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When we hear the terms "discipline" and "father," there appears to be a natural connection, but often with negative overtones. The idea of a father as one who punishes or is an authoritarian figure runs deep in our culture. Yet, fathers have much more to offer than only helping their children learn self- control and social rules, and their role involves much more than punishment.

Discipline is one of those familiar words that carry different meanings. To many people, discipline simply implies the setting of firm rules and limits and administering punishments for breaking those rules. But, in fact, the meaning is more complex. The word discipline is based on the Latin word "discipulus," which means "a pupil," or more accurately, "one who is learning." Thus, the ancient origins of discipline are based on the notion of a reciprocal process of teaching and learning.

This notion is included in the modern definition of discipline. According to the American Heritage Dictionary (2000), the verb "to discipline" is defined as: 1. to train by instruction and practice, especially to teach self-control to. 2. to teach to obey rules or accept authority. See Synonyms at teach. 3. to punish in order to gain control of, enforce obedience. See Synonyms at punish.

When discipline refers to training and teaching specific behaviors of selfcontrol and moral development, this becomes a tall order for all parents, yet one that has historically been embraced by fathers. Indeed, prior to the 1900s in western culture, it was assumed that fathers more than mothers were responsible for the development of their children's moral behavior and self control. Men were expected to take on the critical teaching role. How can today's fathers provide discipline, in the sense of teaching and training their children? When does discipline start, and what form does it take?

Why Discipline is Important

The association between child-rearing practices and children's development of self-control has been well documented in research. Studies indicate that the quality of parental care is critical in the first year of life. Parents who are responsive, stimulating, and encouraging with their babies are laying the foundation for the development of self-control. During this first year, babies learn whether or not their signals, such as cries when hungry, or cold, are understood, and if their needs are met. A successful interaction involves a parent reacting to a baby's message and behaving responsively and leads to more successful social interactions (Parke & Sawin 1976). In the second year, when children begin walking and exploring on their own, it is important for parents to set limits for the child's safety and provide guidelines for acceptable behavior. Parents begin to think more and more about how and when to discipline their toddlers who are increasingly asserting their independence and autonomy which are necessary, normal aspects of early development.

The temperament of each young child affects each parent's approach to discipline. Research shows that fussy, active, or difficult toddlers often drive their parents to be more restrictive and more punitive (Patterson 1980). A cycle of negative interactions is set in motion; misbehavior is followed by punishment; punishment is followed by increasing, accelerating patterns of misbehavior. The father's role in these family interactions involves both the support of the mother and direct interactions with the child. Both research studies and parents themselves report that the hard-to-manage children are more compliant and agreeable with their fathers than with their mothers. Also, when the father is present in the room or nearby, children are much more compliant with their mothers (Patterson 1980; Lytton 1980). Research also indicates that when problems spiral out of control, sometimes fathers step in with harsh, direct punishment to get the situation back under control, which, unfortunately, can precipitate a cycle of punishment and misbehavior (DeKlyen 1998). Thus, poorly modulated behavior in a toddler or preschool child can overwhelm the mother or father, as well as split the parents into disagreement as they argue on how to manage the child. When parents disagree on behavior management, there is little improvement in the child.

The first positive strategy is to help the parents agree on how to handle some specific parenting issues. For example, they might come up with a plan to follow at bedtime, including specific ways to talk with the child. In this way, consistency is built up in the home environment. Calm, consistent behavior by adults is the model for teaching self-control in the child. The concept of discipline as teaching a set of behaviors to the child "not just punishment" becomes a reality only when there is consistency. A consistent plan on handling bedtime tantrums carried out by the mother and father can go a long way toward establishing a general pattern of discipline and the development of self-control.

Sidebar: Strategies for disciplining kids who have ADHD. Be clear about the expectations; consistent; patient; rather than just saying "no," explain (preferably show) the child what positive behavior you expect; reward positive behavior with attention.

Research emphasizes the important role of fathers in helping children to learn the standards of behavior for their group and to develop the capacity of self-regulation (Lamb 1987). When fathers are absent, curtail, or ignore their child-rearing responsibilities, there are implications throughout the family system. Mothers are likely to feel unsupported, abandoned, angry, and resentful. The resulting tension exacerbates the child's challenging behaviors. Lack of parental involvement by the father leaves the mother as the sole unsupported teacher of social skills and deprives the child of another role model. When fathers do not participate in child rearing, the results can be heightened intensity and duration of mother-child conflict and problems in discipline (Campbell 2002).

Playing with Children

The role of fathers for all children, not just those with challenging behaviors, is unique and important. As Lamb (1998) has indicated, the father is typically the one who engages in physical rough and tumble play with children. In the course of active play, children may test limits. Whether the activity involves tickling, wrestling or splashing in the pool, paying attention and stopping when needed are important lessons to be learned. Thus, discipline and learning self-control can start with play.

Fathers tend to be more active in their play, helping their children to be first in a race, catch the ball the most times, throw the farthest, jump the farthest, and leap into the water. While mothers are sometimes exasperated at fathers who get their sons and daughters excited, energized, and otherwise "all worked up," play has purpose. It tests limits and boundaries generally pushed less often by mothers. The children have to learn how to play without hurting someone else or getting hurt themselves, and how to direct their energy.

Constructive play is something both fathers and mothers can enjoy. Whether building with blocks to construct a road or a family's house, or "cooking" with play food and utensils, children enjoy the process of creating and constructing, then starting all over again. One of the most valuable interactions a father can have is getting down on the floor each day for 15 minutes and playing with his child - playing, commenting, and giving undivided attention.

Talking to Children

How parents speak greatly influences how often children comply with directions. While individuals certainly differ, the research is fairly consistent that mothers tend to explain more to their children, while fathers tend to use fewer words in all interactions. Fathers are often more tactile and physical, while mothers are typically more verbal and didactic (Parke 1996). Let's look at the task of giving a child the command to get ready to go to bed. Many mothers assume that if the child really understands why it is time for bed, they will be more likely to go to bed. For example, a mother might say, "Go to bed now because you have a busy day tomorrow," and follow it with a long explanation about how the body needs to rest, the child looks tired, and so on. However, the child, may lose track of the direction "go to bed" in the midst of all the other words.

On the other hand, some parents, more often fathers, tend to be a bit more direct, but often without the explanation. A very direct, "Go to bed now" appears harsh and may elicit some negative emotions from the child. An effective middle ground would be a brief explanation, followed by a clear command:" It's past your bedtime, you've had a busy day and have a lot to do tomorrow. It's time to go to bed." Repeating the direction (go to bed) at the end of the verbal exchange helps bring it to the child's attention.

Consequences: Positive and Negative

Consistently positive or negative responses to a child's behavior will change how often the child will respond the same way. Most child behavior is shaped by hundreds of daily back-and-forth interactions with the world around them, not by any single event or response. In short, parents need to do what they say, and to be consistent. If parents promise to do things and do them each time they promise, their children will trust and expect them to follow through. If a parent promises to play after dinner, and does, the child may eat more neatly and quickly. If a parent promises to take away a privilege because the child has broken a rule, the parent needs to do it so the child follows the rule next time. Promises are critically important when fathers do not live with their children and visits are arranged. Promised visits, phone calls and activities must occur, or the child learns not to trust the father, or other adults for that matter.

When positive and negative consequences are used to shape behavior, large, lavish one-time rewards of an expensive toy or video game, or harsh intense punishments such as being spanked severely or sent to one's room for hours, are not as effective as the little rewards of adult attention and time, or consistent brief mild punishments. For most children between the ages of two and six, a brief "Time Out" of sitting away quietly, not isolated, but not being paid attention is the most effective mild punishment. "Time Out" allows both parent and child to cool down, and the withdrawal of adult attention functions to reduce the problem behavior in the future. Other brief logical consequences include a short loss of privilege. For example if two children fight over a toy or what to watch on TV, and are unable to problem-solve, a parent might put the toy away temporarily or turn off the TV for a half hour. The key here is to follow through, calmly and consistently. Of course, these are also opportune times to teach children strategies for working out their disagreements.

Conclusion

When fathers understand that disciplining their child is an opportunity to teach by words and actions, they will have an important role in helping their children learn appropriate behavior and self-control. Engaging in fun play, conversation, and the use of fair consequences are times when discipline can be used in positive, nurturing ways.

Valuing Discipline

The following points are taken from the 21st Century Exploring Parenting Program, a Head Start publication. In Session 7 of the program, values are defined as standards of right and wrong that guide behavior. Though most parents do not realize it, their values determine how and why they discipline their children. It is therefore important for parents to evaluate their own values and to understand that every time they discipline their children, they are teaching about values.

Discipline is better understood as guidance and teaching, not controlling and punishing. Over time, children will learn how to control themselves, but until they can, adults need to help them by setting appropriate limits and modeling correct behavior. Discipline is an all day - every day teaching and learning process. These points will help parents as they continue to guide their young children.

• Values are principles and standards that guide our behavior.
• The values that individual family members hold dear vary considerably.
• Parents want their children to accept their values.
• The words "discipline" and "disciple" come from the Latin word "discipulus" which means pupil or student - one who learns.
• Babies need to be loved, nurtured, and accepted as they are. Nothing they do can be called misbehavior.
• Toddlers need adults to make rules that keep them and others safe and protect the family's belongings. They need help in keeping these rules and controlling their behavior.
• Preschoolers still need help in regulating their behavior. They are ready for more explanations about why they must do some things and cannot do others.
• The more time you spend in positive interaction with your children, the more likely it is that they will accept your values and want to please you.
• The combination of positive time together and discipline usually works better than discipline alone.

References

1. Campbell, S.B. 2002. Behavior Problems in Preschool Children: Clinical and Developmental Issues. Second Edition. New York: Guilford Press.DeKlyen, M., Speltz, M.L., Greenberg, M.T. 1998. Fathering and early onset conduct problems: Positive and negative parenting, father-son attachment, and marital conflict. Clinical Child and Family Psychology Review, 1, 3-22.
2. Lamb, M.E. 1987. The father's role: Cross-cultural perspectives. Hillsdale, N.J.: Erlbaum.
3. Lamb, M.E. 1998. Nonparental child care: Context, quality, correlates, and consequences. In W. Damon (Series Ed.) & I. Sigel & A.K. Renninger (Vol. Eds) Handbook of Child Psychology: Volume 4. Child psychology in practice. San Francisco, CA: John Wiley.
4. Lytton, H. 1980. Parent-Child interaction: The socialization process observed in twins and singleton families. New York: Plenum Press.
5. Mash E.J. & Johnston, C. 1983. Sibling interactions of hyperactive and normal children and their relationship to reports of maternal stress and self-esteem. Journal of Clinical Child Psychology. 12, 91-99.
6. Parke, R.D. 1996. Fatherhood. Cambridge: Harvard University Press.
7. Parke, R.D. & Sawin, D.B. 1976. The father's role in infancy: A Reevaluation. The Family Coordinator. 25, 365-371.
8. Pickett, J. et al (Eds). 2000. American Heritage Dictionary. Boston: Houghton Mifflin.
9. W. Douglas Tynan is a clinical psychologist and Director of the Disruptive Behavior Clinic at A. I. duPont Hospital for Children, Wilmington, DE

Head Start Bulletin
Issue No. 77
by W. Douglas Tynan
Last Modified: 06/17/04

Reviewed by athealth on February 4, 2014.

What is a psychodynamic process group and how does it typically work?

A process group typically consists of eight individuals who agree to meet regularly for a specific period of time, depending on the kind of group being hosted. Rules and expectations are agreed upon prior to the beginning of the group, and maybe discussed by members during the group if and when the need arises. A common purpose among those individuals who join a process group is in their wanting to find out more about who they are and, what it is perhaps that they would like to see change with-in their personal lives and in their relationships with others. In essence, a process group is expected to increase emotional awareness and relational understanding between self and others. The work of putting emotional experiences into words can give an individual the cognitive and emotional tools that lend to self-learning, insight and the potential to function with an increased sense of freedom, and with increased sophistication.

The premise of a process group draws from a psychodynamic perspective and is based upon developmental theory. The group is not apt to be influenced to change from 'outside' social pressures and cultural values making it a very specialized and unique psychotherapeutic method of healing. The group as a whole shapes its own unique culture, common values and norms thus, creating a meaningful context upon which it can evolve and grow at its own pace.

The life of a process group from the beginning to the end parallels different developmental stages of growth and maturity. As a group moves forward through its natural stages, the members and the "group-as-a-whole" are assisted with guided feedback and process comments from the leader and or co-leaders. As a result, the group inherently knits together with an abundance of experiences forming and emulating a social microcosm that bears its own unique culture and identity.

A most remarkable and natural phenomenon in the earlier stages of a process group is the way in which individuals, and sub-groups alike repeat the many characteristic ways once developed to survive the stressors and strains in the very first group...the family. Members may remind each other of significant others in their past or present circumstances bringing feelings, thoughts, ideas and fantasies to the fore.

One of the most important keys to a successful process group is when all group members feel sufficiently relaxed and safe to talk as openly as they possibly can about any aspects of the group experience in which they choose to respond. By engaging with one another on different emotional levels, individuals will hopefully gain wider perspectives about the various ways they relate to their inner world and understand how this becomes reflected in their relationships with others.

As awareness increases individuals may begin to recognize newly found aspects of themselves. Individuals and 'the-group-as-a-whole' may actively and unconsciously attempt not to become aware of various emotional aspects of themselves, to avoid uncomfortable and perhaps painful feelings. This is a common phenomenon of human behavior. It is within the supportive and relaxed atmosphere of the group experience that such feelings can be recognized, acknowledged and replaced with conscious, uncontaminated choices in social behaviors and verbal attitudes. The courage to allow these kinds of meaningful connections to take place can help to resolve emotional conflicts and difficulties with feelings of mastery and empowerment.

Once the group members feel more trusting with the leader and other group members, channels of communication are opened, allowing for a genuine and profound sharing of emotional experiences to take place. Thus, feelings of trust and support as well as other identifying therapeutic factors assist in creating room for innovative and creative risk taking with in the group. For each individual the rewards of creating such a place that is their own can be a place that is very real and fully connected. It is a place to be fully who they are without the need to 'fit-in' to a pre-determined pattern.

In summary, being in an experiential process group all members has the opportunity for considerable personal gains, 'corrective emotional experiences' and 'intrapsychic' change that can last a lifetime. Just as individuals bring old learned behaviors and attitudes into the group they may take new ways of inter-relating outside the group. This may enable individuals to cultivate healthier interdependency with others, as well as increased expressions of mature and authentic intimacy.

References:  The Practice of Group Therapy. S.R. Slavson. International Universities Press, 1947 and Analytic Group Psychotherapy with Children, Adolescents and Adults. S.R. Slavson. Columbia University Press, 1964.

Author: Deborah Reeves, MGPGP, LPC, CGP Deborah Reeves is a licensed professional counselor and a certified specialist in group psychotherapy. She has a private clinical and consulting psychotherapy practice in Philadelphia, PA, and is a spokesperson/group leader for ANAD (National Association of Anorexia/Nervosa and Associated Disorders) for the Philadelphia Region. For additional information, visit her Web site at http://www.healing-minds.com

Reviewed by athealth on February 5, 2014.

This report updates and expands the Guidelines for Alzheimer's Disease Management (California Workgroup on Guidelines for Alzheimer's Disease Management, 2002), which itself was a revision of the California Workgroup's original Guideline published in 1998. All of these documents were based upon work begun by the Ad Hoc Standards of Care Committee of the Alzheimer's Disease Diagnostic and Treatment Centers (ADDTCs) of California (Hewett, Bass, Hart, Butrum, 1995) and were supported in part by the State of California, Department of Health Services, and the Alzheimer's Association, California Southland Chapter.

PURPOSE AND SCOPE

More than 5 million Americans now have Alzheimer's Disease (Alzheimer's Association, 2008), an increase of 25% since the previous version of this Guideline was published. Alzheimer's Disease destroys brain cells, causing problems with memory, thinking, and behavior severe enough to affect work, family and social relationships, and, eventually, the most basic activities of daily living. Alzheimer's Disease gets worse over time, it is incurable, and it is fatal. Today it is the seventh leading cause of death in the United States, and the fifth leading cause for individuals 65 and older (Alzheimer's Association).

Since the 2002 revision was completed, there has been an explosion of research in the field, generating new insights into the progression, treatment, and management of Alzheimer's Disease. The revised Guideline and this report are based in large part on a review of journal articles and meta-analyses published after 2001, incorporating the results of this tremendous body of new work.

Most older adults - including those with Alzheimer's Disease - receive their medical care from Primary Care Practitioners (PCPs) (Callahan et al., 2006), who may lack the information and other resources they need to treat this growing and demanding population (Reuben, Roth, Kamberg, Wenger, 2003). Nevertheless, PCPs should be able to provide or recommend a wide variety of services beyond medical management of Alzheimer's Disease and comorbid conditions, including recommendations regarding psychosocial issues, assistance to families and caregivers, and referral to legal and financial resources in the community. Many specialized services are available to help patients and families manage these aspects of AD, such as adult day services, respite care, and skilled nursing care, as well as helplines and outreach services operated by the Alzheimer's Association, Area Agencies on Aging, Councils on Aging, and Caregiver Resource Centers. This Guideline is intended to provide assistance to PCPs in offering comprehensive care to patients with Alzheimer's Disease and those who care for them over the course of their illness.

Because the Guideline is intended for use by PCPs who will encounter Alzheimer's Disease in the course of their work, we use the word "patients" throughout this report. However, it is important to recognize that the needs of people with Alzheimer's Disease and their families extend far beyond the realm of medical treatment, and that PCPs will be called upon to provide a wide spectrum of information and resources to assist them in dealing with this challenging, sometimes overwhelming condition.

NEW INFORMATION

The 2002 Guideline was written prior to the development and testing of some new pharmacological agents, as well as numerous non-pharmacological interventions designed to improve disease management and quality of life for both Alzheimer's Disease patients and their caregivers. Although some of these treatment methods were already in use, few were supported by evidence of efficacy from well-designed clinical trials. In many cases, this evidence now exists, and it is discussed in the current revision.

A notable advance in pharmacological treatment of Alzheimer's Disease was the introduction of memantine (Namenda) in October 2003, a year after release of the previous version of this Guideline. The first drug approved by the U.S. Food and Drug Administration (FDA) for treatment of moderate to severe Alzheimer's Disease, memantine has become an important component of treatment for many patients. The Treatment section includes two tables devoted to its use.

In the ensuing 6 years, additional emphasis on other topics relevant to the treatment of Alzheimer's Disease, along with the needs of patients and their families, has become apparent. These topics include, among others:

• the importance of cultural and linguistic factors in Alzheimer's Disease treatment;
• the conduct of legal capacity evaluations; and
• the special needs of early-stage and late-stage patients and their families

The revised report includes much new material regarding these critically important subjects, as well as updated references for many points discussed in previous versions.

NEW FORMAT

This version of the report also has been reformatted for convenience and ease of use, with appendices containing copies of many of the assessment instruments and forms cited in the text. Websites containing valuable resources for both PCPs and patients are included, and the online version of the report contains links to many of these resources.

As with the previous versions, the Guideline's recommendations themselves were designed to fit on one page for handy reference and organized by major care issues (assessment, treatment, patient and family education and support, and legal considerations). The revised and expanded report has been organized to conform to this layout. Each section deals with one of the four care issues and provides an overview of the issue, followed by the care recommendations and a review of the literature supporting them. The language used throughout the report reflects the strength of the supporting evidence, either "strong" (e.g., randomized clinical trial) or "moderate." In some instances, recommendations that are not evidence-based are nevertheless supported by expert opinion and Workgroup consensus, and are labeled as such.

View the full - Guideline for Alzheimer's Disease Management - Final Report 2008

See the updated NIH - Alzheimer's Diagnostic Guideline Validation

Source:

California Workgroup on Guidelines for Alzheimer's Disease Management
California Version © April 2008
Used with permission from the Alzheimer's Association of Los Angeles

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Reviewed by athealth on February 5, 2014.

Most parents want their young children to have a healthy sense of self-esteem. That desire can also be seen in education--schools around the country include self-esteem among their goals. Many observers believe that low self-esteem lies at the bottom of many of society's problems.

Even though self-esteem has been studied for more than 100 years, specialists and educators continue to debate its precise nature and development. Nevertheless, they generally agree that parents and other adults who are important to children play a major role in laying a solid foundation for a child's development.

What Is Self-Esteem?

When parents and teachers of young children talk about the need for good self-esteem, they usually mean that children should have "good feelings" about themselves. With young children, self-esteem refers to the extent to which they expect to be accepted and valued by the adults and peers who are important to them.

Children with a healthy sense of self-esteem feel that the important adults in their lives accept them, care about them, and would go out of their way to ensure that they are safe and well. They feel that those adults would be upset if anything happened to them and would miss them if they were separated. Children with low self-esteem, on the other hand, feel that the important adults and peers in their lives do not accept them, do not care about them very much, and would not go out of their way to ensure their safety and well-being.

Sidebar: Children with ADHD and other behavioral disorders are particularly vulnerable to low self-esteem. They frequently experience school problems, have difficulty making friends, and lag behind their peers in psychosocial development.

During their early years, young children's self-esteem is based largely on their perceptions of how the important adults in their lives judge them. The extent to which children believe they have the characteristics valued by the important adults and peers in their lives figures greatly in the development of self-esteem. For example, in families and communities that value athletic ability highly, children who excel in athletics are likely to have a high level of self-esteem, whereas children who are less athletic or who are criticized as being physically inept or clumsy are likely to suffer from low self-esteem.

Families, communities, and ethnic and cultural groups vary in the criteria on which self-esteem is based. For example, some groups may emphasize physical appearance, and some may evaluate boys and girls differently. Stereotyping, prejudice, and discrimination are also factors that may contribute to low self-esteem among children.

How Can We Help Children Develop a Healthy Sense of Self-Esteem?

The foundations of self-esteem are laid early in life when infants develop attachments with the adults who are responsible for them. When adults readily respond to their cries and smiles, babies learn to feel loved and valued. Children come to feel loved and accepted by being loved and accepted by people they look up to. As young children learn to trust their parents and others who care for them to satisfy their basic needs, they gradually feel wanted, valued, and loved.

Self-esteem is also related to children's feelings of belonging to a group and being able to adequately function in their group. When toddlers become preschoolers, for example, they are expected to control their impulses and adopt the rules of the family and community in which they are growing. Successfully adjusting to these groups helps to strengthen feelings of belonging to them.

One point to make is that young children are unlikely to have their self-esteem strengthened from excessive praise or flattery. On the contrary, it may raise some doubts in children; many children can see through flattery and may even dismiss an adult who heaps on praise as a poor source of support--one who is not very believable.

The following points may be helpful in strengthening and supporting a healthy sense of self-esteem in your child:

• As they grow, children become increasingly sensitive to the evaluations of their peers. You and your child's teachers can help your child learn to build healthy relationships with his or her peers.
• When children develop stronger ties with their peers in school or around the neighborhood, they may begin to evaluate themselves differently from the way they were taught at home. You can help your child by being clear about your own values and keeping the lines of communication open about experiences outside the home.
• Children do not acquire self-esteem at once nor do they always feel good about themselves in every situation. A child may feel self-confident and accepted at home but not around the neighborhood or in a preschool class. Furthermore, as children interact with their peers or learn to function in school or some other place, they may feel accepted and liked one moment and feel different the next. You can help in these instances by reassuring your child that you support and accept him or her even while others do not.
• A child's sense of self-worth is more likely to deepen when adults respond to the child's interests and efforts with appreciation rather than just praise. For example, if your child shows interest in something you are doing, you might include the child in the activity. Or if the child shows interest in an animal in the garden, you might help the child find more information about it. In this way, you respond positively to your child's interest by treating it seriously. Flattery and praise, on the contrary, distract children from the topics they are interested in. Children may develop a habit of showing interest in a topic just to receive flattery.
• Young children are more likely to benefit from tasks and activities that offer a real challenge than from those that are merely frivolous or fun. For example, you can involve your child in chores around the house, such as preparing meals or caring for pets, that stretch his or her abilities and give your child a sense of accomplishment.
• Self-esteem is most likely to be fostered when children are esteemed by the adults who are important to them. To esteem children means to treat them respectfully, ask their views and opinions, take their views and opinions seriously, and give them meaningful and realistic feedback.
• You can help your child develop and maintain healthy self-esteem by helping him or her cope with defeats, rather than emphasizing constant successes and triumphs. During times of disappointment or crisis, your child's weakened self-esteem can be strengthened when you let the child know that your love and support remain unchanged. When the crisis has passed, you can help your child reflect on what went wrong. The next time a crisis occurs, your child can use the knowledge gained from overcoming past difficulties to help cope with a new crisis. A child's sense of self-worth and self-confidence is not likely to deepen when adults deny that life has its ups and downs.

Conclusion

Parents can play an important role in strengthening children's self-esteem by treating them respectfully, taking their views and opinions seriously, and expressing appreciation to them. Above all, parents must keep in mind that self-esteem is an important part of every child's development.

Sources

1. Amundson, K. 1991. 101 Ways Parents Can Help Students Achieve. Arlington, VA: American Association of School Administrators.
2. Cutright, M. C. February 1992. "Self-Esteem: The Key to a Child's Success and Happiness." PTA Today 17 (4): 5-6.
3. Dusa, G. S. February 1992. "15 Ways Parents Can Boost Self-Esteem." Learning 20 (6): 26-27.
4. Isenberg, J., and N.L. Quisenberry. February 1988. "Play: A Necessity for All Children." A position paper of the Association for Childhood Education International (ACEI). Childhood Education 64 (3): 138-145. EJ 367 943.
5. Katz, L.G. 1993. Distinctions Between Self-Esteem and Narcissism: Implications for Practice. Urbana, IL: ERIC Clearinghouse on Elementary and Early Childhood Education. ED 363 452.
6. Katz, L.G., and S.C. Chard. 1989. Engaging Children's Minds: The Project Approach. Norwood, NJ: Ablex. ED 326 302.
7. Kramer, P. April 1992. "Fostering Self-Esteem Can Keep Kids Safe and Sound." PTA Today 17 (6): 10-11.
8. Markus, H.R., and S. Kitayama. 1991. "Culture and the Self: Implications for Cognition, Emotions, and Motivation." Psychological Review 98 (2): 224-253.
9. McDaniel, S. April 1986. "Political Priority #1: Teaching Kids To Like Themselves." New Options 27: 1.
10. National Association of Elementary School Principals. 1990. Early Childhood Education and the Elementary School Principal: Standards for Quality Programs for Young Children. Alexandria, VA: NAESP.
11. National Association of Elementary School Principals. 1991. The Little Things Make a Big Difference: How To Help Your Children Succeed in School. Alexandria, VA: NAESP.
12. Popkin, Michael, H. 1993. Active Parenting Today: For Parents of 2 to 12 Year Olds. Parent's Guide. Marietta, GA: Active Parenting Publishers.

Source: ERIC Clearinghouse on Elementary and Early Childhood Education
Author: Lilian Katz, 1995

Reviewed by athealth on February 5, 2014.

What are learning disorders?

A student may have a learning disorder if his/her achievement in reading, writing, or mathematics falls below what is expected for the child's age, grade level, and intelligence. To be called a learning disorder, the problems must have a negative impact on the person's academic success or another important area of life requiring math, reading, or writing skills.

What are the different types of learning disorders?

There are three major types of learning disorders:

• Reading disorder
• Mathematics disorder
• Disorder of written expression

What signs are associated with learning disorders?
In addition to the problems associated with the specific type of learning disorder, many students also suffer from:

• Low self-esteem
• Socialization problems
• Increased dropout rate at school

Learning disorders may also be associated with:

• Conduct disorder
• ADD and ADHD
• Depression

Do learning disorders affect males, females, or both?

Learning disorders can affect both males and females. However, in the United States more boys than girls are diagnosed with learning disorders.

At what age do learning disorders appear?

Although learning disorders are most likely present when a child is quite young, the specific type of learning disorder is usually diagnosed in early elementary school when reading, math, and writing begin to be used in the classroom.

How prevalent are learning disorders in our society?

About five percent (5%) of students in the United States have learning disorders.

How are learning disorders diagnosed?

Because standardized, group testing is not accurate enough for this purpose, it is very important that special, psychoeducational tests be individually administered to the child to determine if he/she has a learning disorder. In administering the test, the examiner should give special attention to the child's ethnic and cultural background.

How are learning disorders treated?

Learning disorders are treated with specialized educational methods. In addition to special classroom instruction at school, students with learning disorders frequently benefit from individualized tutoring which focuses on their specific learning problem.

What can people do if they need help?

If you, a friend, or a family member would like more information and you have a therapist or a physician, please discuss your concerns with that person.

Source: John L. Miller, MD

Reviewed by athealth on February 5, 2014.

What is a mathematics disorder?

Students with a mathematics disorder have problems with their math skills. Their math skills are significantly below normal considering the student's age, intelligence, and education. The poor math skills cause problems with the student's academic success and other important areas in the student's life.

What signs indicate a mathematics disorder?

Students with mathematics disorder have problems which can include the following:

• Writing or printing numbers
• Counting
• Adding and subtracting
• Working with mathematical signs such as +, -, x, and /
• Learning names that include numbers

Students who suffer from mathematics disorders frequently have:

• Low self-esteem
• Social problems
• Increased dropout rate at school

Mathematics disorders may also be associated with:

• Conduct disorder
• ADD/ADHD
• Depression
• Other learning disorders

Are there genetic factors associated with a mathematics disorder?

It is possible that some people have problems in math because of their genetic makeup. In contrast to some families whose members have great difficulty solving math problems, there are other families who tend to have members that consistently have a very high-level of math functioning.

At what age does mathematics disorder appear?

Mathematics disorder is usually brought to the attention of the child?s parents in second or third grade when math instruction becomes a very important part of the classroom teaching.

How often is mathematics disorder seen in our society?

Although it is difficult to determine exactly, about one percent (1%) of children in the United States suffer from a mathematics disorder.

How is mathematics disorder diagnosed?

Mathematics disorder may be discovered when a student shows poor functioning in several math skills. For instance, if a student has difficulty understanding and working with various math terms and concepts or identifying arithmetic symbols and signs, the student may have mathematics disorder. Also, mathematics disorder may be indicated when the child is unable to attend to details such as carrying numbers or has problems counting and memorizing the multiplication tables.

Although standardized, group testing is important, it alone should not be relied on in making this diagnosis. It is very important that special, psychoeducational tests be individually administered to the child to determine if this learning disorder is present. In administering the test the examiner should give special attention to the child?s ethnic and cultural background.

How is a mathematics disorder treated?

Treatment for mathematics disorder includes individual tutoring, placement in special math classrooms with expert math teachers, and other educational aids that focus on math skills.

What happens to someone with a mathematics disorder?

The course of mathematics disorder is varied. Some students go on to do well in math. Others, even with early intervention and remedial attention, continue to struggle with math in their adult years.

What can people do if they need help?

If you, a friend, or a family member would like more information and you have a therapist or a physician, please discuss your concerns with that person.

Source: John L. Miller, MD

Reviewed by athealth on February 5, 2014.

When should you seek counseling?

From childhood through late adulthood, there are certain times when we may need help addressing problems and issues that cause us emotional distress or make us feel overwhelmed. When you are experiencing these types of difficulties, you may benefit from the assistance of an experienced, trained professional. Professional counselors offer the caring, expert assistance that we often need during these stressful times. A counselor can help you identify your problems and assist you in finding the best ways to cope with the situation by changing behaviors that contribute to the problem or by finding constructive ways to deal with a situation that is beyond your personal control. Professional counselors offer help in addressing many situations that cause emotional stress, including, but not limited to:

• anxiety, depression, and other mental and emotional problems and disorders
• family and relationship issues
• substance abuse and other addictions
• sexual abuse and domestic violence
• eating disorders
• career change and job stress
• social and emotional difficulties related to disability and illness
• adopting to life transitions
• the death of a loved one

"Good indicators of when you should seek counseling are when you're having difficulties at work, your ability to concentrate is diminished or when your level of pain becomes uncomfortable," says Dr. Gail Robinson, past president of the American Counseling Association. "However, you don't want to wait until the pain becomes unbearable or you're at the end of your rope."

"If someone is questioning if they should go into counseling that is probably the best indicator that they should," says Dr. William King, a mental health counselor in private practice in Indianapolis, Indiana. "You should trust your instincts."

Joyce Breasure, past president of the American Counseling Association and a professional counselor who has been in private practice for more than 20 years, recommends counseling when you:

• Spend 5 out of 7 days feeling unhappy
• Regularly cannot sleep at night
• Are taking care of a parent or a child and the idea crosses your mind that you may want to hit that person
• Place an elder in a nursing home or in alternative care
• Have lost someone or something (such as a job)
• Have a chronic or acute medical illness
• Can no longer prioritize what is most important in your life
• Feel that you can no longer manage your stress

"If you're not playing some, working some, and learning some, then you're out of balance. There's a potential for some problems," Breasure says.

Robinson points out you don't have to be "sick" to benefit from counseling. "Counseling is more than a treatment of mental illness," she says. "Some difficult issues we face in life are part of normal development. Sometimes it's helpful to see what you're going through is quite normal."

What is professional counseling?

Professional counselors work with individuals, families, groups and organizations. Counseling is a collaborative effort between the counselor and client. Professional counselors help clients identify goals and potential solutions to problems which cause emotional turmoil; seek to improve communication and coping skills; strengthen self-esteem; and promote behavior change and optimal mental health. Through counseling you examine the behaviors, thoughts and feelings that are causing difficulties in your life. You learn effective ways to deal with your problems by building upon personal strengths. A professional counselor will encourage your personal growth and development in ways that foster your interest and welfare.

Who are professional counselors?

Licensed professional counselors provide quality mental health and substance abuse care to millions of Americans. Professional counselors have a master's or doctoral degree in counseling or a related field which included an internship and coursework in human behavior and development, effective counseling strategies, ethical practice, and other core knowledge areas.

Over 80,000 professional counselors are licensed or certified in 44 states and the District of Columbia. State licensure typically requires a master's or doctoral degree, two to three years of supervised clinical experience, and the passage of an examination. In states without licensure or certification laws, professional counselors are certified by the National Board for Certified Counselors (NBCC). Participation in continuing education is often required for the renewal of a license or certification.

Professional counselors adhere to a code of ethics that protects the confidentiality of the counseling relationship; prohibits discrimination and requires understanding of and respect for diverse cultural backgrounds; and mandates that professional counselors put the needs and welfare of clients before all others in their practice.

Will my health insurance cover counseling?

Many insurance and coverage plans cover mental health services by a licensed professional counselor including some Medicaid programs, CHAMPUS, and other government-sponsored health coverage programs. If you do not have health insurance, or if your coverage does not include mental health care or the services of a professional counselor, many professional counselors will work with clients on a sliding-fee scale or will offer a payment plan. Talk to your counselor about your options.

How much does counseling cost?

The cost of counseling can vary greatly depending on your geographic location and whether counseling is being provided by a community mental health center or similar agency or by a counselor in private practice. In general, the average paid fee for individual counseling sessions is about $65. Fees for group counseling are generally lower, about $35 per group session. For clients with health insurance that does not cover mental health care and others who cannot afford the counselor's standard fee, some counselors will lower their fee on a sliding scale basis or will work out a payment plan. Your counselor should explain to you, prior to beginning the counseling relationship, all financial arrangements related to professional services.

How long does counseling take?

Ideally, counseling is terminated when the problem that you pursued counseling for becomes more manageable or is resolved. However, some insurance companies and managed care plans may limit the number of sessions for which they pay. You should check with your health plan to find out more about any limitations in your coverage. During the first few counseling sessions your counselor should also discuss the length of treatment that may be needed to achieve your goals.

Is everything I say confidential?

All members of the American Counseling Association subscribe to the Code of Ethics and Standards of Practice which require counselors to protect the confidentiality of their communications with clients. Most state licensure laws also protect client confidentiality. As a client, you are guaranteed the protection of confidentiality within the boundaries of the client/counselor relationship. Any disclosure will be made with your full written, informed consent and will be limited to a specific period of time. The only limitations to confidentiality occur when a counselor feels that there is clear and imminent danger to you or to others, or when legal requirements demand that confidential information be disclosed such as a court case. Whenever possible, you will be informed before confidential information is revealed.

How do I find a counselor?

There are many different ways to locate a professional counselor. Some common ways include:

• The National Board for Certified Counselors referral service (phone NBCC at 336-547-0607 between 8:30 a.m. and 4:30 p.m. Eastern Standard Time, Monday through Friday to find a certified counselor in your area)
• The yellow pages listed under counselor, marriage and family counselors, therapist or mental health
• Referral from your physician
• Recommendations from trusted friends
• Crisis hotlines
• Community mental health agencies
• Local United Way information & referral service
• Hospitals
• Child protective services
• Referral from clergy
• Employee Assistance Programs (EAPs)

Once you have found a counselor you are interested in seeing, you should ask several important questions, such as:

• Are you a licensed or certified counselor? What is your educational background? How long have you been practicing counseling?
• What are your areas of specialization (such as family therapy, women's issues, substance abuse counseling, etc.)?
• What are your fees? Do you accept my insurance? How is billing handled? Do you offer a sliding fee scale or a payment plan if I do not have insurance for mental health services?
• How can you help me with my problems? What type of treatment do you use? How long do you think counseling will last?

Some of these questions may be addressed during your initial phone conversation with the counselor and others may be more appropriately discussed in your first face-to-face meeting.

After you have had these questions answered by the counselor to your satisfaction, consider how comfortable you feel with the individual, since you will be working closely together during your counseling sessions. It is difficult to open up and share your problems with a stranger and you may feel awkward or anxious during your initial sessions. But it is also important that you have a "chemistry" or rapport with the counselor. Counselors have different styles, personalities, and approaches. Take time to evaluate how you feel interacting with the counselor and whether you believe that the two of you can work effectively together. If you do not feel at ease with a certain counselor, do not get discouraged. Instead, look for a different individual with whom you would feel more comfortable working with.

Together you and your counselor will set goals, work toward achieving them, and assess how well you are actually meeting them. Counseling can help you maximize your potential and make positive changes in your life. Finally, remember that counseling may be hard work at times but change and progress do happen. A professional counselor can provide the help and support to help you master the challenges of life.

Source: American Counseling Association
http://www.counseling.org

Page last modified or reviewed by athealth on January 29, 2014

Complex Trauma in Children and Adolescents

The term complex trauma describes the dual problem of children's exposure to multiple traumatic events and the impact of this exposure on immediate and long-term outcomes. Typically, complex trauma exposure results when a child is abused or neglected, but it can also be caused by other kinds of events such as witnessing domestic violence, ethnic cleansing, or war. Many children involved in the child welfare system have experienced complex trauma.

Often, the consequences of complex trauma exposure are devastating for a child. This is because complex trauma exposure typically interferes with the formation of a secure attachment bond between a child and her caregiver. Normally, the attachment between a child and caregiver is the primary source of safety and stability in a child's life. Lack of a secure attachment can result in a loss of core capacities for self-regulation and interpersonal relatedness. Children exposed to complex trauma often experience lifelong problems that place them at risk for additional trauma exposure and other difficulties, including psychiatric and addictive disorders, chronic medical illness, and legal, vocational, and family problems. These difficulties may extend from childhood through adolescence and into adulthood.

The diagnosis of posttraumatic stress disorder (PTSD) does not capture the full range of developmental difficulties that traumatized children experience. Children exposed to maltreatment, family violence, or loss of their caregivers often meet diagnostic criteria for depression, attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder, anxiety disorders, eating disorders, sleep disorders, communication disorders, separation anxiety disorder, and/or reactive attachment disorder. Yet each of these diagnoses captures only a limited aspect of the traumatized child's complex self-regulatory and relational difficulties. A more comprehensive view of the impact of complex trauma can be gained by examining trauma's impact on a child's growth and development.

Impact on Development

A comprehensive review of the literature suggests seven primary domains of impairment observed in children exposed to complex trauma. Each of the seven domains is discussed below.

Attachment

Complex trauma is most likely to develop if an infant or child is exposed to danger that is unpredictable or uncontrollable, because the child's body must devote resources that are normally dedicated to growth and development instead to survival. The greatest source of danger and unpredictability is the absence of a caregiver who reliably and responsively protects and nurtures the child. The early care giving relationship provides the primary context within which children learn about themselves, their emotions, and their relationships with others. A secure attachment supports a child's development in many essential areas, including his capacity for regulating physical and emotional states, his sense of safety (without which he will be reluctant to explore his environment), his early knowledge of how to exert an influence on the world, and his early capacity for communication.

When the child-caregiver relationship is the source of trauma, the attachment relationship is severely compromised. Care giving that is erratic, rejecting, hostile, or abusive leaves a child feeling helpless and abandoned. In order to cope, the child attempts to exert some control, often by disconnecting from social relationships or by acting coercively towards others. Children exposed to unpredictable violence or repeated abandonment often learn to cope with threatening events and emotions by restricting their processing of what is happening around them. As a result, when they confront challenging situations, they cannot formulate a coherent, organized response. These children often have great difficulty regulating their emotions, managing stress, developing concern for others, and using language to solve problems. Over the long term, the child is placed at high risk for ongoing physical and social difficulties due to:

• Increased susceptibility to stress (e.g., difficulty focusing attention and controlling arousal),
• Inability to regulate emotions without outside help or support (e.g., feeling and acting overwhelmed by intense emotions), and
• Inappropriate help-seeking (e.g., excessive help-seeking and dependency or social isolation and disengagement).

Biology

Toddlers or preschool-aged children with complex trauma histories are at risk for failing to develop brain capacities necessary for regulating emotions in response to stress. Trauma interferes with the integration of left and right hemisphere brain functioning, such that a child cannot access rational thought in the face of overwhelming emotion. Abused and neglected children are then prone to react with extreme helplessness, confusion, withdrawal, or rage when stressed.

In middle childhood and adolescence, the most rapidly developing brain areas are those that are crucial for success in forming interpersonal relationships and solving problems. Traumatic stressors or deficits in self-regulatory abilities impede this development, and can lead to difficulties in emotional regulation, behavior, consciousness, cognition, and identity formation.

It is important to note that supportive and sustaining relationships with adults-or, for adolescents, with peers-can protect children and adolescents from many of the consequences of traumatic stress. When interpersonal support is available, and when stressors are predictable, escapable, or controllable, children and adolescents can become highly resilient in the face of stress.

Affect Regulation

Exposure to complex trauma can lead to severe problems with affect regulation. Affect regulation begins with the accurate identification of internal emotional experiences. This requires the ability to differentiate among states of arousal, interpret these states, and apply appropriate labels (e.g. "happy," "frightened"). When children are provided with inconsistent models of affect and behavior (e.g., a smiling expression paired with rejecting behavior) or with inconsistent responses to affective display (e.g., child distress is met inconsistently with anger, rejection, nurturance, or neutrality), no coherent framework is provided through which to interpret experience.

Following the identification of an emotional state, a child must be able to express emotions safely and to adjust or regulate internal experience. Complexly traumatized children show impairment in both of these skills. Because they have difficulty in both self-regulating and self-soothing, these children may display dissociation, chronic numbing of emotional experience, dysphoria and avoidance of emotional situations (including positive experiences), and maladaptive coping strategies (e.g., substance abuse).

The existence of a strong relationship between early childhood trauma and subsequent depression is well-established. Recent twin studies, considered one of the highest forms of clinical scientific evidence because they can control for genetic and family factors, have conclusively documented that early childhood trauma, especially sexual abuse, dramatically increases risk for major depression, as well as many other negative outcomes. Not only does childhood trauma appear to increase the risk for major depression, it also appears to predispose toward earlier onset of depression, as well as longer duration, and poorer response to standard treatments.

Dissociation

Dissociation is one of the key features of complex trauma in children. In essence, dissociation is the failure to take in or integrate information and experiences. Thus, thoughts and emotions are disconnected, physical sensations are outside conscious awareness, and repetitive behavior takes place without conscious choice, planning, or self-awareness. Although dissociation begins as a protective mechanism in the face of overwhelming trauma, it can develop into a problematic disorder. Chronic trauma exposure may lead to an over-reliance on dissociation as a coping mechanism that, in turn, can exacerbate difficulties with behavioral management, affect regulation, and self-concept.

Behavioral Regulation

Complex childhood trauma is associated with both under-controlled and over-controlled behavior patterns. As early as the second year of life, abused children may demonstrate rigidly controlled behavior patterns, including compulsive compliance with adult requests, resistance to changes in routine, inflexible bathroom rituals, and rigid control of food intake. Childhood victimization also has been shown to be associated with the development of aggressive behavior and oppositional defiant disorder.

An alternative way of understanding the behavioral patterns of chronically traumatized children is that they represent children's defensive adaptations to overwhelming stress. Children may reenact behavioral aspects of their trauma (e.g., through aggression, or self-injurious or sexualized behaviors) as automatic behavioral reactions to trauma reminders or as attempts to gain mastery or control over their experiences. In the absence of more advanced coping strategies, traumatized children may use drugs or alcohol in order to avoid experiencing intolerable levels of emotional arousal. Similarly, in the absence of knowledge of how to form healthy interpersonal relationships, sexually abused children may engage in sexual behaviors in order to achieve acceptance and intimacy.

Cognition

Prospective studies have shown that children of abusive and neglectful parents demonstrate impaired cognitive functioning by late infancy when compared with non-abused children. The sensory and emotional deprivation associated with neglect appears to be particularly detrimental to cognitive development; neglected infants and toddlers demonstrate delays in expressive and receptive language development, as well as deficits in overall IQ. By early childhood, maltreated children demonstrate less flexibility and creativity in problem-solving tasks than same-age peers. Children and adolescents with a diagnosis of PTSD secondary to abuse or witnessing violence demonstrate deficits in attention, abstract reasoning, and problem solving.

By early elementary school, maltreated children are more frequently referred for special education services. A history of maltreatment is associated with lower grades and poorer scores on standardized tests and other indices of academic achievement. Maltreated children have three times the dropout rate of the general population. These findings have been demonstrated across a variety of trauma exposures (e.g., physical abuse, sexual abuse, neglect, and exposure to domestic violence) and cannot be accounted for by the effects of other psychosocial stressors such as poverty.

Self-Concept

The early caregiver relationship has a profound effect on a child's development of a coherent sense of self. Responsive, sensitive caretaking and positive early life experiences allow a child to develop a model of self as generally worthy and competent. In contrast, repetitive experiences of harm and/or rejection by significant others and the associated failure to develop age-appropriate competencies are likely to lead to a sense of self as ineffective, helpless, deficient, and unlovable. Children who perceive themselves as powerless or incompetent and who expect others to reject and despise them are more likely to blame themselves for negative experiences and have problems eliciting and responding to social support.

By 18 months, maltreated toddlers already are more likely to respond to self-recognition with neutral or negative affect than non-traumatized children. In preschool, traumatized children are more resistant to talking about internal states, particularly those they perceive as negative. Traumatized children have problems estimating their own competence. Early exaggerations of competence in preschool shift to significantly lowered estimates of self-competence by late elementary school. By adulthood, they tend to suffer from a high degree of self-blame.

Family Context

The family, particularly the child's mother, plays a crucial role in determining how the child adapts to experiencing trauma. In the aftermath of trauma, family support and parents' emotional functioning strongly mitigate the development of PTSD symptoms and enhance a child's capacity to resolve the symptoms.

There are three main elements in caregivers' supportive responses to their children's trauma:

• Believing and validating the child's experience,
• Tolerating the child's affect, and
• Managing the caregiver's own emotional response.

When a caregiver denies the child's experiences, the child is forced to act as if the trauma did not occur. The child also learns she cannot trust the primary caregiver and does not learn to use language to deal with adversity. It is important to note that it is not caregiver distress per se that is necessarily detrimental to the child. Instead, when the caregiver's distress overrides or diverts attention away from the needs of the child, the child may be adversely affected. Children may respond to their caregiver's distress by avoiding or suppressing their own feelings or behaviors, by avoiding the caregiver altogether, or by becoming "parentified" and attempting to reduce the distress of the caregiver.

Caregivers who have had impaired relationships with attachment figures in their own lives are especially vulnerable to problems in raising their own children. Caregivers with histories of childhood complex trauma may avoid experiencing their own emotions, which may make it difficult for them to respond appropriately to their child's emotional state. Parents and guardians may see a child's behavioral responses to trauma as a personal threat or provocation, rather than as a reenactment of what happened to the child or a behavioral representation of what the child cannot express verbally. The victimized child's simultaneous need for and fear of closeness also can trigger a caregiver's own memories of loss, rejection, or abuse, and thus diminish parenting abilities.

Ethnocultural Issues

Children's risk of exposure to complex trauma, as well as child and family responses to exposure, can also be affected by where they live and by their ethnocultural heritage and traditions. For example, war and genocide are prevalent in some parts of the world, and inner cities are frequently plagued with high levels of violence and racial tension. Children, parents, teachers, religious leaders, and the media from different cultural, national, linguistic, spiritual, and ethnic backgrounds define key trauma-related constructs in many different ways and with different expressions. For example, flashbacks may be "visions," hyperarousal may be "un ataque de nervios," and dissociation may be "spirit possession." These factors become important when considering how to treat the child.

Resilience Factors

While exposure to complex trauma has a potentially devastating impact on the developing child, there is also the possibility that a victimized child may function well in certain domains while exhibiting distress in others. Areas of competence also can shift as children are faced with new stressors and developmental challenges.

Several factors have been shown to be linked to children's resilience in the face of stress: positive attachment and connections to emotionally supportive and competent adults within the family or community, development of cognitive and self-regulation abilities, and positive beliefs about oneself and motivation to act effectively in one's environment. Additional individual factors associated with resilience include an easygoing disposition, positive temperament, and sociable demeanor; internal locus of control and external attributions for blame; effective coping strategies; a high degree of mastery and autonomy; special talents; creativity; and spirituality.

The greatest threats to resilience appear to follow the breakdown of protective systems. This results in damage to brain development and associated cognitive and self-regulatory capacities, compromised caregiver-child relationships, and loss of motivation to interact with one's environment.

Assessment and Treatment

Regardless of the type of trauma that leads to a referral for services, the first step in care is a comprehensive assessment. A comprehensive assessment of complex trauma includes information from a number of sources, including the child's or adolescent's own disclosures, collateral reports from caregivers and other providers, the therapist's observations, and standardized assessment measures that have been completed by the child, caregiver, and, if possible, by the child's teacher. Assessments should be culturally sensitive and language-appropriate. Court evaluations, where required, must be conducted in a forensically sound and clinically rigorous manner.

The National Child Traumatic Stress Network is a partnership of organizations and individuals committed to raising the standard of care for traumatized children nationwide. The Complex Trauma Workgroup of the National Child Traumatic Stress Network has identified six core components of complex trauma intervention:

• Safety: Creating a home, school, and community environment in which the child feels safe and cared for
• Self-regulation: Enhancing a child's capacity to modulate arousal and restore equilibrium following disregulation of affect, behavior, physiology, cognition, interpersonal relatedness and self-attribution.
• Self-reflective information processing: Helping the child construct self-narratives, reflect on past and present experience, and develop skills in planning and decision making.
• Traumatic experiences integration: Enabling the child to transform or resolve traumatic reminders and memories using such therapeutic strategies as meaning-making, traumatic memory containment or processing, remembrance and mourning of the traumatic loss, symptom management and development of coping skills, and cultivation of present-oriented thinking and behavior.
• Relational engagement: Teaching the child to form appropriate attachments and to apply this knowledge to current interpersonal relationships, including the therapeutic alliance, with emphasis on development of such critical interpersonal skills as assertiveness, cooperation, perspective-taking, boundaries and limit-setting, reciprocity, social empathy, and the capacity for physical and emotional intimacy.
• Positive affect enhancement: Enhancing a child's sense of self-worth, esteem and positive self-appraisal through the cultivation of personal creativity, imagination, future orientation, achievement, competence, mastery-seeking, community-building and the capacity to experience pleasure.

In light of the many individual and contextual differences in the lives of children and adolescents affected by complex trauma, good treatment requires the flexible adaptation of treatment strategies in response to such factors as patient age and developmental stage, gender, culture and ethnicity, socioeconomic status, and religious or community affiliation. However, in general, it is recommended that treatment proceed through a series of phases that focus on different goals. This can help avoid overloading children-who may well already have cognitive difficulties-with too much information at one time.

A phase-based approach begins with a focus on providing safety, typically followed by teaching self-regulation. As children's capacity to identify, modulate and express their emotions stabilizes, treatment focus increasingly incorporates self-reflective information processing, relational engagement, and positive affect enhancement. These additional components play a critical role in helping children to develop in positive, healthy ways, and to avoid future trauma and victimization.

While it may be beneficial for some children affected by complex trauma to process their traumatic memories, this typically can only be successfully undertaken after a substantial period of stabilization in which internal and external resources have been established. Notably, several of the leading interventions for child complex trauma do not include revisiting traumatic memories but instead foster integration of traumatic experiences through a focus on recognizing and coping with present triggers within a trauma framework.

Best practice with this population typically involves adoption of a systems approach to intervention, which might involve working with child protective services, the court system, the schools, and social service agencies. Finally, there is a consensus that interventions should build strengths as well as reduce symptoms. In this way, treatment for children and adolescents also serves to protect against poor outcomes in adulthood.

References

This article has been adapted from the following sources:

Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M.; Cloitre, M, DeRosa, R., Hubbard, R., Kagan, R., Liautaud, J., Mallah, K., Olafson, E., & van der Kolk, B. (2005). Complex trauma in children and adolescents. Psychiatric Annals, 35, 390-398.

Cook, A., Blaustein, M., Spinazzola, J, & van der Kolk, B. (Eds.). Complex trauma in children and adolescents. National Child Traumatic Stress Network. www.nctsnet.org/nccts/nav.do?pid=typ_ct

Authors

Alexandra Cook, Joseph Spinazzola, Julian Ford, Cheryl Lanktree, Margaret Blaustein, Caryll Sprague, Marylene Cloitre, Ruth DeRosa, Rebecca Hubbard, Richard Kagan, Joan Liautaud, Karen Mallah, Erna Olafson, Bessel van der Kolk.

The authors wish to acknowledge the contributions of the Complex Trauma Workgroup of the National Child Traumatic Stress Network.

Source:
Focal Point: A National Bulletin on Family Support and Children's Mental Health
Winter 2007 Focal Point, Vol. 21, No. 1
Used with permission
Research and Training Center
Portland State University
http://www.pdx.edu/

Page last modified or reviewed by February 2, 2014

For many years, depression and other disorders of mood were thought to be afflictions of only adults. Within the past three decades, however, it has become evident that mood disorders are common among children and adolescents. Population studies reveal that between 10% and 15% of the child and adolescent population exhibit some symptoms of depression (U. S. Department of Health and Human Services [USDHHS], 2000).

In children and adolescents, the most frequently diagnosed mood disorders are major depressive disorder, dysthymic disorder, and bipolar disorder. This digest focuses on these three disorders as they are exhibited in childhood and adolescence - their symptoms, causal factors, and treatment.

Major Depressive Disorder

Major depressive disorder is a serious condition characterized by one or more major depressive episodes. In children and adolescents, an episode lasts an average of seven to nine months (Birmaher et al., 1996a, 1996b). Depressed children are sad and lose interest in activities they used to enjoy. They feel unloved, pessimistic, or even hopeless; they think that life is not worth living; and they may think about or threaten suicide. They are often irritable, which may lead to disruptive or aggressive behavior. They may be indecisive, have problems concentrating, and lack energy or motivation. They may neglect appearance and hygiene, and their normal eating and sleeping patterns may be disturbed (USDHHS, 2000).

Dysthymic Disorder

Dysthymic disorder has fewer symptoms, but is more persistent. The child or adolescent is depressed for most of the day on most days, and symptoms may continue for several years, the average dysthymic period being approximately four years. Seventy percent of children and adolescents with dysthymia eventually experience an episode of major depression. When this combination of major depression and dysthymia occurs, the condition is referred to as double depression (USDHHS, 2000).

Bipolar Disorder

In bipolar disorder, episodes of depression alternate with episodes of mania. The depressive episode usually comes first, with the first manic features becoming evident months or even years later. Adolescents with mania feel energetic and confident; may have difficulty sleeping but do not tire; and talk a great deal, often speaking very loudly or rapidly. They may complain of racing thoughts. They may do schoolwork quickly and creatively, but in a chaotic, disorganized way. In the manic stage, they may have exaggerated or even delusional ideas about their capabilities and importance, become overconfident, and be uninhibited with others. They may engage in reckless behavior (e. g., fast driving or unsafe sex). Sexual preoccupations are increased and may be associated with promiscuous behavior (USDHHS, 2000).

Other Disabilities Associated With Depressive Disorders

Approximately two-thirds of children and adolescents with major depressive disorder also have another mental disorder, such as anxiety disorder, conduct disorder, oppositional defiant disorder, psychoactive substance abuse or dependence, or phobias (Anderson & McGee, 1994). Authorities have also noted that children with medical problems often face extreme and/or chronic stress, which places them at risk for depression. Estimates of depression among youngsters with medical problems range from 7% in general medical patients to 23% in orthopedic patients (Guetzloe, 1991). Depression has also been linked to a variety of other medical conditions, including endocrinopathies and metabolic disorders (e.g., diabetes and hypoglycemia), viral infections (e.g., influenza, viral hepatitis, and viral pneumonia), rheumatoid arthritis, cancer, central nervous system disorders, metal intoxications, and disabling diseases of all kinds. Some of these conditions may be temporary, but some may be diagnosed as primary disabilities in youngsters with health impairments.

The Link Between Depression and Suicide

A number of studies have confirmed that children and adolescents with depression are at high risk for suicidal behavior (see Guetzloe, 1991). Because mood disorders substantially increase the risk of suicide, suicidal behavior is a matter of serious concern for parents, educators, and clinicians who deal with the mental health problems of children and adolescents. Over 90% of children and adolescents who commit suicide have a mental disorder (USDHHS, 2000).

Causal Factors Related to Depression

The precise causes of depression are not known. Research on adults with depression generally points to both biological and psychosocial factors, but there has been considerably less research on children and adolescents (Kendler, 1995).

• Family and genetic factors. Between 20% and 50% of depressed children and adolescents have a family history of depression. It is not clear whether the relationship between parent and childhood depression derives from genetic factors or if depressed parents create an environment in which children are more likely to develop mental disorders (USDHHS, 2000).
• Biological factors. Biochemical and physiological correlates of depression have been studied by medical researchers, with results that generally point to a chemical imbalance in the brain as a causal factor (Birmaher et al., 1996a,1996b). Most of these studies have been conducted with adults, so the findings may not apply to children and adolescents (Guetzloe, 1991).
• Cognitive factors. For several decades there has been considerable interest in the relationship between a pessimistic mindset and a predisposition to depression. Pessimistic individuals generally react more passively, helplessly, and ineffectively to negative events than optimistic individuals. The specific origins of pessimistic mindset have not been established (USDHHS, 2000) but are topics of current research interest (Alloy et al., 2001; Garber & Flynn, 2001).

Diagnosis and Assessment of Depressive Illness in Young People

Recent research has focused on the development and validation of checklists and protocols to be used by mental health professionals along with clinical interviews and medical tests. An accurate diagnosis of depression is a complex task, extremely difficult for even highly skilled physicians and other clinicians. It requires a careful examination of physical, mental, emotional, environmental, and cultural factors related to the child or adolescent, his/her family, and the environment. Teachers, counselors, and other school personnel are not expected to diagnose depression in young people; the major roles of educators are to detect the symptoms of depression and make appropriate referrals.

Treatment of Depressive Disorders

Treatment approaches for children and adolescents include psychosocial interventions (e. g., cognitive behavior therapy) and medication, as well as traditional psychotherapy. Two forms of cognitive therapy (i.e., self-control therapy for prepubertal children and coping skills for adolescents) have been judged as probably effective (Kaslow & Thompson, 1998). A number of medications are commonly prescribed for children and adolescents with depression, but many of these have not yet been subjected to sufficient study. Effective treatment requires intervention by both medical and mental health professionals, with support from all others who come in contact with the young person; and is therefore not within the purview of the school alone.

School and Classroom Intervention

The educator's most important contribution is the provision of a positive and supportive environment, components of which include satisfaction of basic needs, caring relationships with adults, and physical and psychological security. Any inclusion in a student's program that serves to enhance feelings of self-worth, self-control, and optimism has the potential for ameliorating feelings of depression. Aversive techniques (e. g., punishment and "get tough" approaches) should be avoided to the extent possible (Guetzloe, 1989, 1991).

Educators must use instructional strategies that are both positive and effective so that the student will achieve success and enjoy the learning process. Examples include direct instruction with positive reinforcement, thematic instructional units with varied levels of classroom assignments, learning strategies (e. g., mnemonic devices) and utilization of the principles of universal design for leaning, which promote access to the general curriculum for students with learning problems. Some protective factors have been addressed in published curricula (e. g., preventing alienation, enhancing self-esteem, and learning self-control). Other interventions that have implications for school programs (e. g., phototherapy and exercise) have been found to have value in reducing symptoms of depression in adults (Brosse, Sheets, Lett, & Blumenthal, 2002; USDHHS, 2003), but have not yet been subjected to sufficient study with children and adolescents.

Summary

Mood disorders, including major depression, dysthymia, and bipolar disorder, are now recognized as serious problems among children and adolescents. This brief discussion has focused on the symptoms of these disorders, their relationships to other mental and physical problems, their treatment, and appropriate school intervention.

Resources

Alloy, L.B., Abramson, L.Y., Tashman, N., Berrebbi, D.S., Hogan, M.E., Whitehouse, W.G., Crossfield, A.G., & Morocco, A. (2001). Developmental origins of cognitive vulnerability to depression: Parenting, cognitive, and inferential feedback styles of the parents of individuals at high and low cognitive risk for depression. Cognitive Therapy and Research, 25, 397-423.

Anderson, J. C., & & McGee, R. (1994). Comorbidity of depression in children and adolescents. In W. M. Reynolds & H. F. Johnson (Eds.), Handbook of depression in children and adolescents (pp. 581-601). New York: Plenum.

Birmaher, B., Ryan, N. D., Williamson, D. E., Brent, D. A., & Kaufman, J. (1996a). Childhood and adolescent depression: A review of the past 10 years. Part II. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1575-1583.

Birmaher, B., Ryan, N. D., Williamson, D. E., Brent, D. A., Kaufman, J., Dahl, R. E., Perel, J., & Nelson, B. (1996b). Childhood and adolescent depression: A review of the past 10 years. Part I. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1427-1439.

Brosse, A. L., Sheets, E. S., Lett, H. S., & Blumenthal, J. A. (2002). Exercise and the treatment of clinical depression in adults: Recent findings and future directions. Sports Medicine 32 (12),741-760.

Garber, A., & Flynn, C. A. (2001).Predictors of depressive cognitions in young adolescents. Cognitive Therapy and Research, 25, 353-376.

Guetzloe, E. C. (1991). Depression and suicide: Special education students at risk. Reston, VA: Council for Exceptional Children.

Guetzloe, E. C. (1989). Youth suicide: What the educator should know. Reston, VA: The Council for Exceptional Children.

Kaslow, N. J., & Thompson, M. P. (1998). Applying the criteria for empirically supported treatments to studies of psychosocial interventions for child and adolescent depression. Journal of Clinical Child Psychology, 27, 146-155.

Kendler, K. S. (1995). Genetic epidemiology in psychiatry. Taking both genes and environment seriously. Archives of General Psychiatry, 52, 895-899.

U. S. Department of Health and Human Services (USDHHS). (2000). Mental health: A report of the Surgeon General. Rockville, MD: U. S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administraion, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

U. S. Department of Health and Human Services (2003). Mood disorders. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administraion, The Center for Mental Health Services, National Institutes of Health, National Institute of Mental. http://www.mentalhealth.org/publications/allpubs/ken98-0049/default.asp
Source: ERIC Digest
ERIC Clearinghouse on Disabilities and Gifted Education
ERIC Identifier: ED482340
Publication Date: 2003-08-00
Author: Eleanor Guetzloe

Reviewed by athealth.com February 3, 2014

ADHD is a chronic health condition, and early identification and treatment of the disorder increase the child's chance for academic, emotional, and social success. -- Harlan Gephart, MD

Athealth.com: We are pleased to welcome Harlan Gephart, MD, Past Chair of the American Board of Pediatrics and an ADHD expert, who talks about the diagnosis and treatment of attention deficit / hyperactivity disorder. Dr. Gephart, former director of the Group Health ADHD Clinic, is the ADHD consultant at Pediatric Associates in Bellevue, Washington, and a Clinical Professor of Pediatrics at the University of Washington Medical School in Seattle. He is a member of the editorial boards of Contemporary Pediatrics and Journal Watch - Pediatric and Adolescent Medicine. Dr. Gephart has also served as the pediatric delegate to the American Board of Medical Specialists and as a member of the Future of Pediatric Education II Project (FOPE II), the national joint task force of pediatric societies studying pediatric practice and education into the 21st century.

Athealth.com: How did you become interested in ADHD?

Dr. Gephart: I completed a pediatric residency at the University of Washington and particularly enjoyed the behavioral side of pediatrics. I considered taking a residency in child psychiatry, but the Viet Nam war intervened, and after I completed a tour of duty with the Air Force, I decided to take additional training in behavioral pediatrics. I returned to the University of Washington as chief resident in pediatrics and spent much of that year at what is now called the Center for Human Development and Disability, working with Dr. Michael Rothenberg, a nationally-known pediatrician / child psychiatrist.

Following my fellowship, I joined Group Health as a general pediatrician. My interest in ADHD and behavioral pediatrics was fueled by my work as physician for one of the local school districts and the significant number of ADHD patients that I was seeing in my practice.

Athealth.com: How did the Center for Attention Deficit Disorders at Group Health come into being?

Dr. Gephart: Another physician, Dr. Connie McDonald, who was a fully trained developmental pediatrician, and I established the clinic in 1989.

It was becoming increasingly difficult for primary care physicians to carve out the block of time necessary to do a complete assessment for ADHD, and we were receiving a large number of these kinds of referrals. We needed a place where we could facilitate the assessment and management of children with the disorder. When Dr. McDonald retired in 1990, I became medical director of the center, and for a number of years I practiced half time in the center and half time in general pediatrics. Today, I limit my practice to half time, but devote 100% of my practice time to assessments, medication management, supervision, teaching, and administration at the center.

Athealth.com: How many patients have been assessed at the center?

Dr. Gephart: We have assessed or managed between 5,000 - 6,000 young people.

Athealth.com: How are patients referred to the center?

Dr. Gephart: We receive around 40 - 50 referrals each month. The majority of our referrals come from within the Group Health system, but about 10% - 15% of the kids are private patients referred to our center from outside of Group Health. About two-thirds to three-quarters of our referrals come from family doctors, and the rest generally come from pediatricians or mental health care providers.

Athealth.com: Why aren't these patients assessed for ADHD by their own health care providers?

Dr. Gephart: The family physician may not have time to conduct a comprehensive evaluation, or his/her clinical expertise may lie elsewhere. Some clinicians do not feel comfortable diagnosing ADHD, but they are able to manage the treatment of the child once the diagnosis is made.

The referrals we receive from pediatricians are often the more complex cases not easily managed in a general pediatric practice. Mental health care providers may refer to the center for an assessment and then rely on us for medication management.

Athealth.com: What is the prevalence of ADHD?

Dr. Gephart: Prevalence estimates vary, but among school-aged children the prevalence is estimated to be between 6% - 10%.

Athealth.com: Why is it important to treat ADHD?

Dr. Gephart: Attention deficit/hyperactivity disorder is the most common behavioral disorder of childhood. Children with ADHD exhibit symptoms of inattention, hyperactivity, and impulsivity, and as a result, they frequently experience school problems, have difficulty with peers and family members, and show poor psychosocial development. They are at higher risk for teen pregnancy, substance abuse, and other comorbid conditions, and they are more likely to drop out of school at an early age. Virtually all children with ADHD suffer from low self-esteem.

ADHD is a chronic health condition, and early identification and treatment of the disorder increase the child's chance for academic, emotional, and social success. If we let an ADHD child go untreated, we may well be handing that child a life sentence of academic and social failure.

Athealth.com: What is being done to improve the diagnosis and treatment of ADHD?

Dr. Gephart: In recent years a significant effort has been made to develop evidence-based guidelines that standardize the diagnosis and treatment of the disorder. For example, the American Academy of Pediatrics (AAP) recently published guidelines for the diagnosis and treatment of ADHD in children 6 to 12 years of age. The American Academy of Child and Adolescent Psychiatry has published similar guidelines.

The next important step is developing effective programs that teach physicians, nurses, mental health providers, school staff, and other members of the treatment team how to apply the guidelines.

Athealth.com: How do you conduct an ADHD assessment?

Dr. Gephart: ADHD assessments require a considerable amount of time and effort. At the center we plan about four hours for an initial assessment.

The diagnosis of ADHD requires that a child meet the criteria set forth in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). A complete assessment includes the following:

A complete history from the child's parent or caretaker, including information about the child's inattention, hyperactivity, and impulsivity, the age of onset of the symptoms, and the extent of the child's academic and social impairment;

Behavior and academic reports, including report cards and samples of school work, from the child's school. It is also helpful to gather information from other collateral resources such as counselors, day care providers, or coaches if they have significant contact with the child.

Use of ADHD-specific behavior rating scales and questionnaires. Scales are used in an attempt to quantify the level of the child's impairment. All kids have some characteristics of ADHD. However, if a child has ADHD, the symptoms will be clinically significant for longer than 6 months and will manifest themselves in at least two environments, typically at home and at school. The scales also assist us in establishing a baseline so that once the condition is treated, we have something against which we can measure improvement.

The AAP guidelines recommend several parent and teacher rating scales, including:

• CPRS-R:L-ADHD Index (Conners Parent Rating Scale-1997 Revised Version: Long Form, ADHD Index Scale);
• CTRS-R:L-ADHD Index (Conners Teacher Rating Scale-1997 Revised Version: Long Form, ADHD Index Scale);
• CPRS-R:L-DSM-IV Symptoms (Conners Parent Rating Scale-1997 Revised Version: Long Form, DSM-IV Symptoms Scale); and
• CTRS-R:L-DSM-IV Symptoms (Conners Teacher Rating Scale-1997 Revised Version: Long Form, DSM-IV Symptoms Scale).

A complete physical examination, including a neurological examination if indicated, to determine if there is a physical reason for the problem, such as a visual or hearing impairment or a genetic disorder;

An interview with the child separate from the physical examination;

An assessment for co-existing conditions. There are a number of look alike and/or co-occurring disorders associated with ADHD - depression, anxiety, substance abuse, learning disorders, conduct disorder, oppositional defiant disorder (ODD), and Tourette syndrome to name a few.

It is not uncommon for an ADHD child to have a co-existing condition. In patients with ADHD about fifty percent (50%) fulfill the criteria for ODD and about twenty-five percent (25%) fulfill the criteria for conduct disorder.

Learning disorders are two times more common in children with ADHD. If an ADHD child is performing below grade level in school, the clinician should recommend that the school conduct a psychoeducational evaluation.

Athealth.com: What causes ADHD and can it be cured?

Dr. Gephart: We don't have a complete answer for what causes ADHD, but we certainly understand a great deal more than we did. We now know that:

• ADHD doesn't occur because the parent is a bad parent or because the child is a bad kid;
• ADHD runs in families;
• ADHD may, at least in part, be caused by neurotransmitter deficits;
• Although chronic, ADHD is a highly treatable medical condition.

We used to say that ADHD kids would eventually outgrow the disorder. Today, we know that inattention and lack of organization can persist into adulthood - although hyperactivity and impulsivity tend to diminish with age.

School is a burden for kids with ADHD. In adults, it isn't that the disorder goes away, it's that school goes away, and therefore, the focus on the symptoms and the resultant impairment is often reduced.

Athealth.com: What about girls with ADHD?

Dr. Gephart: I would say that ADHD is under-diagnosed in girls. This may be, in part, because girls with ADHD tend to be more inattentive than hyperactive, and therefore, draw less attention to themselves. In recent years we have come to recognize that this disorder has a significant impact on girls, too.

For example, it was previously thought that ADHD was ten times more common in boys than in girls. However, recent studies indicate that the ratio is much lower than that, i.e., ADHD is four times more common in boys than in girls. As patients get older, the ratios are reduced. In adults, the ratio between males and females with ADHD is 1:1.

In our clinic we see two definite referral spikes related to age and gender:

The first referral spike occurs around the first grade where we see a large influx of hyperactive boys, ages 5 - 7.

The second referral spike occurs around the sixth grade, and girls are predominate in this referral group. Often, these are previously well-liked girls who, once they reach middle school, are overwhelmed by classroom changes, increased assignments, and large class sizes. They begin to fall further behind academically, and they start to struggle socially.

The DSM-IV criteria are somewhat limited with regard to diagnosing ADHD in girls. Prior to reaching middle school, the inattentive girl may not exhibit all of the symptoms required by the DSM-IV, and as a result, the diagnosis may be missed.

Athealth.com: Is the evaluation and treatment for boys different than for girls?

Dr. Gephart: The assessment and the treatment are the same. However, if the patient is a hyperactive, impulsive child, that child will require more intervention. And, since boys tend to be more hyperactive than girls, boys will often require more intense intervention than girls.

Athealth.com: Do you treat children differently than you treat teenagers?

Dr. Gephart: No. Teenagers respond to stimulant medication and behavioral treatment approaches in the same ways that younger children do. However, teenagers have more control over how they participate in treatment, and therefore, adolescents present a different set of compliance issues than children do.

Athealth.com: How is ADHD treated?

Dr. Gephart: There are two proven treatments:

Stimulant medication such as Ritalin, Dexedrine, and Adderall, and

Behavioral therapy such as parent training, social skills programs, and the daily report card.

The best treatment involves the use of both approaches.

In parent training classes parents learn how to work with their kids on a daily basis. These programs focus on teaching parents how to deal with the child's social and academic problems - when to use time-outs, how to give clear, concise instructions to the child, how to set up a system of rewards and consequences. It is important to keep in mind that many ADHD kids have ADHD parents. The parents, therefore, may forget to give the child his/her medication or be disorganized in their approach to the child. These programs teach parents how to be more successful in dealing with the child.

Many ADHD children exhibit socially inappropriate behavior and have problems getting along with siblings and peers. Social skills programs, particularly camping programs that provide intense intervention, group work, and a lot of one-on-one assistance, can help these kids learn skills in problem solving, working with others, and anger management. ADHD kids need to experience success, and when a child learns how to interact appropriately with others, this can be an important self-esteem builder.

The daily report card is a tool used by the school to give more immediate feedback to the parent (and the clinician) about the child's progress. The report card focuses both on behavior and academics, and a system of rewards and consequences can be designed to reinforce the performance goals.

Athealth.com: We hear a lot in the media that ADHD is over-diagnosed and that kids are over-medicated. Can you comment on this?

Dr. Gephart: People are certainly more aware of the disorder. Although there may be evidence of over-prescribing in some communities, one recent study concluded that, in fact, ADHD is actually under-diagnosed in the U.S., that only 50% of children with ADHD are actually being treated with stimulant medication (despite its proven effectiveness), and that for a significant number of children who are taking stimulant medication, the treatment is inadequate.

In addition, it is possible that prescribing variations could be attributed to such wide-ranging factors as inconsistent care, affluent neighborhoods where families have more resources to cover the costs of diagnosis and treatment, or a greater number of child psychiatrists and other clinicians in a community who are trained to make the diagnosis.

Athealth.com: What do you do if parents are resistant to giving their child medication?

Dr. Gephart: I think the key is to spend a lot of time conducting a careful assessment before ever talking to parents about medication and other treatment options. Most parents are eager for help, but they want to be certain that their child has been properly evaluated, and they may be resistant to certain treatments if they feel their child has not received a complete evaluation. Also, practitioners need to spend time giving parents information about the pluses and minuses of each intervention and educating families about how to manage the disorder.

In our clinic we schedule a separate appointment to discuss treatment options. For parents who don't want to use medication, we recommend parent groups, skills training, and other educational interventions.

With regard to medication, a more common problem is the ADHD teen that refuses to take his/her medication. In such situations adherence to the treatment plan is disrupted, and we have to develop strategies that encourage the teen to participate in the treatment.

Athealth.com: Is there any concern about the risk of increased substance abuse for kids taking ADHD medication?

Dr. Gephart: ADHD kids are at increased risk for substance abuse, but research indicates that ADHD kids who are on stimulant medication are not more prone to substance abuse. In fact, early treatment reduces the risk of substance abuse.

We do talk to kids about the possibility of adverse drug reactions if they use alcohol or other substances while taking their medications. Unfortunately, this doesn't necessarily mean that they refrain from the use of alcohol or drugs. The more likely result is that they may not take their medication when they are drinking.

Athealth.com: Do you find that kids share their medications with other students?

Dr. Gephart: Generally, this has not been a problem in my practice. Kids know that the medication helps them, and even though they may not like to take it, they recognize that there are benefits when they do take it.

Athealth.com: How important is it to work with the school and others who have significant contact with the child?

Dr. Gephart: It is very important. Treating an ADHD child is a team effort. Parents, teachers, nursing staff, mental health professionals, case managers, and others are essential members of the team and are critical to the success of the treatment. We also need to remember that building a therapeutic alliance with the child is an important component.

In treating ADHD we use a chronic illness treatment model as opposed to an acute illness treatment model. Consequently, treatment is usually a long-term proposition that requires the implementation of a medication schedule as well as education and behavioral interventions at home, in day care, at school, and wherever else the child spends time.

Athealth.com: Earlier you mentioned the importance of obtaining a learning assessment. Can you comment further on that?

Dr. Gephart: It is essential to determine if the child has a comorbid learning disorder. ADHD kids slowly fall behind in school. They may have normal IQs, but they frequently perform below grade level.

These kids daydream and are easily distracted. They find it hard to process language, organize their materials, and pay attention to details - tasks that are required in all educational settings. If a child is not paying attention for one-third of the day, that child is essentially missing every third day of school.

The parent or the clinician can initiate a request for a learning assessment. There are at least two federal statues that apply to children with disabilities:

The Individuals with Disabilities Education Act (IDEA) and

Section 504 of the Rehabilitation Act of 1973.

IDEA governs special education, and Section 504 provides for reasonable accommodations for children with disabilities. It is difficult to get kids into special education, but ADHD kids can receive certain accommodations such as extra time for tests, preferential seating, taking tests in a quiet room, and so on. Parents can be a great deal of help in advocating for the child on these kinds of issues.

Athealth.com: In 1999 you wrote an article entitled, The ADHD History: 42 Questions to Ask Parents (Contemporary Pediatrics 1999;10:127-128, 130-136), in which you described a list of questions that you use when evaluating a child for ADHD. Describe some of those questions.

Dr. Gephart: In my initial interview with the parents I try to ask such questions as: Does your child have a history of accidents or injuries? How does your child react to schedule changes? Does your child sit quietly when watching TV? Does anyone in the family have ADHD or learning problems? Does your child have friends? Does your child interrupt others when they are talking? What are your child's strengths? Does your child obey you? How would you describe your child's self-esteem?

These questions are not all inclusive nor are they meant to be used as a checklist for diagnosing ADHD. Rather, they are designed to flesh-out the DSM-IV criteria. For example, if I ask a parent if the child is fidgety, the parent may say, "No." However, if I ask if the child is able to sit through dinner in a restaurant, the parent may give a very different response. These more specific responses often provide information that is pertinent to the diagnosis.

Athealth.com: Do you consider one or two of the questions to be more important than the others?

Dr. Gephart: No. All of the questions used in the parent interview are important to learning about the child. However, if you really pressed me to choose a question that seems to describe a significant percentage of ADHD kids, it would be: Does your child do his/her homework and forget to turn it in?

Athealth.com: Describe how you treat a child with ADHD.

Dr. Gephart: Once the diagnosis is made, we develop a child-specific treatment plan that includes goals, methods of treatment, patient education, a system for monitoring progress, and plans for follow-up.

Athealth.com: What do you do if the child does not respond to treatment?

Dr. Gephart: If the target outcomes are not met and the child is not responsive to treatment, we re-group and try to find out why. This means reassessing the original diagnosis, evaluating the selection of medications, looking to see if all appropriate treatments have been tried, examining compliance issues, and determining if there is a co-occurring condition that we may have missed.

Athealth.com: Does the presence of ADHD in a child pose particular problems for other members of the family?

Dr. Gephart: Parents of ADHD children have a higher incidence of depression and alcohol-related disorders and are at greater risk for marital problems. Dealing with an ADHD child can place a considerable amount of stress on a family, particularly if the child's symptoms are severe. If sibling relationships are poor (and they often are), the strain on the family is increased. It is not uncommon for more than one child in a family to have the disorder.

Because ADHD is a chronic condition, families who have an ADHD child may be in for a long haul, and they have to develop long-term coping skills. Single parents are particularly hard hit since they are alone on the front line.

In addition, the disorder places a financial burden on families. Evaluation and treatment can be costly, and work schedules and careers sometimes have to be adjusted to meet the child's needs.

Athealth.com: What are some of the most significant developments in the treatment of ADHD in recent years?

Dr. Gephart:

• Despite it's limitations, the development of the DSM-IV criteria for diagnosing ADHD;
• The development of practice guidelines that help us do a better job of assessing and treating ADHD; and
• The introduction of longer-acting medications. For example, once-a-day medications help reduce the social stigma associated with ADHD because they eliminate the need to interrupt after-school activities or single out the child for a trip to the nurse's office to receive his/her medication.

Athealth.com: Are there areas that still need improvement?

Dr. Gephart: Always. We need to develop a better understanding of ADHD in girls. Additional research needs to be done with regard to the diagnosis and treatment of ADHD in adolescents. Also, there is very little information in the literature on ADHD and multicultural issues, and I hope to see some research generated in this area.

Athealth.com: Thank you for taking time to share your expertise with us.

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