment currently available is cognitive-behavior therapy (CBT). Medication may also be used to help ease the symptoms of social anxiety disorder so that CBT is more effective. Drugs may also be used alone. There are several different types of medications used to treat social anxiety disorder, including: antidepressants (like Celexa, Lexapro, Paxil and others); anti-anxiety medications (such as Xanax, Klonopin, Valium and Ativan); beta-blockers (such as Propranolol), often used to treat heart conditions, may also be used to minimize certain physical symptoms of anxiety, such as shaking and rapid heartbeat. Counseling to improve self-esteem and social skills, as well as relaxation techniques, such as deep breathing, may also help a person deal with social anxiety disorder.

Generalized Anxiety Disorder

What is Generalized Anxiety Disorder (GAD)?

Generalized Anxiety Disorder (or GAD) is characterized by excessive, exaggerated anxiety and worry about everyday life events with no obvious reasons for worry. People with Generalized Anxiety Disorder anticipate disaster and are overly concerned about health issues, money, family problems, or difficulties at work. Sometimes just the thought of getting through the day produces anxiety. When the anxiety level is mild, people with Generalized Anxiety Disorder can function socially and be gainfully employed.  In mild cases they may avoid some situations because they have the disorder, but some people can have difficulty carrying out the simplest daily activities when their anxiety is severe. Daily life becomes a constant state of worry, fear, and dread.

What Are the Symptoms of Generalized Anxiety Disorder?

Generalized Anxiety Disorder affects the way a person thinks, but the anxiety can lead to physical symptoms, as well. Symptoms of Generalized Anxiety Disorder can include:

  • Nausea
  • Sweating
  • Tiredness
  • Headaches
  • Trembling
  • Irritability
  • Muscle tension
  • Being easily startled
  • Difficulty concentrating
  • An unrealistic view of problems
  • Trouble falling or staying asleep
  • Excessive, ongoing worry and tension
  • Restlessness or a feeling of being “edgy”
  • The need to go to the bathroom frequently

How Common Is Generalized Anxiety Disorder?

Generalized Anxiety Disorder affects 6.8 million adults, or 3.1% of the U.S. population, in any given year. Women are twice as likely to be affected than men. It most often begins in childhood or adolescence, but can begin in adulthood.

How Is Generalized Anxiety Disorder Diagnosed?

Generalized Anxiety Disorder is diagnosed when a person worries excessively about a variety of everyday problems for at least 6 months. They can’t relax, startle easily, and have difficulty concentrating. Physical symptoms that often accompany the anxiety include fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, nausea, lightheadedness, having to go to the bathroom frequently, feeling out of breath, and hot flashes. If symptoms of Generalized Anxiety Disorder are present, a medical doctor (such as a psychiatrist) will begin an evaluation by asking questions about your medical history and performing a physical examination. The doctor bases his or her diagnosis of Generalized Anxiety Disorder on reports of the intensity and duration of symptoms, including any problems with functioning caused by the symptoms. Generalized Anxiety Disorder is diagnosed if symptoms are present for more days than not during a period of at least six months. The symptoms also must interfere with daily living, such as causing you to miss work or school. In addition, people with Generalized Anxiety Disorder often have other anxiety disorders (such as panic disorder, obsessive-compulsive disorder, and phobias), suffer from depression, and/or abuse drugs or alcohol.

What Causes Generalized Anxiety Disorder?

The disorder comes on gradually and can begin across the life cycle, though the risk is highest between childhood and middle age. Although the exact cause of Generalized Anxiety Disorder is unknown, there is evidence that biological factors, family background, and life experiences, particularly stressful ones, play a role. Some research suggests that family history plays a part in increasing the likelihood that a person will develop Generalized Anxiety Disorder. Generalized Anxiety Disorder has also been associated with abnormal levels of certain neurotransmitters in the brain. Neurotransmitters are special chemical messengers that help move information from nerve cell to nerve cell. This can alter the way the brain reacts in certain situations, leading to anxiety. Trauma and stressful events, such as abuse, the death of a loved one, divorce, changing jobs or schools, may also lead to Generalized Anxiety Disorder. The use of and withdrawal from addictive substances, including alcohol, caffeine and nicotine, can also cause or worsen anxiety.

How Is Generalized Anxiety Disorder Treated?

If no physical illness is found, you may be referred to a psychiatrist, psychologist, or mental health professional that is specially trained to diagnose and treat mental illnesses like Generalized Anxiety Disorder. Generalized Anxiety Disorder is commonly treated with medication and/or therapy. The drugs that are available to treat Generalized Anxiety Disorder may be especially helpful for people whose anxiety is interfering with daily functioning. The medications most often used to treat Generalized Anxiety Disorder in the short-term are from a class of drugs called benzodiazepines. They work by decreasing the physical symptoms of Generalized Anxiety Disorder, such as muscle tension and restlessness. Common benzodiazepines include Xanax, Librium, Valium and Ativan. Antidepressants, such as Paxil, Celexa, Effexor, Prozac, Lexapro, and Zoloft, are also used to treat Generalized Anxiety Disorder and are extremely effective, without the potential for abuse. People suffering from anxiety disorders may participate in a type of therapy called Cognitive-behavioral therapy, in which you learn to recognize and change thought patterns and behaviors that lead to anxious feelings.

Can Generalized Anxiety Disorder Be Prevented?

Anxiety disorders like Generalized Anxiety Disorder cannot be prevented. However, there are some things that you can do to control or lessen symptoms, including:

  • Exercise daily and eat a healthy, balanced diet.
  • Practice stress management techniques like yoga or meditation.
  • Seek counseling and support after a traumatic or disturbing experience.
  • Stop or reduce your consumption of products that contain caffeine, such as coffee, tea, cola, and chocolate.
  • Ask your doctor or pharmacist before taking any over-the-counter medicines or herbal remedies. Many contain chemicals that can increase anxiety symptoms.

Panic Disorder

What is Panic Disorder?

Panic disorder is a real illness that can be successfully treated. It is characterized by sudden attacks of terror, usually accompanied by a pounding heart, sweatiness, weakness, faintness, or dizziness. During these attacks, people with panic disorder may flush or feel chilled; their hands may tingle or feel numb; and they may experience nausea, chest pain, or smothering sensations. Panic attacks usually produce a sense of unreality, a fear of impending doom, or a fear of losing control.

What are the Symptoms of Panic Disorder?

Adults, children and adolescents with panic disorder have unexpected and repeated periods of intense fear or discomfort, along with other symptoms such as a racing heartbeat or feeling short of breath.  These periods are called “panic attacks” and last minutes to hours.  Panic attacks can interfere with a child’s or adolescent’s relationships, schoolwork, and normal development. In adults, it can interfere with social relationships, work and family.  Those with panic disorder may begin to feel anxious most of the time, even when they are not having panic attacks.  They fear they may have another panic attack at any time, since panic attacks frequently develop without warning.

Symptoms of a panic attack, which often last about 10 minutes, may include:

  • Sweating
  • Difficulty breathing
  • Chills or hot flashes
  • Trembling or shaking
  • Intense feeling of terror
  • Nausea or stomachache
  • Dizziness or feeling faint.
  • Pounding heart or chest pain
  • Sensation of choking or smothering
  • Tingling or numbness in the fingers and toes
  • Fear that you are losing control or are about to die

In severe cases, the individual may be afraid to leave home. Some children and adolescents with panic disorder can develop severe depression and may be at risk of suicidal behavior. As an attempt to decrease anxiety, some adolescents and adults with panic disorder will use alcohol or drugs. People having panic attacks sometimes believe they are having heart attacks, losing their minds, or on the verge of death. They can’t predict when or where an attack will occur, and between episodes many worry intensely and dread the next attack. People who have full-blown, repeated panic attacks can become very disabled by their condition and should seek treatment before they start to avoid places or situations where panic attacks have occurred. Some people’s lives become so restricted that they avoid normal activities, such as grocery shopping or driving. When the condition progresses this far, it is called agoraphobia, or fear of open spaces.

Many people don’t know that their disorder is real and highly responsive to treatment. Some are afraid or embarrassed to tell anyone, including their doctors and loved ones, about what they experience for fear of being considered a hypochondriac. Instead they suffer in silence, distancing themselves from friends, family, and others who could be helpful or supportive.

How Common Is Panic Disorder?

Panic disorder affects about 6 million American adults and is twice as common in women as men. Panic attacks often begin in late adolescence or early adulthood, but not everyone who experiences panic attacks will develop panic disorder. Many people have just one attack and never have another.

What Causes Panic Disorder?

Although the exact cause of panic disorder is not fully understood, studies have shown that a combination of factors, including biological and environmental, may be involved. The tendency to develop panic attacks appears to be inherited. Panic disorder has been shown to run in families. It may be passed on to some people by one or both parent(s) much like hair or eye color can. Panic disorder may also be caused by problems in parts of the brain. And lastly, stressful events and major life transitions, such as the death of a loved one, can trigger a panic disorder.

How is Panic Disorder Diagnosed?

Panic disorder can be difficult to diagnose.  This can lead to many visits to physicians and multiple medical tests, which are expensive and potentially painful.  When properly evaluated and diagnosed, panic disorder usually responds well to treatment.  If no other physical illness or condition is found as a cause for the symptoms, a comprehensive evaluation by a psychiatrist should be obtained (or a Child Psychiatrist in children and adolescents).  Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a person for panic disorder.

Panic disorder is diagnosed in people who experience spontaneous seemingly out-of-the-blue panic attacks and are preoccupied with the fear of a recurring attack. Panic attacks occur unexpectedly, sometimes even during sleep. The doctor bases his or her diagnosis on reported intensity and duration of symptoms, including the frequency of panic attacks, and the doctor’s observation of the patient’s attitude and behavior. The doctor then determines if the symptoms and degree of dysfunction suggest panic disorder.

How is Panic Disorder Treated?

A combination of the following therapies is often used to treat panic disorder. Psychotherapy (a type of counseling) addresses the emotional response to mental illness. It is a process in which trained mental health professionals help people by talking through strategies for understanding and dealing with their disorder. With techniques taught in “cognitive behavioral therapy,” the person may also learn new ways to control anxiety or panic attacks when they occur. Specific medications may also stop panic attacks. The anti-depressant drugs (such as Celexa, Lexapro, Paxil and Zoloft) and anti-anxiety medications such as Xanax or Klonopin are used to treat panic disorders. Sometimes, heart medications (such as beta blockers) are used to control irregular heartbeats. In addition, relaxation techniques, such as breathing retraining and positive visualization, may help a person during an attack.

Many individuals (including children and adolescents) with panic disorder respond well to the combination of medication and psychotherapy. With treatment, the panic attacks can usually be stopped. Early treatment can often prevent agoraphobia, depression, and substance abuse, but people with panic disorder may sometimes go from doctor to doctor for years and visit the emergency room repeatedly before someone correctly diagnoses their condition. Panic disorder is one of the most treatable of all the anxiety disorders, responding in most cases to certain kinds of medication or certain kinds of cognitive psychotherapy, which help change thinking patterns that lead to fear and anxiety. If not recognized and treated, panic disorder and its complications can be devastating.

Oppositional Defiant Disorder

What Is Oppositional Defiant Disorder (ODD)?

Oppositional Defiant Disorder (ODD) is one of a group of behavioral disorders called disruptive behavior disorders (DBD) that occur in children and adolescents. These disorders are called this because children who have these disorders tend to disrupt those around them. Oppositional Defiant Disorder (ODD) is one of the more common mental health disorders found in children and adolescents. In children with Oppositional Defiant Disorder (ODD), there is an ongoing pattern of uncooperative, defiant, and hostile behavior toward authority figures that seriously interferes with the child’s day-to-day functioning. All children are oppositional from time to time, particularly when tired, hungry, stressed or upset.  They may argue, talk back, disobey, and defy parents, teachers, and other adults.  Oppositional behavior is often a normal part of development for two to three year olds and early adolescents.  This occurs as they begin to establish a sense of independence from their parents and a greater sense of self.  However, openly uncooperative and hostile behavior becomes a serious concern when it is so frequent and consistent that it stands out when compared with other children of the same age and developmental level and when it affects the child’s social, family and academic life. Even the best-behaved children can be uncooperative and hostile at times, particularly adolescents, but those with Oppositional Defiant Disorder (ODD) show a constant pattern of angry and verbally aggressive behaviors, usually aimed at parents and other authority figures. The most common behaviors that children and adolescents with Oppositional Defiant Disorder (ODD) show are:

•    Defiance
•    Spitefulness
•    Negativity
•    Hostility
•    Verbal aggression

How Common Is Oppositional Defiant Disorder (ODD)?

There is a range of estimates for how many children and adolescents have Oppositional Defiant Disorder (ODD). Evidence suggests that between 1 and 16 percent of children and adolescents have Oppositional Defiant Disorder (ODD). However, there is not very much information on the prevalence of Oppositional Defiant Disorder (ODD) in preschool children, and estimates cannot be made. Oppositional Defiant Disorder (ODD) usually appears in late preschool or early school-aged children. In younger children, Oppositional Defiant Disorder (ODD) is more common in boys than girls. However, in school-age children and adolescents the condition occurs about equally in boys and girls. Although the disorder can seem to occur more often in lower socioeconomic groups, the reality is that Oppositional Defiant Disorder (ODD) affects families of all backgrounds.

What Causes Oppositional Defiant Disorder (ODD)?

The specific causes of Oppositional Defiant Disorder (ODD) are unknown, but many parents report that their child with Oppositional Defiant Disorder (ODD) was temperamentally more rigid and demanding than the child’s siblings from an early age.  Biological, psychological and social factors may have a role.
Biological Factors
Children and adolescents are more susceptible to developing Oppositional Defiant Disorder (ODD) if they have:

  • A parent with a history of attention-deficit/ hyperactivity disorder (ADHD), ODD, or conduct disorder (CD).
  • A parent with a mood disorder (such as depression or bipolar disorder)
  • A parent who has a problem with drinking or substance abuse
  • Impairment in the part of the brain responsible for reasoning, judgment, and impulse control
  • A brain-chemical imbalance
  • A mother who smoked during pregnancy
  • Exposure to toxins
  • Poor nutrition
  • Consistent lack of adequate sleep

Psychological Factors

  • A neglectful or absent parent
  • A poor relationship with one or more parent
  • A difficulty or inability to form social relationships or process social cues

Social Factors

•    Abuse
•    Poverty
•    Neglect
•    Lack of supervision
•    Uninvolved parents
•    Chaotic environment
•    Inconsistent discipline
•    Adoption (“your not my REAL parents so I don’t need to listen to you”)
•    Family instability (such as parental divorce or separation or frequent moves)

What Are the Symptoms of Oppositional Defiant Disorder (ODD)?

In children with Oppositional Defiant Disorder (ODD), there is an ongoing pattern of uncooperative, defiant, and hostile behavior toward authority figures that seriously interfere with the child’s day-to-day functioning.  The symptoms are usually seen in multiple settings, but may be more noticeable at home or at school.

Children with Oppositional Defiant Disorder (ODD) show an ongoing pattern of extreme negativity, hostility, and defiance that:

•    Is constant
•    Lasts at least 6 months
•    Is excessive compared with what is usual for the child’s age
•    Is disruptive to the family and the school
•    Is usually directed toward an authority figure (parents, teachers, principal, coach)

The following behavioral symptoms are associated with Oppositional Defiant Disorder (ODD):

•    Frequent temper tantrums
•    Excessive arguments with adults
•    Actively refusing to comply with requests and rules
•    Often questioning rules
•    Deliberately annoying and upsetting others
•    Often touchy or annoyed by others
•    Blaming others for their mistakes
•    Frequent outbursts of anger and resentment
•    Spiteful attitude and revenge seeking

How Is Oppositional Defiant Disorder (ODD) Diagnosed?

A child presenting with Oppositional Defiant Disorder (ODD) symptoms should have a comprehensive evaluation.  A mental health professional is often called upon if these behaviors create a major disturbance at home, at school, or with peers. Seeking treatment for children and adolescents suspected of having Oppositional Defiant Disorder (ODD) is critical. It may be difficult to improve the symptoms of Oppositional Defiant Disorder (ODD) without treating the coexisting disorder. This disorder is often accompanied by other serious mental health disorders, and, if left untreated, can develop into conduct disorder (CD), a more serious disruptive behavior disorder. Children with Oppositional Defiant Disorder (ODD) who are not treated also are at an increased risk for substance abuse and delinquency.

During the evaluation, the child’s primary care clinician will look for physical or other mental health issues that may cause problems with behavior. If the doctor cannot find a physical cause for the symptoms, he or she may refer the child to a child and adolescent psychiatrist or a mental health professional who is trained to diagnose and treat mental illnesses in children and adolescents. A child and adolescent psychiatrist or a qualified mental health professional usually diagnoses Oppositional Defiant Disorder (ODD).

The mental health professional will determine whether:
•    The behavior is severe
•    The conflicts are with peers or authority figures
•    The behavior is a result of stressful situations within the home
•    The child reacts negatively to all authority figures, or only his or her parents or guardians

Can Oppositional Defiant Disorder (ODD) Occur with Other Conditions?

It is important to look for other disorders which may be present; such as, attention-deficit hyperactivity disorder (ADHD), learning disabilities, mood disorders (depression, bipolar disorder) and anxiety disorders, all of which can lead to or contribute to Oppositional Defiant Disorder (ODD).

How Is Oppositional Defiant Disorder (ODD) Treated?

Treatment of Oppositional Defiant Disorder (ODD) may include: Parent Management Training Programs to help parents and others manage the child’s behavior, Individual Psychotherapy to develop more effective anger management, Family Psychotherapy to improve communication and mutual understanding, cognitive problem-solving skills training and therapies to assist with problem solving and decrease negativity, and Social Skills Training to increase flexibility and improve social skills and frustration tolerance with peers. Medication may be helpful in controlling some of the more distressing symptoms of Oppositional Defiant Disorder (ODD) as well as the symptoms related to coexistent conditions such as ADHD, anxiety and mood disorders. A child with Oppositional Defiant Disorder (ODD) can be very difficult for parents.  These parents need support and understanding.  Parents can help their child with Oppositional Defiant Disorder (ODD) in the following ways:

  • Always build on the positives, give the child praise and positive reinforcement when the child shows flexibility and cooperation.
  • Take a time-out or break if you are about to make the conflict with your child worse, not better.  This is good modeling for your child.  Support your child if he decides to take a time-out to prevent overreacting.
  • Pick your battles.  Since the child with Oppositional Defiant Disorder (ODD) has trouble avoiding power struggles, prioritize the things you want your child to do.  If you give your child a time-out in his room for misbehavior, don’t add time for arguing.  Say, “Your time will start when you go to your room.”
  • Set up reasonable, age appropriate limits with consequences that can be enforced consistently.
  • Maintain other interests so that managing your child with Oppositional Defiant Disorder (ODD) doesn’t take all your time and energy.  Try to work with and obtain support from the other adults (teachers, coaches, and spouse) dealing with your child.
  • Manage your own stress with healthy life choices such as exercise and relaxation.  Use respite care and other breaks as needed

With treatment, children and adolescents with Oppositional Defiant Disorder (ODD) can overcome their difficult behaviors and lead happier, more fulfilling lives.

– Compiled with information from the American Academy of Child & Adolescent Psychiatry

Tic Disorders and Tourette’s Syndrome

What are Tics?  

Tics are short-lasting repetitive muscle movements that may involve any voluntary muscle groups and occur suddenly during what is otherwise normal behavior.  Most tics are mild and hardly noticeable. However, in some cases they are frequent and severe, and can affect many areas of an individual’s life.  With tics a part of the body moves repeatedly, quickly, suddenly and uncontrollably.  Despite this, they can be stopped or partially controlled for brief periods of time, during which an individual makes a strong effort to control them.   However, after some time the tics will reoccur and may be stronger as a result of having held them back.  Think of a tic as resulting from an internal pressure or itch at the location of the where the tic will occur.  This grows in intensity until the tic is released.  Imagine if you felt the need to sneeze and without touching your nose you would try to prevent yourself from doing this.  How long could you go without sneezing?  This is how a person with a tic disorder feels constantly.  Additionally, while no one knows exactly what causes tics to occur, it is known that tics become worse when people are under stressful situations or just escaped one.  Basically, anything that causes excitement, good or bad, can bring out tics.  In addition to stress, sleep deprivation seems to play a role in both the occurrence and severity of motor tics.  Tics usually fluctuate in intensity and are often temporary.  It is only when they occur with increased frequency that they qualify for a specific tic disorder.

What are the Different Types of Tics?

There are two kinds of tics.  There can be vocal tics, motor tics or a combination of both.  Motor Tics can include the hands, arms, shoulders, legs, face, neck, mouth, eyes and nose.  Vocal Tics can include throat clearing, grunting sounds, coughing sounds, sniffing sounds or basically any sound, produced by the mouth, throat, or nose.   In addition to this, tics can be simple or complex.  Simple Vocal Tics  are purposeless and can include humming, grunting, or any other sound.  They usually occur in a spastic explosive fashion and at times are out of context to what is being discussed, such as an odd sound inserted into the middle of a sentence.  Simple Motor Tics can include, but are not limited to eye blinking, nose twitching, head-jerking, shoulder-shrugging, facial grimacing, mouth opening or nasal flaring.  A Complex Vocal Tic is one that actually produces a word, not just a sound.  They can include bad words (coprolalia).  Complex Motor Tics consist of a series of muscle movements performed with a purpose, such as scratching, throwing, or chewing.  A person with a complex motor tic might reach out and touch something repeatedly or kick out with one leg and then the other.  Finally, tics can be transient or chronic.  While Transient Tics disappear within a year, Chronic Tics can last for a year or more.  Chronic tics affect less than one percent of children and may be related to a special, more unusual tic disorder called Tourette’s Disorder.

What is the Difference Between Tics and Twitches?

It is important to note that while many people interchange the words tic and twitch, there are significant differences between these two forms of movements.  Unlike tics, the majority of muscle twitches occur rarely and are not repetitive actions. Muscle twitches are also known as myoclonic jerks. They are entirely involuntary and cannot be controlled or suppressed.  Many people experience these spastic movements of particular muscles at some point.  They often affect the eyelids or face, but can occur anywhere in the body.  In most instances they are harmless and temporary.  While an eyelid twitch may mimic an eye-blinking tic, it is different because it cannot be controlled.  However, they can be aggravated by having dry eyes or worsened by stress, lack of sleep, caffeine, and harsh light conditions.

How Common are Tic Disorders and Tourette’s Syndrome?

While people of all ages can experience tics, they are most common in children.  In fact, experts say that around 25% of children can experience tics and they are much more likely to affect boys than girls.  For instance, Tourette’s syndrome is three times more common in boys than in girls.  Tic symptoms typically begin when children are between 5 and 18 years old.  They are generally most severe between 10 and 12 years of age and decrease by adulthood.  Children who develop tics between ages 6 and 8 usually do very well.  Their symptoms may last 4 to 6 years, and then stop without treatment in early adolescence.  However, when the disorder begins in older children and continues into the 20s, it may become a life-long condition.  Some children are more susceptible than others.  Non-Hispanic white children were more than twice as likely as non-Hispanic black children or Hispanic children to have a parent-reported case of Tourette’s syndrome.  According to the CDC, those with chronic tics including Tourette’s syndrome include about one in 100 people and three out of every 1,000 children between ages 6 and 17 in the United States.  It is estimated that 200,000 people in the U.S. are living with Tourette’s syndrome, though many people with the disorder have not been diagnosed.  Twenty-seven percent of children with Tourette’s syndrome have moderate or severe cases and 79% of those diagnosed with Tourette’s also have been diagnosed with at least one additional mental health or Neurodevelopmental condition, including higher rates of attention deficit/hyperactivity disorder, obsessive-compulsive disorder, and impairments associated with these conditions, such as learning disabilities and problems with peer relations.

Do Tic Disorders Have a Genetic/Biological Component?

The exact cause of tic disorders, such as Tourette’s syndrome, is unknown.  However, it is thought that Tic Disorders are transmitted in an autosomal dominant manner, but other genetic factors may play a role.  These include gene amplification (worsening effects in affected individuals through consecutive generations) and genetic imprinting (having a different presentation whether the gene is inherited from the mother’s or father’s chromosomes).   Additionally, Tourette’s syndrome may be more likely to occur in children whose mothers drank alcohol, drank caffeine, smoked, or suffered extreme stress during pregnancy.  Children with low birth weights may also be more likely to develop tics and Tourette’s syndrome.

How are Tic Disorders Diagnosed?

It is important to keep in mind that the majority of tics are not severe and have very little effect on an individual’s quality of life. However, in some instances tics can occur frequently enough to be very disruptive and troubling. When this occurs, they can affect several areas of a person’s life, including school, work, and social life.  In diagnosing tic disorders, doctors use four characteristics to identify and diagnose the various types:  1) the age when the tics began; 2) the duration of the tics; 3) the severity of the tics and 4) whether the tics are motor, vocal, or both.

What are the Types of Tic Disorders?

Transient Tic Disorder most commonly appears in kids and affects between 5% and 25% of school-age children. Transient tic disorder is the most common of the tic disorders.  It is characterized by the presence of one or more tics for at least one month, but less than one year. It may affect up to 10 percent of children during the early school years. The majority of tics seen in this disorder are motor tics, though vocal tics may also be present.  Many children with this disorder experience multiple episodes of the transient tics, which may vary in how they manifest over time and eventually go away by themselves.  Some may get worse with anxiety, tiredness, and some medications.

Chronic Motor or Vocal Tic Disorder is characterized by the presence of one or more long-lasting tics.  It involves quick, uncontrollable movements or vocal outbursts (but not both).  For the diagnosis of a chronic tic disorder, the symptoms must begin before a child is 18 years of age.  About 1 to 2% of the population has a chronic motor tic disorder and this is the second most common of the tic disorders.  The tics can even occur during all stages of sleep. They may get worse with excitement, fatigue, heat or stress.  Keep in mind that in some instances, what appears to be a chronic tic may be a sign of Tourette’s syndrome.  Tourette’s syndrome is the most severe tic disorder. It is characterized by the presence of both motor tics and vocal tics.

Tourette’s Syndrome or Tourette’s disorder is the most complicated and concerning of the tic disorders. It is a combination of both vocal and motor tics that must be present for at least 1 year and never stop for longer than 2 months at a time. The vocal and motor tics may occur at the same time, but don’t have to in order to qualify for the diagnosis of Tourette’s.  They also must be causing a significant impairment in the individual’s life.  Tourette’s disorder has a fluctuating course and the severity of the symptoms often changes over time.  There may be periods of reduced tic frequency followed by increased tic activity. Fortunately, many people with Tourette’s syndrome find that their condition improves, as they get older.  The usual presentation of Tourette’s disorder may include hyperactivity and irritability. At this time some kids may be diagnosed with ADHD and started on stimulant medication, which may be discontinued later as tics develop. The tics usually evolve, initially involving motor tics in the face area, such as eye blinking, facial grimacing, hair fixing, mouth opening, nasal flaring, and neck jerking. The tics then move to the shoulders and extremities. Usually the vocal tics develop later and frequently consist of throat clearing. Other vocal tics may consist of humming sounds, grunting, high-pitched noises, yelling, and actual words including occasional profanity.  For the most part, those with Tourette’s cannot control these sounds and movements and should not be blamed for them. Punishment by parents, teasing by classmates, and scolding by teachers will not help the child to control the tics but will hurt the child’s self-esteem and increase their distress.  The full-blown condition may be extremely disruptive and living with it may be difficult.  Additionally, obsessive-compulsive behaviors, anxiety, and depression may be associated with Tourette’s and, if not present at initial presentation, may develop later into the course of the disorder.

Tic Disorder Not Otherwise Specified includes all the other tic disorders that do not

Separation Anxiety Disorder

Does your child hover around you like a shadow? Does he or she refuse to let you go out without her? Does she get upset or refuse to go to school or a friend’s house without you? Your child may suffer from Separation Anxiety.

Separation Anxiety Disorder (SAD) is the most common anxiety disorder among children and affects 2-3% of grade-school children. It involves excessive distress over day-to-day separation from parents, home or other familiar situations, and unrealistic fears of harm to loved ones. Seventy-five to eighty percent of the children who refuse to go to school have separation anxiety. Whereas normal separation fears are outgrown by age 5 or 6, SAD usually begins between the ages of 7 and 11. It often occurs fairly abruptly among children who previously had no problems with separation. Separation Anxiety Disorder (SAD) is diagnosed only if fears persist, with very extreme reactions, beyond that expected for the age of the child. A ten-year-old who cries and clings to a parent, refuses to go to school, or is afraid to stay at a friend’s house may be showing signs of Separation Anxiety Disorder (SAD). Children with Separation Anxiety Disorder (SAD) may beg for reassurance when a parent is away even briefly, cower from any opportunity to be separated, and sometimes even follow them from room to room. When questioned, they may disclose worries about parents or other family members getting hurt or killed, and may feel responsible for protecting them from harm.

Signs and symptoms of Separation Anxiety Disorder

  • Extreme, disproportionate distress over separation from loved ones
  • Unwillingness to leave home, attend school, or go on outings
  • Unrealistic worry about harm to self or loved ones
  • Frequent seeking of reassurance regarding safety of self and loved ones Crying, clinging, nausea, vomiting or tantrums in anticipation of separation
  • Reluctance to be alone, especially at night
  • Nightmares about harm and danger
  • Symptoms for at least four weeks

Indications of SAD in school

School refusal and tardiness are common indicators of Separation Anxiety Disorder (SAD). Once in school, a child with Separation Anxiety Disorder (SAD) may be agitated, restless and nervous, and complain of stomachaches, headaches or nausea. The child may make frequent trips to the nurse’s office, and ask to call her parent or to go home. The child may not eat or drink in school, and may ask for repeated reassurance about safety. Phone calls to “check in” with parents may bring reprieve. Usually, the child experiences tremendous relief when the parent takes her home.

Helping your child overcome Separation Anxiety

  • Remain calm, matter of fact and firm during routine separations.
  • Don’t hover, question or reassure excessively.
  • Limit reassurance to one or two times.
  • Use the Parent-Teacher Log to communicate between home and school.
  • Limit check-in visits or phone calls when the child is in school.
  • Allow a transitional object for comfort until the child masters anxiety.
  • Limit the child’s ability to leave school and return home.
  • Remove the comforts of staying home or returning home from school.
  • Use the Feeling Thermometer as an index of intensity and change in emotions.
  • Teach calming self-talk when upset.
  • For the child who has been out of school, plan a gradual return to school.
  • Seek opportunities to separate from the child for increasing lengths of time.
  • Create opportunities for repetition and practice.
  • Encourage independent activities and self-reliance.
  • Reward independence and initiative.
  • Set a positive example; role model the behavior the child is expected to learn.
  • Make You And Me Alone (YAMA) time to increase positive interactions.
  • Praise any efforts in the direction of separation.
  • Use tangible rewards for any effort in the right direction.
  • Be consistent in the child management approach at home and at school.

If your child’s separation fears persist despite your interventions, seek consultation with a qualified mental health professional.

– Proliance Center would like to thank: Aureen Pinto Wagner, Ph.D. Copyright © 2002 for the use of the above material.

What Is the Treatment for Separation Anxiety Disorder (SAD)?

Most mild cases of Separation Anxiety Disorder (SAD) do not need medical treatment.  However, in more severe cases of Separation Anxiety Disorder (SAD), or when the child refuses to go to school, treatment may be needed.  There are three goals of treatment for Separation Anxiety Disorder (SAD).  They include reducing anxiety in the child, developing a sense of security in the child and the caregivers, and educating the child and family/caregivers about the need for natural separations.  Treatment options for Separation Anxiety Disorder (SAD) that may be used include psychotherapy and/or medications.

Psychotherapy (a type of counseling) is the main treatment approach for Separation Anxiety Disorder (SAD), where the goal is to help the child tolerate being separated from the caregiver without the separation causing distress or interfering with function. A type of therapy called cognitive-behavioral therapy works to reshape the child’s thinking in Separation Anxiety Disorder (SAD), so that the child’s behavior becomes more appropriate.  Family therapy also may help teach the family about Separation Anxiety Disorder (SAD) and help family members better support the child during periods of anxiety.

Medication: Antidepressant medications may be used to treat severe cases of Separation Anxiety Disorder (SAD).

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