According to PL 94-142 (the federal law mandating educational services for all children with handicapping conditions), "seriously emotionally disturbed" is defined as a condition exhibiting one or more of the following characteristics over a long period of time, to a marked degree adversely affecting educational performance:
- An inability to learn which cannot be explained by intellectual, sensory, or health factors
- An inability to build or maintain satisfactory interpersonal relationships with peers and teachers
- Inappropriate types of behavior or feelings under normal circumstances
- A general pervasive mood of unhappiness or depression; or
- Personal or school problems
Children with severe emotional disabilities (SED) often arouse negative feelings and reactions from other children and adults. Because of their disruptive, impulsive and boisterous behavior, children with SED are often alienated and isolated from their classmates and playmates. They have usually experienced both academic and social failure, and most teachers find it difficult to work with these children. Children with SED carry the added burden of having a handicapping condition that is not visible. The stigma surrounding mental illness in our society means children with SED and their families experience shame, embarrassment and isolation from the rest of their communities.
In an effort to change the way mental health services have been provided to families and children, and to increase the partnership between families and providers, community-based services look at family strengths. Focusing on family strengths assumes that:
- Families of children with emotional and behavioral disabilities have strengths.
- Families are sources of wisdom and knowledge about their children and should be recognized as experts.
- Parents should be provided as much information as they want about their child's disability.
- Children with emotional and behavioral difficulties have strengths, deserve caring and respect.
- Diversity and individual differences are to be valued and celebrated.
- Children with emotional and behavioral difficulties need to live in their own homes and their own communities.
- The values, choices, and preferences of families should be respected.
One of the key elements of family strength-based community services is parent-provider collaboration. Instead of "we" and "they", providers and families become partners in the therapeutic process. Families have knowledge about what has happened to their child and they are the primary resource for the respite worker. From the very beginning of a working relationship, it is imperative that providers find ways to build a positive partnership with parents and their child. This means seeing parents as the experts, and engaging them as equal members of the team.
Respite providers can be active participants in creating this partnership. Workers should look at the resilience, flexibility, endurance and courage displayed by children with special needs and their families. Providers should provide accurate information and support. It is also very important to acknowledge the limits of our own knowledge about mental illness. Parents expect and appreciate honesty. If you don't know what to do, say so, directly and clearly.
The Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) was first published by the American Psychiatric Association Committee on Nomenclature and Statistics in 1952 in order to establish an official psychiatric classification system, to assist clinicians in making accurate and appropriate diagnoses, as well as to collect statistical information on mental disorders. Since that time, The DSM has gone through a number of revisions, resulting in the DSM-IV, which was published in 1994 by the American Psychiatric Association. According to the DSM-IV the definition of a mental disorder is "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g. a painful symptom), or disability (i.e., impairment in one of or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom" (p. xxi). The behavioral needs discussed in this module all contain specific criteria for diagnosis in the DSM-IV. Criteria in the DSM-IV should be used as guidelines by individuals trained and experienced in diagnosis and mental health issues.
Attention Deficit (Hyperactivity) Disorder (ADD / ADHD)
Children with ADD or ADHD have difficulty sticking to tasks, sustaining attention, following through on instructions, chores or duties, organization and completing tasks work. Often the child fails to give adequate attention to work and makes careless mistakes. Children who are diagnosed with ADHD also have additional problems with impulsivity. In school, the child may talk out of turn, have trouble remaining seated, fidget, squirm or run. Because the child with ADHD displays many behaviors that other children find annoying and bothersome, making and maintaining friendships can be frustrating and difficult. This can lead to low self-esteem, low frustration tolerance, and temper tantrums. As children reach adolescence, impulsive and "acting-out" behaviors can become more serious. Approximately 3% - 7% of school age children are diagnosed with ADD/ADHD and the disorder is twice as frequent in boys as in girls. Children with ADD/ADHD are also more likely to have learning disabilities.
The child diagnosed with conduct disorder shows a persistent pattern of conduct that repeatedly violates social rules and the basic rights of others. Low self-esteem, irritability, temper outbursts, and a low frustration tolerance are also present. It is estimated that as many as one in every ten children has conduct disorder, and is considered one of the most frequently seen mental disorders of adolescence (APA, 1998). Symptoms of conduct disorder include:
- Aggression towards people and/or animals
- Destruction of property/setting fires
- Deceitfulness or theft (e.g. breaking into homes, cars)
- Serious violations of rules (e.g. staying out all night, running away from home, truancy)
- Often starting fights/using weapons in fights
- Forcing sexual activity
Other problems such as hyperactivity, anxiety, depression and academic difficulties may also be present. Factors that can also influence the development of conduct disorder include:
- Inconsistent rules and harsh discipline
- Lack of supervision or guidance
- Frequent changes in caregivers
- Involvement with a delinquent peer group
While conduct disorder is one of the most difficult behavior disorders, symptoms can be lessened with psychotherapy and medication. Other interventions such as parent training, family therapy, training in problem-solving skills and community based services which focus on the child can also help.
Oppositional Defiant Disorder (ODD)
Children diagnosed with oppositional defiant disorder (ODD) display patterns of negativistic, hostile and defiant behavior. Often, this diagnosis occurs before a diagnosis of conduct disorder is given. ODD can begin when the child is of preschool age. Generally, the diagnosis of conduct disorder is given to an older child. Individuals diagnosed with ODD are argumentative with adults, become easily annoyed by others, defy rules and adult requests, and tend to blame others for difficulties. These children and youth also have low self-esteem, poor frustration tolerance, and school difficulties. They are at high risk for drug and alcohol abuse.
Depression is one of the most common psychiatric diagnoses given to children. It occurs in as many as one in every 33 children and one in eight adolescents. Children with this diagnosis tend to look sad, are not physically or verbally aggressive towards others, and are often at high risk for hurting themselves. They may appear anxious, immature, irritable or sad. They show a diminished interest or pleasure in all, or almost all school, family or social activities. Children and youth with depression may experience physical symptoms such as fatigue, stomachaches, headaches or insomnia. The child often expresses feelings of worthlessness, self-doubt and guilt.
The individual may have difficulty concentrating on schoolwork or other regular activities. For some children and youth, the intense feelings of worthlessness may lead to recurrent thoughts of death and suicide. Children and youth with more severe forms of depression may have attempted suicide or have a specific plan for committing suicide. Counseling and/or medication along with a well-developed plan of care are helpful in alleviating depressive episodes. Statistics show that with treatment, the majority of people (80%-90%) with depression show improvement.
Causes of depression include:
- Biochemistry - a deficiency in the chemicals serotonin and norepinephrine;
- Genetics - depression can be present in families. A family history of depression increases the chances of an individual developing depression;
- Personality - people who are easily overwhelmed by stress, have low self-esteem, or generally pessimistic appear to be more vulnerable to depressive disorders;
- Environmental factors - such as abuse, neglect, poverty and violence can increase the risk of depression in people who are already vulnerable.
Individuals diagnosed with an anxiety disorder experience an overwhelming sense of fear and dread that generally incapacitates them for a period of time. The feelings of anxiety and dread are often accompanied by physiological responses such as sweating, a "racing heart", and dizziness. Anxiety disorders are among the most common mental, emotional and behavioral problems that occur during childhood and adolescence.
In phobic disorders, children experience a fearful and/or anxious response to such events as: social situations, closed spaces, heights, or animals. In all instances, the extent of the anxiety and fear is disproportionate to the actual situation.
Children and youth diagnosed with Post-Traumatic Stress Disorder show symptoms of anxiety as a reaction to extreme stress and psychological and/or physical trauma that are beyond the range of normal human experience. Adolescents experience recurrent, intrusive, and distressing recollections of the trauma. In young children experiencing PTSD, repetitive play involving themes or aspects of the trauma is expressed. In very young children, loss of recently acquired developmental skills, for example, toilet training, may be considered equivalent to the "numbing" or non-responsiveness seen in adults diagnosed with PTSD.
Post-Traumatic Stress Disorder
"Our brains are sculpted by our early experience. Maltreatment is a chisel that shapes a brain to contend with strife, but at the cost of deep, enduring wounds." (Teicher, 2000, p.67)
Trauma is a sudden unexpected event outside the realm of typical human experience that overwhelms and creates feelings of helplessness, vulnerability, loss of safety and control in an individual. The Merriam-Webster Collegiate Dictionary defines trauma as "(a) an injury (as a wound) to living tissue caused by an extrinsic agent [surgical trauma]; (b) a disordered psychic or behavioral state resulting from mental or emotional stress or physical injury..."
Trauma information grew out of work in the 1980s with veterans of the Vietnam War. The medical profession realized that large numbers of the individuals returning from Vietnam were exhibiting the same symptoms - hyper-vigilance, hyper-arousal, depression, sleep and eating disorders, flashbacks and nightmares. This led to the establishment of the medical framework of trauma and the classification in the DSM-IV of Post-Traumatic Stress Disorder. PTSD is given as a diagnosis when a person is seen to have adopted pathological behaviors in order to cope with the traumatic event. These behaviors interfere with a person's daily functioning and can impact work and relationships.
A second trauma framework developed in the past 25 years is the Survival Theory. This theory looks at responses to traumatic events as adaptations; the ways in which individuals manage to cope with the event. Specific behaviors are manifested so that the person can adapt or cope with what has happened.
Trauma is laid down in the psyche in sensory/motor form. Sights, sounds, smells, feels and tastes of the trauma can be triggered and relived over and over again. Trauma results in changes to the central nervous system keeping people either very revved up or relaxed or both. Trauma is a highly individualized experience viewed through one's own unique set of resources. Each individual will find a way to make sense of the experience. For example, one person in a car accident may come away determining never to forget to wear a seatbelt again while another may decide never to drive again.
Children are more at risk to develop problems because they have less capacity to control their fight/flight or freeze/surrender responses to trauma. They have less capacity to use language or to analyze what is happening and may act impulsively or withdraw. Bessel van der Kolk , M.D. (1996) states that a child who has experienced a traumatic experience is focused on survival, not living. He notes that there are changes to the use of the right and left hemispheres of the brain which can result in difficulty in moving from feelings to using words to describe emotions. Factors that can impact how a child responds include whether the incident was a one-time event or continuous exposure (ex. a car vs. being in a war zone). The involvement of family as either victims or perpetrators is also an important factor in how the event will be perceived. The child's level of development can make a difference in the perception and response to trauma. Many developmental theorists suggest that a child's developmental process, at certain stages of development, can be interrupted by a traumatic event (Finkelhor, 1995).
Responses to trauma can be physical, cognitive, emotional and behavioral. Physical responses included changes to the central nervous system. Breathing can become more rapid and the heart rate can rise to 100 beats per minute or more as the fight or flight response engages. Individuals can develop sleep and eating disorders, or somatoform disorders such as chronic headaches, stomachaches or dizziness. They may experience panic or anxiety attacks. Cognitive responses can include lack of concentration or short attention spans. An individual may withdraw into fantasy. Children can appear to be daydreaming, and there can be a change in academic progress. Unwanted intrusive thoughts and images, called flashbacks, may interfere with thought processes, or they may be an avoidance of thoughts or feelings associated with the event. Traumatized individuals believe that safety is lost, that people cannot be trusted and that adults can hurt and betray you.
Emotionally people experience fear, depression, anger or irritability or extreme terror. They may feel guilty, shameful (especially in situations of abuse) and powerless. There is a sense of not belonging. Extreme emotional responses can lead to the development of abnormal states of consciousness such as dissociative disorders or multiple personality disorders. Other trauma related disorders can include Reactive Attachment Disorder, Adjustment Disorders, Mood Disorders, Acute Stress Disorder and Obsessive-Compulsive Disorder. Individuals may be diagnosed with anxiety, depression or attention deficit disorders when the underlying cause is trauma and the PTSD diagnosis has been missed.
People respond to trauma with many different behaviors. Children or adolescents may exhibit age regression such as returning to thumb sucking or bedwetting. Others might revert to anti-social behavior towards peers or adults. Individuals may engage in self-destructive behaviors such as risk-taking, cutting, substance abuse, suicide attempts or ideation. Self-destructiveness is a powerful need to be self-punitive. Sexual abuse is often the trauma that has been the foundation for self-mutilating behavior. Responses will vary from child to child depending on the duration of the event, physical injury involved, disruption to basic care-giving, the degree to which the event is perceived to be life-threatening or the child's own genetic inheritance and temperament.
Loss and grief happen to us all, and working with children and families who are grieving can be difficult. These individuals are experiencing emotional pain and can be irritable or angry. Children may be emotionally withdrawn, difficult to motivate or may exhibit out of control behaviors because they do not know words to verbalize how they feel. Children may also be limited in their ability to attach to others emotionally. A child's grieving process can be unique because children often do not have the experience of dealing with the loss of someone on whom they have depended. As a result children may also have feelings of alarm and panic and react as though they are in physical danger. There may be regression in skills already learned such suddenly not being able to dress independently or reverting to baby talk. Children may become more hyperactive in order to avoid thinking about what has happened to them.
It is important to create a safe environment when working with grieving children so that they can be encouraged to talk about their feelings. For children who are non-verbal or have limited verbal ability can be encouraged to use their bodies actively to "act out" their feelings of anger or frustration. Using art or music can also be mediums to help individuals express how they are feeling. Support should be constant and consistent as this will help to build a trust relationship and allow children to express their feelings openly. Maintaining a safe, consistent environment also helps to promote resiliency.
Resiliency is the capacity to bounce back from a loss or traumatic event; to withstand hardship and repair oneself. It is the universal capacity which allows an individual to prevent, minimize and overcome the damaging effects of adversity.
Respite providers can foster resiliency by encouraging independence, clarifying rules and expectations, communicating with the child around daily events and feelings, providing consistent rules and consequences and helping the child to recognize and express their own feelings. Remember that children rely on caregivers for help in structuring, organizing and understanding events that happen in their physical environment.
Creating a safe environment is of utmost importance when helping someone who has been traumatized. Safety strategies used are dependent on the developmental stage of the child and no physical intervention (such as MANDT, NAPPI, TCI or CPI) should ever be used to keep a child safe unless the person performing it has been trained. It is a Respite Provider's responsibility to understand the agency's policy on using physical intervention. Provider's should treat the family and child with unconditional positive regard, collaborate with the family on strategies for keeping the child safe and offer encouragement and hope. Help children put their feelings into words and to sort reality from fantasy. Giving children opportunities to use their bodies actively can help with self-regulation.
Being consistent and predictable in what is said and done can also help create safety for a traumatized individual. It is important to establish clear rules and expectations for time together and to follow-through on limits. Help the child understand the provider's role as a mandated reporter, but also explain about confidentiality. Offer opportunities for communication and listen to what the child is saying.
Finally, it is important to understand that working with people who have been traumatized can have a traumatizing effect on the worker. This is called vicarious trauma and it refers to the extended exposure to traumatic stories and images. Pearlman (1995) defines vicarious trauma as "the exposure to painful aspects of the client's experience, which leads to potential alteration of beliefs about self and world." Vicarious trauma affects all types of workers who help disaster and trauma victims. The symptoms are usually less severe than those of PTSD, but can affect the livelihoods and careers of those working with survivors. Vicarious trauma is often a cause for burnout in the social service field. Symptoms of vicarious trauma can include a sudden seriousness or cynicism, sadness, a decrease trust in one's own instincts, a loss of perspective and sense of humor and depression.
Vicarious trauma can be managed and transformed. First remember, that vicarious trauma is natural, so accept those responses as normal. Attend to emotional, physical and spiritual needs. Take time to enjoy activities that are replenishing, and create time to get away. To transform vicarious trauma meaning must be created. Bring meaning to daily activities of work and other activity by focusing attention on the sensory and emotional aspects of daily activities - even the mundane. Recognize and change negative beliefs and build a strong supportive network. Stay connected to others. Discuss problems with a supervisor or peer or seek therapy, if necessary.
Follow the ABCs of protecting against vicarious trauma. These are:
Awareness: Being attuned to one's needs, limits, emotions, and resources. Heed all levels of awareness and sources of information, cognitive, intuitive, and somatic. Practice mindfulness and acceptance.
Balance: Maintaining balance among work, play and rest. This balance allows attention to all aspects of oneself.
Connection: Connections to oneself, to others, and to something larger. Communication is part of connection and breaks the silence of unacknowledged pain. These connections offset isolation and increase validation and hope.
About Trauma, David Baldwin's Trauma Information
Assessing VT II: Self Care, Trauma Research, Education and Training Institute, Inc. (TREATI)
The Behavioral Health Sciences Institute (BHSI) and the Department of Health and Human Services (DHHS) Behavioral Health Professional Curriculum, Module 4, Trauma.
The Body Keeps the Score: Memory and the evolving psychobiology of post traumatic stress, Bessel van der Kolk, M.D>
The Victimization of Children: A Developmental Perspective, David Finkelhor, Ph.D.
Bi-Polar Disorder is often known as "manic depression." This disorder is characterized by the extreme changes in mood, energy and behavior. In the manic phase of Bi-Polar disorder, an individual will experience feelings of euphoria. They will feel as though they are on top of the world, or feel they are experiencing a happiness that nothing can change. The individual may have grandiose delusions, imagining they have special connections to leaders, celebrities or God. They feel invincible, as though nothing can stand in the way of what they want to accomplish.
Other symptoms of the manic phase of Bi-Polar Disorder include:
- Hyperactivity - inability to relax or sit still;
- Excessively risky behavior;
- Uncontrollable racing thoughts/rapid speech;
- Less need for sleep;
- Sudden irritability or rage.
Symptoms of the depressed phase are:
- Intense sadness or despair;
- No interest in activities once enjoyed;
- Loss of energy, fatigue;
- Sleep difficulties;
- Changes in appetite;
- Difficulty concentrating;
- Constant thoughts of death or suicide.
Research indicates that many children diagnosed with Bi-Polar disorder also carry a diagnosis of ADHD, OCD (Obsessive-Compulsive Disorder) and ODD. The American Academy of Child and Adolescent Psychiatry reports that up to one-third of the 3.4 million children with depression in the United States may actually be experiencing the early onset of Bi-Polar disorder.* Bi-Polar disorder can run in families, and it is estimated that there is a genetic cause. As many as 90% of individuals with Bi-Polar Disorder have a family history of depression or Bi-Polar Disorder, a rate that is 10-20 times higher than the general population.
*Information obtained from "About Early-Onset Bi-Polar Disorder" www.bpkids.org/printing/about.htm
Obsessions are persistent ideas, thoughts, or images that are experienced as intrusive and inappropriate and cause anxiety or distress. Common obsessions include thoughts about contamination (ex. Being contaminated with a disease by shaking hands), the need to have or do things in a particular order, doubts (ex. repeatedly returning to the house to make sure the door has been locked), aggressive impulses, or sexual imagery.
Compulsions are the repetitive behaviors or mental acts that help the person to reduce or prevent the anxiety produced by the obsessions. Common compulsions are repeated hand washing, checking off lists, counting, repeating words silently or out loud and establishing routines for tasks (such as counting to 10 five times before locking a door).
The diagnosis of Obsessive-Compulsive behavior is given when the following are present:
- Thoughts that are recurrent and persistent even when the individual attempts to ignore them;
- Intentional, repetitive activities or behaviors are compulsively enacted by the person;
- Obsessions and compulsions are sufficiently severe and time consuming to interfere with social, school and family functioning.
Impaired Thought Processes
Individuals with impaired thought processes experience auditory hallucinations, visual hallucinations, and intrusive thoughts. Mental health professionals commonly refer to this behavior as "psychotic". The term psychotic describes a broad range of behaviors that indicate that the individual is not "in touch with reality". In other words, the person is not able to accurately perceive what he or she is seeing, hearing or thinking, leading to incorrect assumptions about the world. Schizophrenia is primarily a disorder of young adulthood, however, the symptoms for schizophrenia often begin during adolescence.
(This is a reprint from the newsletter of the Maine Parent Federation)
Tourette syndrome (TS) is a neurological movement disorder which begins between the ages of two and sixteen and lasts for life. Rapid repetitive movements of the body, often called "tics", are characteristic of Tourette's syndrome. Such movements can include rapid eye blinking, shoulder shrugging, head jerking, and facial twitching.
Involuntary vocalizations, repeated sniffing, throat clearing, coughing, grunting, barking, shrieking, echolalia (repeating other people's words), palilalia (repeating own words), stuttering and coprolalia (utterance of inappropriate or obscene words) are often observed. These symptoms are often confused as abnormal behavior or "nervous habits". Individuals with TS rarely have all the symptoms, but may develop several over a long period of time.
Researchers believe that Tourette syndrome is caused by chemical imbalance in the brain. Studies have shown a chemical abnormality in the basal ganglia of the brain. Stimulants such as Ritalin, Cylert and Dexedrine, which speed up the central nervous system, can worsen TS. Symptoms also worsen during puberty. Tourette' syndrome symptoms sometimes stabilize somewhat during adulthood. A few individuals learn to control TS symptoms while in public, but once they are in a more relaxed situation, the symptoms frequently emerge more explosively.
Children with Tourette syndrome often have difficulties in school. It is estimated that 60% of children with TS have learning disabilities, such as Attention Deficit Disorder, and should be referred to special education for an education evaluation. After an evaluation is completed an Individual Education Plan is developed to meet the child's needs.
There is no cure for Tourette syndrome, although several drugs, such as Haldol, Catapres, Prolexin, and Clonopin can reduce the symptoms in some cases. Unless the symptoms interfere with a person's life, medication should not be used. Individuals often seek psychological counseling to build coping skills and to deal with society's reaction to this disorder.
Researchers are still working to find a cure. Genetic studies are being done to help determine how it is transmitted from one generation to the next, as 50% - 70% of the cases appear to be hereditary.
Linda M. Levine, M.Ed.
Sheila's parents had been worried about her for a long time. At 4 years old Sheila seemed bright, but she had trouble remembering things. Sheila was always in motion. She never sat down long enough to watch a favorite TV show. She had a hard time catching a ball and was always tripping over her feet. Sheila seemed to hear her parents, but couldn't always follow directions. She confused up and down, front and back, squares and circles. When she started school she continued to have problems. When Sheila was tested she was found to have learning disabilities.
What are learning disabilities?
Learning disabilities include problems such as short attention span, poor memory and delayed language development. Children with learning disabilities have difficulty learning even though they have NORMAL intelligence. They are not "slow." But they do learn differently. An individual may have one or many learning disabilities. Some children with learning disabilities do well in a regular classroom with extra help from a special teacher. Others with more serious problems need a special classroom.
What to look for in children.
- BEHAVIOR problems:
- Poor MEMORY:
- SPEECH or LANGUAGE problems:
- Poor COORDINATION:
- SOCIAL problems:
- Problems with SCHOOLWORK:
What causes learning disabilities?
Almost everything we know about learning disabilities has been discovered in the past 20 years. Researchers know that many more boys than girls have learning disabilities. Some learning disabilities run in families. The cause of learning disabilities is still unknown. But physical problems, emotional problems, hearing or seeing problems are not the MAIN cause of learning disabilities.
Tips for working with children with learning disabilities:
- Be honest. Your child can tell that something is wrong. Explain the child's learning disability and ways to help. Don't promise a quick "cure." But do tell your child that many people have succeeded in careers despite learning disabilities.
- Accept your child's unique strengths and weaknesses. Help other family members understand.
- Help your child organize activities and schoolwork. Help plan ahead. Today is good. Next week is too far away.
- Give short-term jobs, one at a time. Use clear, short sentences to give directions.
- Reduce distractions.
- Keep pressure off. Give praise for small accomplishments.
- Tell your child the behavior you expect and the consequences of behavior.
- Really listen. Misbehavior is often a "help me" signal.
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