Archive for the ‘School Psychology’ Category

School Testing and the Rising Rate of ADHD

In ADHD, ADHD child/adolescent, Common Core, School Psychology on Tuesday, 1 April 2014 at 05:36

School Testing and the Rising Rate of ADHD

by Miriam

A new book finds a startling connection

Read the Interview: http://www.nbcnews.com/health/kids-health/could-school-testing-be-driving-adhd-n55661

Is the increased demand for performance behind the increased diagnoses of ADHD? Two University of California professors have released a book this month titled, “The ADHD Explosion.” They call it a “reality check” for parents, providers, educators and politicians.

The Berkeley professors, Dr. Stephen Hinshaw and Dr. Richard Scheffler, are noted researchers on ADHD. Their research tells them that federal policy issues may be behind the recent explosion in cases of ADHD.

“When you look at that [national testing policy], you get the
closest thing there is to a smoking gun,” says Dr.Scheffler.

The Journal of the American Medical Association (JAMA) Pediatrics, found that rates of ADHD in California have jumped by 24% since 2001. Additionally, the Center for Disease Control (CDC) reports increases from 7.8 percent in 2003 to
9.5 percent in 2007 and to 11 percent in 2011— a rate of 5 percent a year.

It looks for all the world like a growing epidemic. But ADHD wasn’t even something people noticed until recently,” says Hinshaw.

“It started about the same time in history that we made kids go to school,” Hinshaw told NBC News in an interview.

Then come the 1990s, and a crisis of falling test scores. “What happened is that a number of states began to pass accountability laws,” Hinshaw said.

Hinshaw and Scheffler examined the correlation between diagnoses of ADHD and maps of states that had passed accountability laws.

According to NBC News, by the turn of the century, 30 states had passed accountability laws. They tended to be Republican-leaning states in the South, such as North Carolina. In 2007, 15.6 percent of all children in North Carolina had been diagnosed with ADHD at some point, including nearly one in three teenage boys.

Two things happening together don’t prove a correlation. Is it coincidence? Hinshaw and Scheffler were persuaded to look further.

AN NBC News article reports that the professors then examined date related to the No Child Left Behind federal policy enacted in 2002. It was one of the first official acts of President George W. Bush after he took office. NCLB required standardized testing to show if schools were, in fact, educating students. A truly salient aspect of NCLB was that it held teachers and principals directly responsible for the results and removed federal and state bureaucrats who mandate curriculum and educational policy.

According to the NBC News article:

“Now what happens is a natural experiment,” says Hinshaw. The other states raced to write accountability laws, requiring schools to show they are actually educating children.

“When you incentivize test scores above all else, there is probably pressure to get kids diagnosed with ADHD.”

Hinshaw and Scheffler compared ADHD rates in the 30 states that had been requiring testing with the 20 states that had to play catchup.

Rates of ADHD diagnoses soared.

“Children ages 8 to 13, living in low-income homes and in states without previous consequential accountability laws, went from a 10 percent to a 15.3 percent rate of ADHD diagnoses once No Child Left Behind started,” they wrote. That’s a 53 percent increase over four years.

California’s current rate, post-testing? It’s 7.3 percent. North
Carolina’s rate actually fell slightly, to 14.4 percent in 2011.

“When you incentivize test scores above all else, there is probably pressure to get kids diagnosed with ADHD,” Hinshaw said. “We know from our own research that medication not only makes you less fidgety but also can bump up your test scores.”

That would be the benign interpretation, that testing has
encouraged parents to get their kids in to see specialists for
much-needed medical care. But there’s also a more sinister
possibility and one that Hinshaw and Scheffler say is at work in
some states.

“If you can identify the children with ADHD, you can take them out of the pool that measures how schools are doing,” says Scheffler.

He says some districts — he won’t say where — do seem to have been doing so. State school officials and the federal Department of Education did not respond when contacted by NBC News.

No Child Left Behind ties federal funding to test scores, Scheffler points out.“You can see the incentive for schools to get kids diagnosed with ADHD,” he says.

Either way, Scheffler and Hinshaw say the increase in ADHD cases is real, and it’s not just affecting kids. Recent studies show adult diagnoses are on the rise, too.

“Although often ridiculed, ADHD represents a genuine medical
condition that robs people of major life chances,” they write in the book.

“You can see the incentive for schools to get kids diagnosed with ADHD.”

Scheffler doesn’t see the increase in adult ADHD diagnoses as
surprising. “This has nothing to do with the schools. This has to do with global competition and performance,” he says. People are under pressure to perform better at work.

And news about adult ADHD in turn sends more people to their doctors, and diagnoses spike even more, Hinshaw adds. “Here are we are in 2014 with evidence that medications can benefit. Adult ADHD clinics spring up,” he says.

“That’s not necessarily a bad thing,” says Hinshaw.

What is bad is if ADHD is not being diagnosed with the proper care, Hinshaw says. A 10-minute pediatrician visit is not adequate for an ADHD diagnosis and certainly not as the basis for writing a prescription for a powerful stimulant, such as Ritalin or Adderall, to treat it.

“Many pediatricians are not trained in the emotional disorders of childhood, or not reimbursed for the time it takes,” Hinshaw said.

“It is easy to pull out prescription pad at the end of a visit.”

He calls the book a “reality check” and says parents, providers, educators and politicians should take note, and make sure the right kids are being diagnosed, and helped, properly.

Rertieved from: http://www.playattention.com/school-testing-rising-rate-adhd/


Could School Testing Be Driving ADHD?


All it took was a map to convince health economists Stephen Hinshaw and Richard Scheffler that it must be some kind of policy issue driving a recent explosion in cases of ADHD.

And a convenient natural experiment — in the form of the federal government’s No Child Left Behind — provided the answer, the two experts argue in a new book. It’s school testing, they say.

“When you look at that, you get the closest thing there is to a smoking gun,” says Richard Scheffler, of the University of California Berkeley who co-authored the book, “The ADHD Explosion”, which was just published this month.

“You get the closest thing there is to a smoking gun.”

But it’s not necessarily a bad thing, the authors say, if children are being diagnosed properly, and if they’re getting the right treatments.

There’s no question there’s been a huge increase in the number of kids diagnosed with Attention Deficit/Hyperactivity Disorder, or ADHD. The Centers for Disease Control and Prevention found that about 6.4 million kids aged 4 to 17, or 11 percent of that age group, were diagnosed with ADHD as of 2011.

And CDC documents a steady increase, from 7.8 percent in 2003 to 9.5 percent in 2007 and to 11 percent in 2011— a rate of 5 percent a year.

It looks for all the world like a growing epidemic, says Stephen Hinshaw, a professor of psychology at Berkeley who wrote the book with Hinshaw. But ADHD wasn’t even something people noticed until recently, he says.

“It started about the same time in history that we made kids go to school,” Hinshaw told NBC News in an interview.

Then come the 1990s, and a crisis of falling test scores. “What happened is that a number of states began to pass accountability laws,” Hinshaw said.

In the early 2000s, the CDC began tracking ADHD diagnoses. Hinshaw and Scheffler looked at the maps showing the rates of ADHD, and compared them to a map that showed which states had passed accountability laws.

By the turn of the century, 30 states had passed accountability laws. They tended to be Republican-leaning states in the South, such as North Carolina. In 2007, 15.6 percent of all children in North Carolina had been diagnosed with ADHD at some point, including nearly one in three teenage boys.

This was more than twice the rate in California, with a 6 percent rate.

But this was just a correlation, Hinshaw says. Just because two things happen together in time doesn’t mean one caused the other. They looked at differences in culture, ethnicity, in the number of doctors per capita and at possible other causes. Nothing really explained the different rates of ADHD in different states.

Then No Child Left Behind became federal policy in 2002. One of the first official acts of President George W. Bush after he took office was to ask Congress to write and pass the law.

It called for standardized testing to show if schools were, in fact, educating students. Local state laws often held teachers and principals directly responsible for the results.

“Now what happens is a natural experiment,” says Hinshaw. The other states raced to write accountability laws, requiring schools to show they are actually educating children.

“When you incentivize test scores above all else, there is probably pressure to get kids diagnosed with ADHD.”

Hinshaw and Scheffler compared ADHD rates in the 30 states that had been requiring testing with the 20 states that had to play catchup. Rates of ADHD diagnoses soared.

“Children ages 8 to 13, living in low-income homes and in states without previous consequential accountability laws, went from a 10 percent to a 15.3 percent rate of ADHD diagnoses once No Child Left Behind started,” they wrote. That’s a 53 percent increase over four years.

California’s current rate, post-testing? It’s 7.3 percent. North Carolina’s rate actually fell slightly, to 14.4 percent in 2011.

“When you incentivize test scores above all else, there is probably pressure to get kids diagnosed with ADHD,” Hinshaw said. “We know from our own research that medication not only makes you less fidgety but also can bump up your test scores.”

That would be the benign interpretation, that testing has encouraged parents to get their kids in to see specialists for much-needed medical care. But there’s also a more sinister possibility and one that Hinshaw and Scheffler say is at work in some states.

“If you can identify the children with ADHD, you can take them out of the pool that measures how schools are doing,” says Scheffler. He says some districts — he won’t say where — do seem to have been doing so. State school officials and the federal Department of Education did not respond when contacted by NBC News.

No Child Left Behind ties federal funding to test scores, Scheffler points out.“You can see the incentive for schools to get kids diagnosed with ADHD,” he says.

Either way, Scheffler and Hinshaw say the increase in ADHD cases is real, and it’s not just affecting kids. Recent studies show adult diagnoses are on the rise, too.

“Although often ridiculed, ADHD represents a genuine medical condition that robs people of major life chances,” they write in the book.

“You can see the incentive for schools to get kids diagnosed with ADHD.”

Scheffler doesn’t see the increase in adult ADHD diagnoses as surprising. “This has nothing to do with the schools. This has to do with global competition and performance,” he says. People are under pressure to perform better at work.

And news about adult ADHD in turn sends more people to their doctors, and diagnoses spike even more, Hinshaw adds. “Here are we are in 2014 with evidence that medications can benefit. Adult ADHD clinics spring up,” he says.

“That’s not necessarily a bad thing,” says Hinshaw.

What is bad is if ADHD is not being diagnosed with the proper care, Hinshaw says. A 10-minute pediatrician visit is not adequate for an ADHD diagnosis and certainly not as the basis for writing a prescription for a powerful stimulant, such as Ritalin or Adderall, to treat it.

“Many pediatricians are not trained in the emotional disorders of childhood, or not reimbursed for the time it takes,” Hinshaw said. “It is easy to pull out prescription pad at the end of a visit.”

He calls the book a “reality check” and says parents, providers, educators and politicians should take note, and make sure the right kids are being diagnosed, and helped, properly.

Retrieved from: http://www.nbcnews.com/health/kids-health/could-school-testing-be-driving-adhd-n55661


suicide is not painless…

In General Psychology, Psychiatry, School Psychology on Wednesday, 19 February 2014 at 17:30


Asperger Syndrome Revisited

In Autism Spectrum Disorders, General Psychology, Psychiatry, School Psychology, Special Education on Wednesday, 11 December 2013 at 05:59

Asperger Syndrome Revisited

By: Lee Wilkinson, Ph.D.

The deletion of Asperger’s disorder (Asperger’s syndrome) as a separate diagnostic category from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has been widely publicized. The new DSM-5 category of autism spectrum disorder (ASD), which subsumes the previous DSM-IV diagnoses of autistic disorder (autism), Asperger’s disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS), reflects the scientific consensus that symptoms of the various DSM-IV subgroups represent a single continuum of impairment that varies in level of severity and need for support.

An important feature of the DSM-5 criteria for ASD is a change from three symptom domains (triad) of social impairment, communication deficits and repetitive/restricted behaviors, interests, or activities to two domains (dyad); social/communication deficits and fixated and repetitive pattern of behaviors. Several social/communication criteria were merged to clarify diagnostic requirements and reflect research indicating that language deficits are neither universal in ASD, nor should they be considered as a defining feature of the diagnosis. The criteria also feature dimensions of severity that include current levels of language and intellectual functioning as well as greater flexibility in the criteria for age of onset and addition of symptoms not previously included in the DSM-IV such as sensory interests and aversions.

DSM-IV Criteria in Practice

Problems in applying the DSM-IV criteria were a key consideration in the decision to delete Asperger’s disorder as a separate diagnostic entity. Numerous studies indicate that it is difficult to reliably distinguish between Asperger syndrome, autism, and other disorders on the spectrum in clinical practice (Attwood, 2006; Macintosh & Dissanayake, 2006; Leekam, Libby, Wing, Gould & Gillberg, 2000; Mayes & Calhoun, 2003; Mayes, Calhoun, & Crites, 2001; Miller & Ozonoff, 2000; Ozonoff, Dawson, & McPartland, 2002; Witwer & Lecavalier, 2008). For example, children with autism who develop proficient language have very similar trajectories and later outcomes as children with Asperger disorder (Bennett et al., 2008; Howlin, 2003; Szatmari et al., 2000) and the two are indistinguishable by school-age (Macintosh & Dissanayake, 2004), adolescence (Eisenmajer, Prior, Leekam, Wing, Ong, Gould & Welham 1998; Ozonoff, South and Miller 2000) and adulthood (Howlin, 2003). Individuals with Asperger disorder also typically meet the DSM-IV communication criterion of autism, “marked impairment in the ability to initiate or sustain a conversation with others,” making it is possible for someone who meets the criteria for Asperger’s disorder to also meet the criteria for autistic disorder.

Treatment and Outcome

Another important consideration was response to treatment. Intervention research cannot predict, at the present time, which particular intervention approach works best with which individual. Likewise, data is not available on the differential responsiveness of children with Asperger’s disorder and high-functioning autism to specific interventions (Carpenter, Soorya, & Halpern, 2009). There are no empirical studies demonstrating the need for different treatments or different responses to the same treatment, and in clinical practice the same interventions are typically offered for both autism and Asperger’s disorder (Wilkinson, 2010). Treatments for impairments in pragmatic (social) language and social skills are the same for both groups.

Application of the New Criteria

It’s important to remember that in the DSM, a mental disorder is conceptualized as a clinically important collection of behavioral and psychological symptoms that causes an individual distress, disability or impairment. The objective of new DSM-5 criteria for ASD is that every individual who has significant “impairment” in social-communication and restricted and repetitive behavior or interests should meet the diagnostic criteria for ASD.  Because language impairment/delay is not a necessary criterion for diagnosis, anyone who demonstrates severe and sustained impairments in social skills and restricted, repetitive patterns of behavior, interests, or activities in the presence of generally age-appropriate language acquisition and cognitive functioning, who might previously have been given a diagnosis of Asperger’s disorder, will now meet the criteria for ASD.

The new DSM-5 criteria for ASD have created significant controversy over concerns that it would exclude many individuals currently diagnosed with Asperger syndrome and PDD-NOS, and thus make it difficult for them to access services. However, recently published field trials suggest that the revisions actually increase the reliability of diagnosis, while identifying the large majority of those who would have been diagnosed under the DSM-IV-TR. Of the small numbers who were not included, most received the new diagnosis of “social communication disorder.” Moreover, the accuracy of non-spectrum classification (specificity) made by DSM-5 was better than that of DSM-IV, indicating greater effectiveness in distinguishing ASD from non-spectrum disorders such as language disorders, intellectual disability, attention-deficit/hyperactivity disorder (ADHD), and anxiety disorders. It is also important to note that all individuals who have a DSM-IV diagnosis on the autism spectrum, including those with Asperger syndrome and PDD-NOS, will be able to retain an ASD diagnosis. This means that no one should “lose” their diagnosis because of the changes in diagnostic criteria.  According to DSM-5, individuals with a well-established DSM-IV diagnosis of Autistic Disorder, Asperger’s Disorder, or PDD-NOS should be given a diagnosis of ASD.  Those who have marked deficits in social communication, but whose symptoms do not meet the criteria for ASD, should be evaluated for Social (Pragmatic) Communication Disorder.


In conclusion, the DSM-5 category of autism spectrum disorder (ASD), which subsumes the current diagnoses of autistic disorder, Asperger’s disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS), better describes our current understanding about the clinical presentation and course of the neurodevelopmental disorders. Conceptualizing autism as a spectrum condition rather than a categorical diagnostic entity is in keeping with the extant research suggesting that there is no clear evidence that Asperger’s disorder and high-functioning autism are different disorders. As Gillberg (2001) notes, the terms Asperger’s syndrome and high-functioning autism are more likely “synonyms” than labels for different disorders. Lord (2011) also comments that although there has been much controversy about whether there should be separate diagnoses, “Most of the research has suggested that Asperger’s syndrome really isn’t different from other autism spectrum disorders.” “The take-home message is that there really should be just a general category of autism spectrum disorder, and then clinicians should be able to describe a child’s severity on these separate dimensions.” Unfortunately, many individuals may have been advised (or assumed) that a diagnosis of Asperger’s disorder was separate and distinct from autistic disorder and that intervention/treatment, course, and outcome were clinically different for each disorder. While including Asperger’s Disorder under the DSM-5 category of ASD will likely continue to require a period of transition and adjustment, the proposed dimensional approach to diagnosis will likely result in more effective identification, treatment, and research for individuals on the spectrum.


American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders. Washington, DC: Author.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders(4th ed., text rev.). Washington, DC: Author.

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders(5th ed.). Washington, DC: Author.

Attwood, T. (2006). The complete guide to Asperger’s syndrome. London: Jessica Kingsley.

Carpenter, L. A., Soorya, L. & Halpern, D. (2009). Asperger’s syndrome and high- functioning autism. Pediatric Annals, 38, 30-35.

Eisenmajer, R., Prior, M., Leekam, S., Wing, L., Ong, B., Gould, J. & Welham, M. (1998)

Delayed Language Onset as a Predictor of Clinical Symptoms in Pervasive Developmental Disorders. Journal of Autism and Developmental Disorders, 28, 527–34.

Gillberg, C (2001). Asperger’s syndrome and high functioning autism: Shared deficits or

different Disorders? Journal of Developmental and Learning Disorders, 5, 79-94.

Howlin, P. (2003). Outcome in high-functioning adults with autism with and without early language delays: Implications for the differentiation between autism and Asperger syndrome. Journal of Autism and Developmental Disorders, 33, 3–13.

Leekam, S., Libby, S., Wing, L., Gould, J. & Gillberg, C. (2000) Comparison of ICD-10 and Gillberg’s criteria for Asperger syndrome. Autism, 4, 11–28.

Lord, C. et al. (2011). A multisite study of the clinical diagnosis of different autism spectrum disorders. Archives of General Psychiatry. doi:10.1001/archgenpsychiatry.2011.148

Macintosh, K., & Dissanayake, C. (2006). Social skills and problem behaviors in school aged children with high-functioning autism and Asperger’s disorder. Journal of Autism and Developmental Disorders, 36, 1065–1076.

Macintosh, K.E., & Dissanayake, C. (2004). Annotation: The similarities and differences

between autistic disorder and Asperger’s disorder: A review of the empirical evidence. Journal of Child Psychology and Psychiatry, 45, 421–434.

Mayes, S., & Calhoun, S. (2003). Relationship between Asperger syndrome and high functioning autism. In M. Prior (Ed.), Learning and behavior problems in Asperger syndrome (pp. 15-34). New York: Guilford Press.

Mayes SD, Calhoun SL, Crites DL (2001) Does DSM-IV Asperger’s disorder exist? Journal of Abnormal Child Psychology, 29, 263–271.

Miller, J. N., & Ozonoff, S. (2000). The external validity of Asperger disorder: Lack of evidence from the domain of neuropsychology. Journal of Abnormal Psychology, 109, 227–238.

Ozonoff, S., Dawson, G., & McPartland, J. (2002). A parent’s guide to Asperger syndrome and high-functioning autism: How to meet the challenges and help your child to thrive. New York: Guilford Press.

Ozonoff, S., South, M., & Miller, J. N. (2000). DSM-IV-defined Asperger syndrome: Cognitive, behavioral and early history differentiation from high-functioning autism. Autism, 4, 29–46.

Szatmari, P., Bryson, S.E., Streiner, D.L., Wilson, F.J., Archer, L., & Ryerse, C. (2000). Two year outcome of preschool children with autism or Asperger’s syndrome. American Journal of Psychiatry, 15, 1980–1987.

Szatmari, P., Bryson, S., Duku, E., Vaccarella, L., Zwaigenbaum, L., Bennett, L. & Boyle, M.H. (2009). Similar developmental trajectories in autism and Asperger syndrome: from early childhood to adolescence. Journal of Child Psychology and Psychiatry, 50, 1459-1467.

Wilkinson, L. A. (2008). Adults with Asperger syndrome: A childhood disorder grows up. The Psychologist, 21, 764-770.

Wilkinson, L. A. (2010). A best practice guide to assessment and intervention for Asperger syndrome and autism in schools. London: Jessica Kingsley Publishers.

Wilkinson, L. A. (Ed.) (in press). Autism spectrum disorder in children and adolescents: Evidence-based assessment and intervention in schools. American Psychological Association (APA): Washington, DC.

Williams, K., Tuck, M., Helmer, M., Bartak, L., Mellis, C. & Peat, J.K. (2008). Diagnostic labelling of autism spectrum disorders in NSW. Journal of Paediatrics and Child Health, 44, 108-113.

Wing, L. (2005). Problems of categorical classification systems. In F. R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.),Handbook of autism and pervasive developmental disorders: Vol. 1. Diagnosis, development, neurobiology, and behavior (3rd ed., pp. 583–605). New York: John Wiley.

Witwer, A.N., & Lecavalier, L. (2008). Validity of autism spectrum disorder subtypes. Journal of Autism and Developmental Disorders, 38, 1611–1624.

Lee A. Wilkinson, PhD, CCBT, NCSP is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers.

Retrieved from: http://bestpracticeautism.blogspot.com/2013/12/asperger-syndrome-revisited.html?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+BestPracticeAutism+%28Best+Practice+Autism%29


adhd coming to a computer near you…

In ADHD, ADHD Adult, ADHD child/adolescent, School Psychology on Tuesday, 20 August 2013 at 15:11


and more dsm-v controversy…

In Child/Adolescent Psychology, DSM-V, Neuropsychology, Psychiatry, School Psychology on Tuesday, 21 May 2013 at 06:48

DSM-V: Past Imperfect

By: Nassir Ghaemi, MD, MPH

 Thoughts on a New DSM

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is here. We might as well pretend that Ronald Reagan is still president. Radical changes were made, with limited scientific evidence, when DSM-III was published in 1980 (the year Reagan was elected); even the tiniest changes, with great scientific evidence, are now the subject of outrage.

For me, DSM-5 is a disappointment. I take no pleasure in making this judgment. I wish I could say that DSM revisions are increasingly scientific and getting us closer to truths. But this simply hasn’t happened.

DSM-5 is a disappointment for me not because it is much different from DSM-IV, but because it is so similar. Almost 2 decades after the fourth revision in 1994, despite thousands of research studies on psychiatric conditions, our profession hardly can bring itself to change anything of importance. The radical bipolar/major depressive disorder (MDD) dichotomy is unchanged and untouchable — the third rail of US psychiatry — despite numerous studies casting doubt on the validity of the MDD definition and providing support for broader definitions of bipolar disorder.

The personality disorder concept was nothing but the description of psychoanalytic speculations in 1980. It has remained basically unchanged, despite little research evidence of validity. Personality traits, one of the most well-proven facts in psychology, were recommended by the DSM-5 task force but vetoed by the American Psychiatric Association Board of Trustees. Science was rejected; psychoanalytic tradition was not.

Clinicians may have assumed that we have scientific validity for most of the approximately 400 diagnoses in DSM-5; we have hardly any validity data for the vast majority of those diagnoses, and we have notable validity evidence for numerous concepts that are excluded.

The claim in the Reagan presidency was that DSM would provide reliability; we could agree on definitions. Then, we would do more research so that definitions would evolve toward better validity. Reliability would lead to validity.

When Bill Clinton was president and DSM-IV was published in 1994, a change happened: DSM became an end in itself. The DSM-IV leadership explicitly stated that unless a very high bar of scientific evidence was reached, no changes were allowed. The bar kept being moved higher and higher for science, and lower and lower for politics. The DSM-IV leadership called it “pragmatism”: DSM changes were made on the basis of what that leadership thought was best for patients, they said, and for the profession.

Reliability had become an end in itself; validity no longer mattered because, in a species of extreme social constructionism, the DSM-IV leadership saw the nosology as a way to influence practice, not as a way to discover causes of and treatments for mental illnesses. (They didn’t bother with the question of how you could practice well if you didn’t find out the causes and treatments of illnesses.)

There were hopes that DSM-5 would be different, with scientifically based changes. But a major backlash came: The DSM-IV leadership opposed changes on “pragmatic” grounds, and many in the larger public criticized DSM on social constructionist grounds, as just a means for psychiatrists to make money and influence people. Major changes became minor, and even the minor ones were often dropped to an appendix for further research, which is likely to be ignored.

After 2 decades of being a loyal follower of DSM, the debates of recent years led me to make a sad but definite conclusion: DSM has caused stagnation in psychiatry. If DSM categories are devised primarily because professional leaders want to achieve some clinical or even economic goals, there is no reason why nature should play along. By being “pragmatic” and not scientific, DSM has doomed biological and pharmacologic research in psychiatry to failure for 2 generations.

Now I see a generational change. The leaders of the DSM-III, -IV, and -5 workgroups are often literally the same people, representatives of the 1970’s/1980’s generation in psychiatry. Some of us in later generations do not venerate DSM as the bible of psychiatry, as it’s often called; we instead question it as theology instead of science. Recently, the leadership of the National Institute of Mental Health (NIMH) reached the same conclusion and stated it forcefully: DSM criteria are not scientifically valid, and patients deserve better.

DSM-5 is out, and clinicians will use it, but unfortunately it represents a failed past. Those of us who grew up in that past, and have seen how it has led us to stand still, are inclined to agree with the NIMH that our future deserves to be different.

Retrieved from: http://www.medscape.com/viewarticle/804102?src=nl_topic&uac=184795PG

Use DSM-5 ‘Cautiously, If at All,’ DSM-IV Chair Advises

By: Pam Harrison

On the eve of the official launch of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Allen Frances, MD, chair of the DSM-IV Task Force and one of the new manual’s staunchest critics, is advising physicians to use the DSM-5 “cautiously, if at all.”

“Psychiatric diagnosis is facing a renewed crisis of confidence caused by diagnostic inflation,” Dr. Frances, Duke University, Durham, North Carolina, writes in a new commentary published online May 17 in the Annals of Internal Medicine.

Unlike the DSM-IV, which held the line against diagnostic inflation, he states, “The DSM-5, the recently published fifth edition of the diagnostic manual, ignored this risk and introduced several high-prevalence diagnoses at the fuzzy boundary with normality.”

For example, the DSM-5 opens the door for patients worried about having a medical illness to be diagnosed with somatic symptom disorder.

Normal grief may be misdiagnosed as major depressive disorder, and the forgetfulness of old age may now be interpreted as mild neurocognitive disorder.

“The already overused diagnosis of attention-deficit disorder will be even easier to apply to adults thanks to criteria that have been loosened further,” Dr. Frances adds.

Other changes in the DSM-5 will allow clinicians to label a child with temper tantrums as having disruptive mood dysregulation disorder, and overeating can now be called binge eating disorder.

Real Danger

The real danger in diagnostic inflation is overdiagnosis and overtreatment of patients who are essentially well, he says.

“Drug companies take marketing advantage of the loose DSM definitions by promoting the misleading idea that everyday life problems are actually undiagnosed psychiatric illness caused by a chemical imbalance and requiring a solution in pill form,” Dr. Frances writes.

“New psychiatric diagnoses are now potentially more dangerous than new psychiatric drugs.”

Quite apart from the risk for overtreatment, however, is the risk of neglecting patients with clear psychiatric illness whose access to care has been sharply reduced by slashed state mental health budgets.

As Dr. Frances points out, only one third of persons with severe depression receive mental health care, and a large percentage of the swollen prison population in the United States is made up of true psychiatric patients who have no other place to go.

More damning, however, is the flawed process by which committee members of the DSM-5 arrived at their expanded diagnoses, in Dr. Frances’ view.

As he states, the DSM-5 did not address professional, public, and press charges that its changes lacked sufficient scientific support and defied clinical common sense.

Field trials produced reliability results that did not meet historical standards, and deadlines were consistently missed, he adds.

The American Psychiatric Association also refused a petition from an independent scientific review of the DSM-5 that was endorsed by more than 50 mental health associations.

Dr. Frances said he personally found the DSM-5 process “secretive, closed, and disorganized.”

“I believe that the American Psychiatric Association (APA)’s financial conflict of interest, generated by DSM publishing profits needed to fill its budget deficit, led to premature publication of an incompletely tested and poorly edited product,” Dr. Frances states.

“The problems associated with the DSM-5 prove that the APA should no longer hold a monopoly on psychiatric diagnosis…. The codes needed for reimbursement are available for free on the Internet.”

The APA declined to comment.

Ann Intern Med. Published online May 17, 2013. Full article

DSM-5: Past Imperfect. Medscape. May 18, 2013.

Retrieved from: http://www.medscape.com/viewarticle/804378DSM-5 Officially Launched, but Controversy Persists

By: Caroline Cassels

SAN FRANCISCO — After more than a decade of development and more than 2 years of frequently searing controversy, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has finally been released.

Here at the American Psychiatric Association’s (APA’s) 2013 Annual Meeting, the APA leadership officially launched the manual, which is widely known by clinicians and patients alike as the “Bible of Psychiatry.”

“This is really an important day. I have been involved with the DSM-5 almost from the beginning, and I have seen the work unfold over the past decade. There have been literally hundreds of people, experts from all over the world, from different disciplines, who have contributed [to the DSM-5],” outgoing APA president Dilip Jeste, MD, told reporters attending a press briefing here.

“What we are seeing is a clinical manual based on the best science available…for today’s patients, this is the best manual that we could develop,” Dr. Jeste added.

Key changes in the new edition include a new chapter organization that shows how mental disorders may relate to one another on the basis of underlying vulnerabilities or symptom characteristics.

In addition, in DSM-5, disorders are organized in the context of age — that is, along a developmental lifespan within each chapter — as well as sex and cultural expectations.

What’s New

According to DSM-5 Task Force chair David Kupfer, MD, although the number of disorders are “about the same” as in the last edition of DSM, several new disorders have been added, including binge eating disorder, disruptive mood dysregulation disorder, and hoarding disorder.

A new section for the manual, Section III, describes several conditions that warrant more research before they can be considered as formal disorders in the main part of the manual.

The changes to the manual are designed to help clinicians more precisely identify mental disorders and improve diagnosis while maintaining the continuity of care.

“We expect these changes to help clinicians better serve patients and to deepen our understanding of these disorders based on new research.”

However, not everyone is as enthusiastic about the manual’s release. Allen Frances, MD, who chaired the DSM-IV Task Force and is among the DSM-5’s staunchest critics, told Medscape Medical News that he is filled with “sadness and worry — and I am not a person usually given to either emotion.”

He added that he is very concerned that the “DSM 5 will result in the mislabeling of potentially millions of people who are basically normal. This would turn our current diagnostic inflation into hyperinflation and exacerbate the excessive use of medication in the ‘worried well.’ ”

“DSM-5 turns grief into Major Depressive Disorder; temper tantrums into Disruptive Mood Dysregulation; the expectable forgetting of old age into Mild Neurocognitive Disorder; worrying about illness into Somatic Symptom Disorder; gluttony into Binge Eating Disorder; and anyone who wants a stimulant for recreation or performance enhancement can claim Attention Deficit Disorder,” he said.

“Don’t Buy It, Don’t Use It”

However, incoming APA president Jeffrey Lieberman, MD, told reporters that the idea that the revisions to the manual will lead to overtreatment is “inaccurate and unwarranted.”

“The DSM is a diagnostic guide that reflects what we currently know about how best to define disorders. How it is applied is something that reflects clinical practice,” he said.

The manual’s diagnostic criteria, he added, are based on the current state of the scientific evidence to “verify the existence of a certain condition that we know to be impairing and distressing and enduring for people,” Dr. Lieberman added.

Dr. Frances also expressed concern that the new manual will divert scarce mental health care resources away from those who need it most.

“While we are overtreating people with everyday problems who don’t need it, we are shamefully neglecting the people with moderate to severe psychiatric problems who desperately do.”

His advice to frontline clinicians regarding the DSM-5? “Don’t buy it, don’t use it, don’t teach it. There is nothing at all official about DSM-5, and the codes for reimbursement are available for free on the Internet or in DSM-IV. APA is price-gouging a badly flawed document, no one need feel captive to it.”

NIMH Blog Not an Indictment of DSM-5?

Dr. Frances is not alone in his criticism of the manual. An April 29 blog post by Thomas Insel, MD, director of the National Institute of Mental Health (NIMH), and published on the NIMH Web site stated that although the upcoming manual is reliable, it lacks validity.

As reported by Medscape Medical News at that time, Dr. Insel pointed out that unlike diagnostic criteria for other diseases, the DSM-5 criteria are based on consensus rather than objective laboratory measures, and he noted that the NIMH will be “re-orienting its research away from DSM-5 categories.”

Toward that end, Dr. Insel went on to announce the launch of the NIMH Research Domain Criteria (RDoC) in a first step toward “precision medicine.”

Following Dr. Insel’s blog post, on May 14, the APA and the NIMH issued a joint statement in which the organizations emphasized the need to work together for the good of patients.

Nevertheless, the statement underscored the fact that the NIMH’s position on the DSM-5 had not changed and that “the diagnostic categories represented in the DSM-IV and the International Classification of Diseases-10 (ICD-10, containing virtually identical disorder codes) remain the contemporary consensus standard for how mental disorders are diagnosed and treated.”

However, Dr. Lieberman, who has since collaborated with Dr. Insel, said that the blog post should not be viewed as an indictment of the DSM-5 but rather as an expression of frustration that psychiatry does not yet have the biologically based diagnostic tools as other areas of medicine.

“Even though his blog was interpreted this way, we don’t think Tom intended to impugn the DSM so much as to say that he wanted to exhort the biomedical research community to try and break new ground that will lead to more dynamic and fundamental changes in psychiatric diagnosis,” said Dr. Lieberman.

The DSM-5 is available immediately in print, and an electronic version will be available later this year.

The American Psychiatric Association’s 2013 Annual Meeting. Opening press conference. May 18, 2013.

Retrieved from: http://www.medscape.com/viewarticle/804410

Autism at School: DSM or IDEA

In Autism Spectrum Disorders, School Psychology, Special Education on Sunday, 24 March 2013 at 08:10

Autism at School: DSM or IDEA

More children than ever before are being diagnosed with autism spectrum disorders (ASD). The U.S. Centers for Disease Control and Prevention (CDC) now estimates that 1 in 88 eight year-old children has an ASD. This dramatic increase in the prevalence of children with ASD over the past decade, together with the clear benefits of early intervention, have created a need for schools to identify children who may have an autism spectrum condition. It is not unusual for children with milder forms of autism to go undiagnosed until well after entering school. In fact, research indicates that only three percent of children with ASD are identified solely by non-school resources. As a result, school professionals are now more likely to be asked to participate in the screening and identification of children with ASD than at any other time in the past.

The Individuals with Disabilities Education Act of 2004 (IDEA) and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV) are the two major systems used to diagnose and classify children with ASD. The DSM-IV is considered the primary authority in the fields of psychiatric and psychological (clinical) diagnoses, while IDEA is the authority with regard to eligibility decisions for special education. The DSM-IV was developed by clinicians as a diagnostic and classification system for both childhood and adult psychiatric disorders. The IDEA is not a diagnostic system per se, but rather federal legislation designed to ensure the appropriate education of children with special educational needs in our public schools. Unlike the DSM-IV, IDEA specifies categories of ‘‘disabilities’’ to determine eligibility for special educational services. The definitions of these categories (there are 13), including autism, are the most widely used classification system in our schools. According to IDEA regulations, the definition of autism is as follows:

(c)(1)(i) Autism means a developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age 3, that adversely affects a child’s educational performance. Other characteristics often associated with autism are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences. The term does not apply if a child’s educational performance is adversely affected primarily because the child has an emotional disturbance, as defined in this section.

(ii) A child who manifests the characteristics of ‘‘autism’’ after age 3 could be diagnosed as having ‘‘autism’’ if the criteria in paragraph (c)(1)(i) of this section are satisfied.
This educational definition is considered sufficiently broad and operationally acceptable to accommodate both the clinical and educational descriptions of autism and related disorders.

While the DSM-IV diagnostic criteria are professionally helpful, they are neither legally required nor sufficient for determining educational placement. It is state and federal education codes and regulations (not DSM IV-TR) that drive classification and eligibility decisions. Thus, school professionals must ensure that children meet the criteria for autism as outlined by IDEA and may use the DSM-IV to the extent that the diagnostic criteria include the same core behaviors (e.g., difficulties with social interaction, difficulties with communication, and the frequent exhibition of repetitive behaviors or circumscribed interests). Of course, all professionals, whether clinical or school, should have the appropriate training and background related to the diagnosis and treatment of neurodevelopmental disorders. The identification of autism should be made by a professional team using multiple sources of information, including, but not limited to an interdisciplinary assessment of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, and cognitive functioning to help with intervention planning and determining eligibility for special educational services.

Legal and special education experts recommend the following guidelines to help school districts meet the requirements for providing legally and educationally appropriate programs and services to students with ASD.

1. School districts should ensure that the IEP process follows the procedural requirements of IDEA. This includes actively involving parents in the IEP process and adhering to the time frame requirements for assessment and developing and implementing the student’s IEP. Moreover, parents must be notified of their due process rights. It’s important to recognize that parent-professional communication and collaboration are key components for making educational and program decisions.

2. School districts should make certain that comprehensive, individualized evaluations are completed by school professionals who have knowledge, experience, and expertise in ASD. If qualified personnel are not available, school districts should provide the appropriate training or retain the services of a consultant.

3. School districts should develop IEPs based on the child’s unique pattern of strengths and weaknesses. Goals for a child with ASD commonly include the areas of communication, social behavior, adaptive skills, challenging behavior, and academic and functional skills. The IEP must address appropriate instructional and curricular modifications, together with related services such as counseling, occupational therapy, speech/language therapy, physical therapy and transportation needs. Evidence-based instructional strategies should also be adopted to ensure that the IEP is implemented appropriately.

4. School districts should assure that progress monitoring of students with ASD is completed at specified intervals by an interdisciplinary team of professionals who have a knowledge base and experience in autism. This includes collecting evidence-based data to document progress towards achieving IEP goals and to assess program effectiveness.

5. School districts should make every effort to place students in integrated settings to maximize interaction with non-disabled peers. Inclusion with typically developing students is important for a child with ASD as peers provide the best models for language and social skills. However, inclusive education alone is insufficient, evidence-based intervention and training is also necessary to address specific skill deficits. Although the least restrictive environment (LRE) provision of IDEA requires that efforts be made to educate students with special needs in less restrictive settings, IDEA also recognizes that some students may require a more comprehensive program to provide FAPE.

6. School districts should provide on-going training and education in ASD for both parents and professionals. Professionals who are trained in specific methodology and techniques will be most effective in providing the appropriate services and in modifying curriculum based upon the unique needs of the individual child.

References and further reading:

Individuals with Disabilities Education Improvement Act of 2004. Pub. L. No. 108-446, 108th Congress, 2nd Session. (2004).

Mandlawitz, M. R. (2002). The impact of the legal system on educational programming for young children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 32, 495-508.

National Research Council (2001). Educating children with autism. Committee on Educational Interventions for Children with Autism. C. Lord & J. P. McGee (Eds). Division of Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.

Twachtman-Cullen, D., & Twachtman-Bassett, J. (2011). The IEP from A to Z: How to create meaningful and measurable goals and objectives. San Francisco, CA: Jossey-Bass.

Wilkinson, L. A. (2010). Best practice in special needs education. In L. A. Wilkinson, A best practice guide to assessment and intervention for autism and Asperger syndrome in schools (pp. 127-146). London: Jessica Kingsley Publishers.

Wrightslaw: Special Education Law, 2ndEdition (2007).

Yell, M. L., Katsiyannis, A, Drasgow, E, & Herbst, M. (2003). Developing legally correct and educationally appropriate programs for students with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 18, 182-191.

Lee A. Wilkinson, PhD is the author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers.

Retrieved from: http://www.examiner.com/article/autism-at-school-dsm-or-idea?goback=%2Egde_2191897_member_225669404

increase in adhd diagnoses…

In ADHD, ADHD Adult, ADHD child/adolescent, Neuropsychology, Neuroscience, School Psychology, Special Education on Tuesday, 12 March 2013 at 11:59

is this because of increased awareness, greater recognition of adhd, better diagnostics and screening, etc. or is it because of the heightened demands put upon all of us in today’s society?  i do believe adhd is a very real diagnosis and can have deleterious effects on the brain if left untreated.  what i can tell you i do see in my work as a school psychologist is some children with a true disability and some very savvy parents (or kids, in some instances) who know that a stimulant will help them meet any increased demands and are able to “get” an adhd diagnosis by going to certain doctors or knowing what to say and what “symptoms” to report.  a comprehensive adhd diagnosis is not an easy one to make and takes way more than a ten-minute session with a pediatrician.  this is one of the reasons i am such a proponent of  the advancements in genome wide association studies, neuroanatomy, neurobiology, etc. that can effectively show differences between a brain with adhd and a brain without adhd, thus, one day hopefully being able to diagnose with more than parent and self-report and some testing.  and, with the large population of untreated adhd or late-diagnosed adhd (so, no treatment until adulthood), we are able to see the effects of no treatment, then getting proper treatment.  

i am a fan of a new book on adhd by cecil reynolds, et al.  it is a comprehensive look at adhd by one of the foremost neuropsychologists today.  http://www.amazon.com/Energetic-Brain-Understanding-Managing-ADHD/dp/0470615168 

there’s my two-cents.  here is the article:

Study Suggests Increased Rate of Diagnosis of Attention-Deficit/Hyperactivity Disorder at Health Plan


Media Advisory: To contact study author Darios Getahun, M.D., Ph.D., call Sandra Hernandez-Millett at 626-405-5384 or email sandra.d.hernandez-millett@kp.org or call Vincent Staupe at 415-318-4386 or email vstaupe@golinharris.com.

CHICAGO – A study of medical records at the Kaiser Permanente Southern California health plan suggests the rate of attention-deficit/hyperactivity disorder (ADHD) diagnosis increased from 2001 to 2010, according to a report published Online First by JAMA Pediatrics, a JAMA Network publication.

ADHD is one of the most common chronic childhood psychiatric disorders, affecting 4 percent to 12 percent of all school-aged children and persisting into adolescence and adulthood in about 66 percent to 85 percent of affected children. The origin of ADHD is not fully understood, but some emerging evidence suggests that both genetic and environmental factors play important roles, the authors write in the study background.

Darios Getahun, M.D., Ph.D., of the Kaiser Permanente Southern California Medical Group, Pasadena, Calif., and colleagues used patient medical records to examine trends in the diagnosis of ADHD in all children who received care at Kaiser Permanente Southern California (KPSC) from January 2001 through December 2010. Of the 842,830 children cared for during that time, 39,200 (4.9 percent) had a diagnosis of ADHD.

“The findings suggest that the rate of ADHD diagnosis among children in the health plan notably has increased over time. We observed disproportionately high ADHD diagnosis rates among white children and notable increases among black girls,” according to the study.

The rates of ADHD diagnosis were 2.5 percent in 2001 and 3.1 percent in 2010, a relative increase of 24 percent. From 2001 to 2010, the rate increased among whites (4.7 percent to 5.6 percent); blacks (2.6 percent to 4.1 percent); and Hispanics (1.7 percent to 2.5 percent). Rates for Asian/Pacific Islanders remained unchanged over time, according to study results.

Boys also were more likely to be diagnosed with ADHD than girls, but the study results suggest that the sex gap for black children may be closing over time. Children who live in high-income households ($70,000 or more) also were at an increased risk of diagnosis, according to the results.

(JAMA Intern Med. Published online January 21, 2013. doi:10.1001/2013.jamapediatrics.401. Available pre-embargo to the media at http://media.jamanetwork.com.)

Retrieved from: http://media.jamanetwork.com/news-item/study-suggests-increased-rate-of-diagnosis-of-attention-deficithyperactivity-disorder-at-health-plan/

flapping hands and wagging tails…

In Autism Spectrum Disorders, Child/Adolescent Psychology, Humane Education, Life with dogs, Pets, School Psychology on Tuesday, 26 February 2013 at 06:02

Your Hands Tell Me When You’re Happy

By: Stewart Duncan

Christmas was one week away, the excitement building as we prepared presents for friends and family. We laughed as we changed the words to our favorite Christmas songs, drank Egg Nog and opened the next door to find out what shape the next chocolate was in our advent calendars.


As we talk about Santa and what each of us is hoping for, I lean over to my son Cameron and say “Do you know how I always know when you’re happy?”


He said “No, how?”

I replied “Your hands tell me.”

He smiled and said “because I flap my hands!”

At that point, he began bouncing on his toes and flapping his hands so hard that I thought he might fly.

Beside us, sitting up against my hip, was my dog Spirit. She is Cameron’s best friend and, I think, Cameron is her best friend too.

I said to Cameron “Cameron, do you know how I always know when Spirit is happy?”

He said “No.”

I told him “Because her tail tells me.”

Again, the excitement building as he flapped his hands really hard, “She wags her tail!!”

I explained to him that Spirit doesn’t have hands so she wags her tail but I imagine that it’s very much the same feeling. There’s just so much happiness inside that it has to come out.

I told him that I know some people might bug him about it, some people might say silly things or tell him that he shouldn’t… but I’ll never stop him from showing me how happy he is.

He got up and gave me a big hug.


About Stuart Duncan

My name is Stuart Duncan, creator of http://www.stuartduncan.name. My oldest son (Cameron) has Autism while my younger son (Tyler) does not. I am a work from home web developer with a background in radio. I do my very best to stay educated and do what ever is necessary to ensure my children have the tools they need to thrive. I share my stories and experiences in an effort to further grow and strengthen the online Autism community and to promote Autism Understanding and Acceptance.

Retrieved from:  http://www.stuartduncan.name/autism/your-hands-tell-me-when-youre-happy/

Large study shows substance abuse rates higher in teenagers with ADHD

In ADHD, ADHD Adult, ADHD child/adolescent, Fitness/Health, Psychiatry, School Psychology on Sunday, 24 February 2013 at 10:03

Large study shows substance abuse rates higher in teenagers with ADHD.

bye bye, bipolar disorder!

In Education, General Psychology, Mood Disorders, School Psychology on Tuesday, 19 February 2013 at 06:57

i love this website and the information.  i find it useful in general and in my work in the schools.  if you work with children with behavioral issues or are interested in learning more, i recommend you join dr. mac’s b-list email list.  i always find interesting and useful articles like the one below.  thanks, dr, mac!

Bye-Bye Bi-Polar Disorder

Hello again, fellow B-Lister!  Where are you located right now on the mood spectrum?  Forlorn?  So-So?  Ecstatic?  How’s the energy level right now? Are you sinking into the sofa for the 3rd day in a row, taking a short-lived seat to read this communication, or jumping up and down on it?

We all have ups and downs in mood, energy, or ability to function well in our daily tasks.  Some folks, though,  re-cycle through these ups and downs, reaching the extreme ends of the continuum.

Back-in-the-day, I typically heard the term “Manic Depression” used for the condition under discussion in our newsletter today.  When I first heard the term “Bi-Polar”, I thought it had something to do with the melting of the polar ice caps or penguins moving up to Santa’s domain!

Bipolar disorder: A mental illness that is evidenced by extreme shifts in mood, energy and functioning.

Yes, now Bipolar Disorder is the clinically correct terminology for the dramatic, recycled changes experienced by individuals with this mental health disorder.  However, I must admit that manic-depressive held more meaning for me. It identified the two opposites of the continuum rather than using vague terminology as a label.

There are different variations of Bipolar Disorder listed in the two mental health diagnostic manuals, the DSM-IVtr (soon to become DSM-5) and the International Classification of Diseases (ICD-10).  Once thought to be a rare condition in children and youth, the 1990’s era saw a massive increase in Bipolar diagnoses for kids with severe sadness, irritability, anger, and grumpiness. a rise of 4000% in just 12 years!  As might be expected, the dramatic increase sparked discussion and disagreement about whether children were being misdiagnosed and then prescribed powerful psychotropic mediations with significant negative side effects. (A future topic for a B-List members)

Bipolar disorder is a life-long mental disability, but most research has shown that  kids diagnosed with childhood bipolar disorder (the expansive version) are no more likely to develop classic Bipolar Disorder than their non-diagnosed peers.  Additionally, the prescribed medications didn’t work as well in children as in adults.  Certainly, these youngsters possessed a legitimate mood disorder, one that may very well extend into adulthood. but for most of them, it wasn’t Bipolar Disorder.

One of the graduate students in my teacher preparation program in behavior disorders created a wonderful video regarding authentic Bi-Polar Disorder in children.  Using a case study of a 6 year old boy, Michelle then compares the youngster’s symptoms with the criteria for the condition, before offering strategies and approaches for intervention. (Thanks, Michelle!)

*Health note: Omega 3 oil, lecithin, and vitamins B6 & B12 have been implicated in the condition, with Bi-Polar individuals being deficient in these nutrients.  If you are seeking a natural alternative or supplement to Lithium and/or the other common medications you can find them in their purest form here: http://www.shop.com/healthnutrition-a.xhtml (Your purchases result in discounts & cash-back while supporting a kid’s pre-teen swim team.  My nutrition consultant, Cindy, is also available to assist you at this site)

A rose by any other name.

In response to the great controversy & disagreement as to whether this mental health disability should be diagnosed in kids, DSM-5 (due for distribution in May 2013) makes an effort to reduce the numbers of Bipolar diagnoses… by creating a new diagnosis!…: Distemper.  Oh Wait!!!  That’s my dog.  For our kids, the mental health diagnostic manual it will soon contain a new condition titled “Temper Dysregulation Disorder with Dysphoria” (TDD).

Dysphoria: An emotional state of feeling unwell or unhappy.

TDD displays itself in severe outbursts of anger/temper interchanging with negative mood states.  Unlike Bipolar Disorder, it does not include phases of mania (but neither did the criteria used to diagnose kids as having Bipolar Disorder… Odd, eh?… Labeling kids as being Bipolar when they didn’t have a second pole).  TDD is also not considered to be a life-long disorder.

The American Psychiatric Association states that it hopes that the majority of kids (perhaps 60-70%) who have or might have been diagnosed with Bipolar Disorder will now receive the TDD label.  This re-diagnosis would probably also include many youngsters with Conduct Disorder who were labeled as being Bipolar in order to obtain health insurance coverage for treatment

The symptoms of TDD in the upcoming DSM-5 manual are similar in many ways to the broad type of childhood bipolar disorder (as it was diagnosed). The proposed diagnostic criteria for TDD include:

severe recurrent temper outbursts that are grossly out of

proportion to the intensity of the situation

frequency of at least three temper outbursts per week

temper outbursts ongoing for at least one year

temper outbursts present in at least two settings (for

example, at home and at school)

onset before age 10

There is an excellent 10 minute video on the new disorder in the archives of National Public Radio: http://www.npr.org/player/v2/mediaPlayer.html?action=1&t=1&islist=false&id=123544191&m=123564957


For those of you working with youngsters who have the symptoms mentioned above:

1. Rob Plevin’s 3-part FREE video series on working effectively with disruptive kids is still availabe.  Click here to view effective strategies for quieting noisy classes and kids.

2. Modify the character of the youngster using the Circle of Courage model of intervention.  This comprehensive, intensive and positive program changes lives.

3.  The Behavior Intervention Guide allows you to determine a disruptive youngster’s present level of readiness to change behaviour.  Based on the outcome of the assessment, strategies are provided that move the youngster toward greater levels of willingness to change his/her behavior for the better.

4.  Use “The Behavior Survival Guide for Kids: How to make good choices and stay out of trouble” in your social skills/anger management programs, or place it in the class library.  Stellar reviews by websites, magazines, parents, teachers, and the kids themselves let you know the effectiveness of this self-help book for kids.  It’s written on a 4th grade reading level… just like these weekly newletters!

5. Implement the FREE 100+ lesson plans that accompany The Behavior Survival Guide (or use them in isolation)

For Parents of Defiant & Angry Youngsters

1. Develop a home-school behavior change program based on the monetary system.  When money and priviledges are involved, kids listen!

2. Learn the principles of changing behaviour for the better, and effective strategies for helping your child make better behavior choices.

3.  Leave “The Behavior Survival Guide for Kids: How to make good choices and stay out of trouble” out on the coffee table for your child to pick up.

4. Seek out family counseling.

5. Acquire the comprehensive program designed specifically to help parents of children with Conduct Disorder/highly disobedient behavior change their child’s behavior for the better. (Click on the Total Transformation box below)

NEXT WEEK: Disruptive Behavior (Not otherwise specified)

(When the actions are disruptive, defiant, and/or aggressive,but don’t meet the criteria for ODD or Conduct Disorder)

Dr. Mac

Room 914west,

Department of Special Education, Hunter College,

695 Park Avenue,

New York,

NY 10021


Retrieved from: http://www.behavioradvisor.com

How Can Teachers Overcome Depression and Strife? – Living in Dialogue – Education Week Teacher

In Education advocacy, Pedagogy, School Psychology, School reform, Well-being on Friday, 15 February 2013 at 09:01

great advice on the article below.  

i have never seen a greater level of stress and lower morale than this school year.  i worry every day for my teachers and staff and hope, no matter what “they” throw at us, that the good ones will stay because even if you feel your system doesn’t appreciate you, those kids do.  sometimes, we school employees might be the only people who give a kid attention or show he or she is cared about.  some might not have parents in the house (maybe raised by an older sibling or another family member), some might not have food most days, clean clothes, some don’t even have a house or place to sleep.  

in the end, it’s all about the kids and i do know most teachers and support staff feel that way.  but i also realize that it is difficult to be in a career where teachers are blamed for “outcomes” when teacher/school influence only accounts for 15-25% of student outcome (i have not seen any study that can account for more than that).  how is it then, that teachers are going to be evaluated and paid based on something that they only have 15-25% control of?  the other 75-85% obviously has a greater effect.  all the teachers i know do it for the love of the kids and try very hard to keep this at the forefront.  but…when you are being told that it’s all about test scores, outcome, academic improvement, it’s difficult to focus on things that make teachers who they are…those who chose a profession, not to make money or get rich because they never will, but for the love of learning and the love of children and our future.  the way our country is going with education “reform” breaks my heart and i am saddened for all the wonderful and inspirational teachers that might just decide it’s no longer worth it.

How Can Teachers Overcome Depression and Strife? – Living in Dialogue – Education Week Teacher.

wired for anxiety?

In Anxiety, Child/Adolescent Psychology, General Psychology, Psychiatry, School Psychology on Sunday, 10 February 2013 at 08:31

Are We All Just Wired for Anxiety?

By: Ben Michaels, Ph.D.

 Michael Shermer’s TEDTalk, “The Pattern Behind Self-deception” is both groundbreaking and earth-shattering. The neuroscience Shermer cites in his talk is tight, his examples are strong and his conclusions far-reaching. The implications that many have drawn from his talk regarding larger belief systems are beyond my expertise as a clinical psychologist and so I will (wisely or cowardly — you choose) sidestep these arguments.

I do however, think that one of the factors that Dr. Shermer stumbles upon in his talk has a wide applications for the field of clinical psychology, which is this:

If Shermer is right (and he is), and that our default setting is to see patterns where they don’t exist because the cost of being wrong (that there is no pattern) is usually much higher than the cost of being right (that there is a pattern) then I have some bad news for you:

We are all just wired for anxiety.

Let me break it down:

Let’s say something bad happens to us: We have a breakup, a breakdown, a trauma, an insult or injury of any kind. This leads us to seek out patterns in our environments that could signify the possibility of future pain. In fact, Shermer says that when we feel uncertain (like after a trauma) we will be even more prone to seeking out patterns, possibly seeing them where they don’t exist.

This desperate pattern seeking is, in essence, the pernicious spiral of anxiety: We are afraid of what’s next so our minds exit the present to try to solve an unsolveable math problem about our futures. The reason the problem is unsolveable is that all of the variables don’t yet exist. The key variable being the actual event.

If this tendency is our natural weakness, we must overcome it by using our natural strength: Thinking and testing our beliefs.

For example, I once worked with a handsome young man, who we will call, Nate, who was constantly told that he was “ugly” and “stupid” by his abusive father. When he first came to me, Nate was convinced that no woman would ever want to date him, let alone, marry him.

I responded to him by saying, maybe he’s right maybe no woman would have him, but there is only one way to find out: test his beliefs in the real world. I told him that if he asked out all the women in the world and none of them want to date him, than his anxiety would be justified If at least one woman wanted to then it would not be.

He realized that this was absurd, but after a great deal of relentless pushing, Nate agreed to try to approach a few women over time.

Fourteen months later he was engaged. He is now happily married and currently expecting his third child.

Science/Empiricism = 1; Anxiety/Fear = 0

The takeaway is this: We may indeed be wired for anxiety, but that does not mean that anxiety is our fate. If we use the gift of our minds well, we can overcome our wiring.

If you read this and are feeling anxious or are buried under the weight of any false belief because of your wiring, do the hard thing: Test it out. The only thing you have to lose is your anxiety!

Ideas are not set in stone. When exposed to thoughtful people, they morph and adapt into their most potent form. TEDWeekends will highlight some of today’s most intriguing ideas and allow them to develop in real time through your voice! Tweet #TEDWeekends to share your perspective or emailtedweekends@huffingtonpost.com to learn about future weekend’s ideas to contribute as a writer.

Retrieved from: http://www.huffingtonpost.com/ben-michaelis-phd/wired-for-anxiety_b_2599944.html?utm_source=linkedin&utm_medium=social&utm_content=2c773f97-31e5-4b88-bbb2-fa255a762ed1

Click here to read the original op-ed from the TED speaker who inspired the post and watch the TEDtalk below:



adhd, 504, private schools, and provision of services…

In ADHD, ADHD child/adolescent, Education, Education Law, School Psychology on Friday, 25 January 2013 at 07:00

District Not Required to Serve ADHD Student Attending Private School

(January 16, 2013) A school district does not have an obligation to provide services to an ADHD child enrolled in a private religious school under current federal disability-rights law.

The United States Court of Appeals for the Fourth Circuit held that Baltimore City Public Schools had no obligation to provided special education services under Section 504 to an 8th grade ADHD student who attended a private Jewish school in Maryland.

D.L., the student around whom the law suit swirled, was diagnosed with ADHD and anxiety as a fifth grade student in 2007. Two years later, Baltimore City Board of School Commissioners (BCBSC) determined that while D.L. did not qualify for services under the Individuals with Disabilities Educational Act (IDEA), he was eligible under Section 504. Upon making this determination though, BCBSC notified D.L.’s parents that it could not provide the student services unless D.L. was enrolled in one of its schools. Since Maryland is a state that does not allow dual enrollment in a private and public school, D.L. would have to withdraw from his Yeshiva and enroll at the local public school.

D.L.’s parents challenged this decision, arguing that Section 504 creates an affirmative duty for school districts to provide services to eligible students enrolled in private schools. The parents’ arguments failed before a hearing officer so they filed suit in the United States District Court of Maryland. BCBSC filed a motion for summary judgment (a motion which basically says that even if D.L.’s parents were to prove all the facts they assert, they would still lose the case as a matter of law) and the parents filed a motion for partial summary judgment. The lower court granted BCBSC’s summary judgment motion and denied the parent’s partial summary judgment motion. The parents filed an appealed that decision to the U.S. Court of Appeals.

In the case, D.L. v. Baltimore City Board of School Commissioners, the parents argued two main points: 1) that Section 504 regulation mandate that BCBSC provide D.L. with afree and appropriate education (FAPE), and 2) that BCBSC’s requirement that the family enroll D.L. in a public school violates their constitutional rights under the First Amendment’s Freedom of Religion clause.

With regard to the first contention, the court recognized that the plain language of Section 504 leaves unclear whether public schools are required to provide services to students enrolled in private schools. 34 C.F.R. § 104.33(a) states in relevant part that districts must “provide each Section 504 eligible student within its jurisdiction with a [FAPE].” The parents contend this language means that public schools have a greater obligation that simply making such education available.

The court reasoned that while the plain language is ambiguous, that further clarification in Appendix A of the regulations where it states in relevant part, “[i]f . . . a recipient offers adequate services and if alternate placement is chosen by a student’s parent or guardian, the recipient need not assume the cost of the outside services.” In looking at this, the court noted that while this shows that a district need not pay for services obtained outside the public school, it leaves open the question of whether such services can be obtained from the school.

Here, the court relied upon a clarification letter by the Department of Education entitled OCR Response to Veir Inquire Re: Various Matters which offers a direct clarification of the disputed regulation. The court noted that where a regulation is ambiguous, courts must grant deference to an agency’s interpretation of its own regulation. In the Vier letter, the DOE stated that “[w]here a district has offered an appropriate education, a district is not responsible under Section 504, for the provision of educational services to students not enrolled in the public education program based on the personal choice of the parent or guardian.” The court applied this language to hold that BCBSC had no responsibility to provide services to D.L. in his private school placement.

In reaching its holding, the court also rejected the parents’ arguments that Section 504′s language should be interpreted broadly since it is a remedial statute. While noting that turth of the parent’s contention that remedial statutes should be broadly construed, the court noted,

“The purpose of Section 504 does not, however, extend as far as Appellants [parents] assert that it should. Section 504 and its implementing regulations prohibit discrimination on the basis of disability, not on the basis of school choice.”

The court next tackled the First Amendment issues raised by the suit. The parents’ suit tried to persuade the court that the Supreme Court’s rulings in Pierce, 268 U.S. 510, andYoder, 406 U.S. 205, show that requiring D.L. to attend Baltimore public schools was a violation of his First Amendment rights.

The court easily distinguished these cases in that both involved parents being charged under criminal statutes for failure to educate their children in public schools. Here, the parents face no such sanctions and retain free choice as to where their child go to school. The issue was one of payment of services. While it is true that the parents would need to pay additional services that would be free were they to attend public schools, such increased economic burden does not meet the standard of a First Amendment violation. The court noted, “The Supreme Court has explained that a statute does not violate the Free Exercise Clause [First Amendment] merely because it causes economic disadvantage on individuals who choose to practice their religion in a specific manner.

Retrieved from: http://www.ocspecialedattorney.com/district-not-required-to-serve-adhd-student-attending-private-school/

to read or not to read…

In Education, Neuropsychology, Neuroscience, School Psychology on Saturday, 19 January 2013 at 09:25

reading is fundamental!


what role does a school psychologist play regarding children’s mental health?

In Education, School Psychology on Monday, 14 January 2013 at 08:46

The Role of School Psychologists in Children’s Mental Health

By: Lee Wilkinson, Ph.D.

According to the U.S. Surgeon General, over the course of a year, approximately 20% of children and adolescents in the U.S. experience signs and symptoms of a mental health problem and 5% experience “extreme functional impairment.” Although more than 2 million adolescents aged 12 to 17 suffered a major depressive episode in the past year, nearly 60% of them did not receive treatment. Statistics also suggest that the dropout rate for students with severe emotional and behavioral needs is approximately twice that of other students. Most children with mental health problems receive no services and of those who do, 70 to 80% receive them from school-based providers. School psychologists are among the school-based personnel (e.g., guidance counselors, school social workers) who are typically called upon to provide mental health services. In order for school psychologists to be effective mental health service providers, they must be competent to fulfill that role and function. This article discusses education and training issues, and related ethical and professional practice issues associated with school psychologists’ role in providing mental health services in the schools.

Role and Function of School Psychologists

Surveys consistently indicate that school psychologists spend a majority of their time in assessment activities rather than delivering direct mental health services (e.g., counseling) to students. This includes determining special education eligibility and working with youth within the context of special education. Indeed, the majority of school psychologists report spending less than 10% of their time per week providing evidence-based mental health services to children and adolescents. Despite the limited amount of time devoted to mental health service delivery, school psychologists are increasingly being called on to serve in this role. Moreover, school psychologists themselves report wanting to spend more time doing activities such as counseling and direct intervention, further supporting the profession’s desire to serve in the mental health service provider role. However, role expansion may prove to be problematic due to training issues and lack of administrative support.

Training and Preparation

Research suggests that training in the diagnosis and treatment of mental disorders and counseling are determinates of the provision of mental health services by school psychologists. According to National Association of School Psychologists (NASP), the term “child psychologist” refers to doctoral-level clinical psychologists who specialize in children. “School psychologist” specifically refers to professionals who bridge psychology and education to address school related issues, including those that concern children, teachers, parents and families, as well as school organizations. School psychologists’ training includes study in education and special education, but compared to clinical psychology, there is less emphasis on psychopathology and counseling. The majority of states require the completion of a 60 graduate semester master’s or specialist-level program in school psychology, including a 1200-hour internship, along with passing a Teacher Certification Test, which has a specialty component for school psychology. In contrast, a doctoral degree (e.g., PhD) generally requires about 5 years of full-time graduate study, culminating in a dissertation based on original research. Doctoral programs in child clinical-school psychology usually include further training and coursework and preparation in child and adolescent psychopathology, behavioral and child therapy, pediatric pharmacology, neuropsychology, advanced research, and a clinical practicum.

Ethical Considerations

Ethical issues are especially important in this discussion. School psychologists must be familiar with the ethical codes that apply to their specialization, as well as to psychology in general. For example, school psychologists must practice within the boundaries of their experience and training. Professional competency standards require school psychologists to recognize the strengths and limitations of their training and experience, and only practice in areas for which they are “qualified.” In fact, the issue of practitioner competence is paramount in the ethics codes of the American Psychological Association (APA), American Counseling Association (ACA), and National Association of School Psychologists (NASP). The parameters of competence involve (a) recognizing one’s professional limitations and needs, (b) understanding one’s professional strengths, (c) confining consultation practice to one’s competence, (d) knowing when to decline work and when to refer to other professionals, (e) ensuring that recommended interventions have an empirical basis, and (f) maintaining a high level of professionalism. Practitioners should seek continuing education and training in areas in which they lack competence and experience and refer to colleagues with the requisite experience and/or community resources.


While the domains of professional school psychology practice include competencies in “prevention, wellness promotion, and crisis intervention,” most school-based practitioners have not received intensive training in child and adolescent psychopathology, counseling and therapeutic intervention. Nor are most school psychologists licensed in another mental health specialty. Consequently, it is especially important for administrators, teachers, and parents to understand the limitations and parameters of school psychology practice and not assume that the school psychologists possesses the clinical training to assess and intervene with complex childhood disorders. Schools often do not draw a distinction made between the specialist and the doctoral level school psychologist. Distinctions may not be critical when school psychologists are performing psychoeducational assessment services, as both sub-doctoral and doctoral level school psychologists receive comparable preparation for these important services. However, the academic and professional preparation of doctoral level school psychologists typically emphasizes clinical issues important to children’s mental health, including methods for working with children and youth, their parents and teachers. In fact, research suggests that school psychologists with a specialist degree provide fewer mental health services than individuals with doctorates.


The educational setting is the most likely setting for students to receive mental health services. Unfortunately, a majority of children and youth who are in need of mental health services do not actually receive them. If psychological services are to be expanded in schools to include a major focus on mental health services, school psychologists must be trained as broadly as possible, so that they are capable of working in different settings and prepared to address a range of issues. In this regard, changes must be made in the graduate-level curriculum of school psychology programs. For example, graduate training programs should provide additional preparation in evidence based mental health services, including individual and group counseling, to ensure school psychologists have the tools they need to help students be successful. Training programs also need to provide practice experiences in the application of evidence-based therapeutic interventions, with a practicum supervised by school psychologists who are competent in the application of these services. A viable service model may call for subdoctoral school psychologists to assume leadership for continuing to provide psychoeducational assessment services for special education and for doctoral level school psychologists to assume leadership for initiatives aimed at promoting children’s mental health. While students in nondoctoral programs may receive a basic introduction to mental health services, they will likely need to pursue further postgraduate training and continuing education/professional development in mental health services. Simply stated, school psychologists cannot be expected to provide mental health services without adequate, appropriate training.

Perfect, M. M., & Morris, R. J. (2011). Delivering school-based mental health services by school psychologists: Education, training, and ethical issues. Psychology in the Schools, 48, 1049–1063. doi: 10.1002/pits.20612


Lee A. Wilkinson, PhD, NCSP, CCBT is a nationally certified school psychologist, licensed school psychologist and certified cognitive-behavioral therapist. He is also a university educator and serves on the school psychology faculty at Nova Southeastern University and Capella University where he teaches courses in assessment, consultation, child and adolescent psychopathology, and clinical intervention. His research and professional writing has focused primarily on behavioral consultation and therapy, and children and adults with autism spectrum disorders. He has published widely on these topics, both in the US and internationally. Dr. Wilkinson is the author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers. He is editor of the soon to be published text, Autism Spectrum Disorders in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools, from APA Books.

If you enjoy reading my articles, you can click on “subscribe” at the top of the page to receive notice when new ones are published. You can also follow me athttp://bestpracticeautism.com.

Retrieved from: http://www.examiner.com/article/the-role-of-school-psychologists-children-s-mental-health

ABCs and ADHD…

In ADHD, ADHD Adult, ADHD child/adolescent, ADHD stimulant treatment, Psychiatry, School Psychology on Wednesday, 9 January 2013 at 07:04

The ABCs of ADHD

Learn about the specific characteristics of a child with ADHD and how it impacts their lives.

By Melvyn Hyman

Who today has not heard the term “attention deficit hyperactivity disorder,” or ADHD? No other term in the diagnostic lexicon has more information and misinformation attached to it than ADHD. Everyone you ask — parents, doctors, teachers, psychologists, nurses, neighbors or relatives — will have an opinion on this disorder, and likely their opinions will all differ. Some will toss it off and say, “Boys will be boys.” Some will insist that a child be medicated right away. Others will be adamant that children should never be medicated. Others will claim that eliminating sugar from the diet will eliminate the problem. Still others will question whether there is anything to the diagnosis at all.

Since first identified as a diagnosis, ADHD has been given a great deal of attention by neurologists and psychologists. ADHD is now widely recognized as a legitimate mental health problem. Although its exact definition continues to be debated, ADHD is thought to be a neurological impairment, probably originating in the frontal lobes of the brain, affecting a child’s ability to control his or her impulses. Lacking the ability to control their impulses, these children do and say whatever occurs to them from minute to minute. They are quite literally out of control.

There has been a great deal of research to understand just what causes children have ADHD. Among the identified causes are: heredity (a parent or other close relative with ADHD, although it may have gone unrecognized); problems at birth; and possibly some kind of early emotional trauma that had an effect on the processing mechanisms of the brain.

In some ways, children with ADHD are no different from their peers. One key diagnostic feature noted in children with ADHD is the intense, often frantic quality of their activity. These children are on the move most of the time: climbing the cupboards, tearing about the room, turning over every object that isn’t nailed down — an unending streak of activity and mischief. They quickly wear out their clothes and toys, and usually have more than their share of accidents.

Short Attention Spans
Children with ADHD also have extremely short attention spans. They seem to have difficulty sitting still or waiting their turn. This may be because they are so easily distracted. It often seems that they fail to remember instructions given by a parent or teacher in the time it takes to get from one end of the room to the other. They appear to live only in the present. They don’t seem to think about future consequences. They sometimes can’t remember what they did only moments earlier.

The behavior of a child with ADHD is qualitatively different from the occasional episodes of increased activity in children who do not have ADHD. Every child fidgets or misbehaves from time to time. Children with ADHD, however, are a constant challenge. Their behaviors cause frustration and anger for those around them. Without proper help, these children can become sad or even depressed due to their very accurate perception that the people around them disapprove of everything they do.

Ironically, these very same overactive children can become completely absorbed in a specific activity or task. They sometimes become so over-focused that being asked to shift their attention causes great upset and anger. It is as if the mechanism in the brain that controls their impulsiveness has now gone into overdrive. Once engaged, they can’t let go. Another theory is that these children have learned to compensate for their distractibility by focusing so completely on an activity that they cannot easily alter the track of their attention. They find change initiated by others to be threatening and difficult. This is very confusing for adults because it seems inconsistent with the general stereotypes about ADHD. Puzzled parents often ask things like: “How is it he can remember every arcane move in a video game but can’t remember to take out the garbage?” or “Why can she sit still to watch MTV for hours but can’t sit still through one classroom lesson?”

Friendships and ADHD
Children with ADHD also wear out friendships. Their behavior can be so thoughtless and aggravating, even exhausting, that other children start to avoid them. They miss usual social cues and often blurt out what they are thinking whether or not it is at all appropriate or tactful. Usually good-hearted and wanting friends, they are often mystified by others’ negative reactions to them. It is important to understand that children with ADHD are not trying to be annoying or malicious. In fact, they often seem surprised and embarrassed when their behavior results in rejection by others.

Evaluation for ADHD includes a family history, a medical exam, psychological testing, and, very importantly, a compilation of ratings on paper and pencil behavioral scales completed by parents and teachers who know the child well. A skilled neuropsychologist will recognize patterns in all of these data that generally point to a diagnosis of ADHD.

Treatment of ADHD
It is generally believed that children with ADHD benefit most from a multidisciplinary approach that comes at the problem in many ways simultaneously. On the medical front, stimulants such as Cylert (premoline), Dexedrine (dextroamphetamine), and Ritalin (methylphenidate) are the medications most often used to treat ADHD in the United States; antidepressants are sometimes prescribed as well. These medications increase activity in the frontal lobes of the brain where impulsivity is managed.

Parents and teachers of children with ADHD must be educated about how to best manage their particular child. Many adults make the mistake of getting into power struggles with these children, trying to control them with harsh disciplinary methods. Children with ADHD really can’t help being the way they are. Yelling, scolding, nagging, and punishing will only make them feel and behave worse. Even more than most children, these children need clear and kind guidance, with an emphasis on what they are doing right.

Early identification of special services in the schools can be very helpful. These children do better is a less stimulating, more orderly environment. They benefit from small classes that are fairly quiet. Activities need to be short and focused, with many opportunities for small successes. Parents and teachers should ideally keep in close contact with each other, sharing what they find to be effective for the child in question.

Finally, physical activity can sometimes help children with ADHD channel some of their excessive energy. They tend to do better at individual sports like swim team, rock climbing, weight lifting, or figure skating. Team sports (where a great deal is going on at once) can sometimes be overstimulating and frustrating for these children.

The goal, of course, is for children with ADHD to get the most enjoyment, learning and growth from each day of their lives. With teaching, encouragement, and support, these children can learn to monitor and manage their symptoms and move on with life.

Retrieved from: http://www.everydayhealth.com/adhd/add-adhd-facts.aspx?xid=tw_adhdfacts_20120217_ABCs

early intervention and autism

In Autism Spectrum Disorders, Intervention, School Psychology, Special Education on Friday, 4 January 2013 at 11:21

Early Intervention Program Alters Brain Activity in Children with Autism

Clinical study of Early Start Denver Model intervention shows that it improves not only social skills, but also brain responses to social cues

Decades of research have shown that behavioral therapies for autism can improve cognitive and language skills. Still, it remained unclear whether behavioral interventions simply reduced autism’s symptoms or actually “treated” the developmental disorder. In other words, could an effective behavioral intervention change the brain biology that underlies autism spectrum disorder?

This year, researchers delivered compelling evidence that the Early Start Denver Model(ESDM), an intensive early intervention program for toddlers with autism, improves brain activity related to social responsiveness. The Journal of the American Academy of Child & Adolescent Psychiatry published the findings in its November issue.

“This may be the first demonstration that a behavioral intervention for autism is associated with changes in brain function as well as positive changes in behavior,” commented Tom Insel, M.D., director of the National Institute of Mental Health.

Psychologists Sally Rogers, Ph.D., and Geraldine Dawson, Ph.D., developed the ESDM therapy program in the 1990s. It adapts key techniques from Applied Behavioral Analysis(ABA) for toddlers, with an emphasis on interactive play between children and their therapists and parents. Dr. Rogers is a professor and researcher at the University of California, Davis, MIND Institute. Dr. Dawson was a professor and researcher at the University of Washington, Seattle, when she and Dr. Rogers developed the program. She is now the chief science officer of Autism Speaks and a professor at the University of North Carolina, Chapel Hill.

Three years ago, Drs. Dawson and Rogers published the first results of a clinical trial comparing ESDM with conventional autism therapy services. They randomly  48 toddlers (ages 18 to 30 months) to receive either ESDM therapy or the early intervention services routinely available in their communities (Seattle). Both groups received roughly 20 hours of weekly therapy for two years. Overall, those in the ESDM group showed greater increases in IQ, language and adaptive behavior than children in the community-intervention group.

In this year’s report, the research team published their analysis of brain activity monitoring performed on both groups of children at the end of their two years of therapy. For comparison, they also performed the brain activity tests on a group of age-matched children without autism.

Noninvasive electroencephalography (EEG) showed that the children in the ESDM group showed greater brain responses to social information compared to children in the community group. When they viewed women’s faces, their brain activity patterns were virtually identical to those of the children without autism. This more-typical pattern of brain activity was associated with improved social behavior including improved eye contact and social communication.

By contrast, children in the community intervention group showed greater brain activity when viewing objects than faces. Previous research has shown that many children with autism have this unusual pattern of brain activity.

“By studying changes in the neural response to faces, Dr. Dawson and her colleagues have identified a new target and a potential biomarker that can guide treatment development,” Dr. Insel said.

“So much of a toddler’s learning involves social interaction,” Dr. Dawson added. “As a result, an early intervention program that promotes attention to people and social cues may pay dividends in promoting the normal development of brain and behavior.”

The American Academy of Pediatrics recommends autism screening for all children twice before 24 months. “When families receive a diagnosis, it’s vitally important that we have effective therapies available for their young children,” Dr. Dawson urged. Currently ESDM is the only early intervention evaluated in clinical trials.

As methods for earlier detection become available, infants flagged at risk for ASD may likewise benefit from early intervention, many experts agree. Research suggests that adults with autism can benefit from interventions that promote social engagement as well.

Dawson G, Jones EJ, Merkle K, et al. Early behavioral intervention is associated with normalized brain activity in young children with autism. J Am Acad Child Adolesc Psychiatry. 2012; 51(11):1150-9.

Retrieved from: http://www.autismspeaks.org/science/science-news/top-ten-lists/2012/early-intervention-program-brain-activity-children-autism

Harrowing, Detailed Account of What Happened on 12/14

In Education, School Psychology, School violence on Sunday, 16 December 2012 at 14:40

well-put, ms. ravitch!  we need to realign our priorities!

Harrowing, Detailed Account of What Happened on 12/14.

know the statistics…

In Education, General Psychology, Humane Education, Personality Disorders, Pets, School Psychology, School violence on Sunday, 16 December 2012 at 12:47


woulda, shoulda, coulda…

In Education, Education advocacy, School Psychology, School violence on Sunday, 16 December 2012 at 09:54

School Psychologists Feel the Squeeze

As school budgets shrink, school-based mental-health services are losing resources and support.

By Kirsten Weir

September 2012, Vol 43, No. 8


The Philadelphia school district came under fire last February when it announced a plan to eliminate half of its 110 school psychologist positions to help close a budget shortfall. After the public outcry, district administrators decided against the cuts.

But not all schools have been so lucky. The economic downturn has forced schools nationwide to tighten their belts — and many school psychologists are feeling the squeeze. Cash-strapped schools have already eliminated what they dub as “nonessential” school personnel and programs, such as art and physical education programs, says Ronald Palomares, PhD, assistant executive director of the APA’s Practice Directorate. And even after making these cuts, schools lack funding.

“Now that there’s less money with the same focus on academics, [schools] are looking at a broader definition of nonessential personnel,” he says. “And unfortunately, that is often where school psychology has fallen.”

That nonessential designation is, of course, all a matter of perspective. Federal special education law requires public school districts to employ school psychologists to evaluate students for special-education services. Fulfilling that role is the primary responsibility of the nation’s estimated 32,300 school psychologists (School Psychology International, 2009). About 6.5 million public school students — about 13 percent — received special-ed services in the 2009–10 school year, according to the National Center for Education Statistics.

In their remaining time, school psychologists tend to students’ mental health needs by consulting with teachers and families of children who have social, behavioral and emotional problems. Some also lead psychosocial groups, such as grief groups for students who have suffered a loss, or pregnancy prevention programs for at-risk girls. They also assist children and schools during times of crisis, such as following a student suicide.

“It’s a combination specialty,” says Frank C. Worrell, PhD, director of the school psychology program at the University of California, Berkeley. “The solution to a psychology problem may be an academic intervention, and the solution to an academic problem may be a psychological intervention. Recognizing the connection between these worlds is important.”

Not enough hours in the day

Despite the need for school psychologists, they are in short supply. The National Association of School Psychologists (NASP) recommends that districts employ one school psychologist for every 500 to 700 students. But that’s not happening, says Philip Lazarus, PhD, director of the school psychology program at Florida International University and 2011–12 NASP president.

“In many states, that ratio is more in the neighborhood of one to 2,000, though in some states it goes as high as one to 3,500,” Lazarus says. “We certainly don’t have the number of personnel we feel is necessary.”

With too few personnel to go around, many school psychologists don’t have the time to perform the full range of services they are trained to provide. Though most school psychologists serve two or three schools, it’s not unusual for a single professional to be responsible for visiting five or even seven different schools, says Worrell.

As money becomes tighter, school psychologists may find they’re stretched even thinner. Most school districts haven’t cut school psychologist positions outright, but many have opted not to fill vacant positions, or have shortened annual contracts by a month or two, says Lazarus. “That’s a subtle way students are losing services,” he says.

Rachel Barrón Stroud, PhD, a school psychologist at Hays Consolidated Independent School District outside Austin, Texas, has seen that trend firsthand. “Our district continues to grow, but there’s no talk of adding additional personnel. The needs of students are being met, but the staff continues to get busier,” she says.

Meanwhile, the district has lost technology specialists and academic interventionists, hurting students and staff alike. Without those technology specialists, for instance, school psychologists may have to spend more time trouble-shooting for special-education students who use assistive technology to communicate.

“The job is getting more difficult in terms of time management,” says Barrón Stroud, who still makes time to provide counseling and teacher consultations and to lead two social-skills groups each week. She says she manages to fit in the extra tasks because she regularly takes work home at night. But she adds, “I think, in general, school psychologists feel like they don’t have time to do all the things they’d like to do.”

Changing the conversation

Budget shortfalls are also undermining psychologists’ prevention efforts at schools — even though research suggests schools are often the best places to reach kids (Cognitive and Behavioral Practice, 2008).

“Children spend the majority of their day in schools,” says Tammy Hughes, PhD, a professor of counseling, psychology and special education at Duquesne University. “Further, because school psychologists work with parents and teachers, they are uniquely situated to help children across multiple settings.”

But too often, when budget cuts loom, prevention and early intervention are the first to go. “The trimming happens at the prevention end — at the time we have the most ability to influence positive social and emotional development and address symptoms very early,” says Hughes.

School psychologists aren’t the only mental health positions affected. School counselors, social workers and academic interventionists can all be considered nonessential when there’s not enough money to go around. Cutting these positions puts extra stress on teachers, who have fewer resources to help them manage students with behavioral and emotional problems.

“Teachers are getting overwhelmed with responsibilities,” Palomares says. “How much can they do at such a high level of expectation and still be successful?”

Inadvertently adding to the burden is the No Child Left Behind Act of 2001, which places an emphasis on student testing and school performance. Unfortunately, policymakers have failed to acknowledge the close link between mental health and academic achievement, says Lazarus.

“Students who can’t focus, or are dealing with difficult family problems, won’t succeed in schools no matter how many reforms are put in place by governors or presidents,” he says.

He and others point out that education reform has focused on increasing academic test scores without considering students’ emotional well-being. “And there’s a direct correlation between emotional health and academic success,” Lazarus says.

Bright spots

In spite of the grim economy, school psychologists’ efforts are making significant headway. One positive sign is a new national focus on bullying, says Susan Swearer, PhD, a professor of school psychology at the University of Nebraska–Lincoln, who participated in the White House Bullying Prevention Conference earlier this year. That focus has helped to bring student mental health to the forefront, she says.

“Issues like bullying really point to the importance of school psychologists being at the leading edge of mental health service delivery for youth. It’s a perfect issue to address the fact that we can’t shortchange mental health services in schools,” she says. “But in this era of dwindling budgets, the [school] leadership has to really prioritize mental health treatment.”

And indeed, some districts are already boosting their focus on students’ mental health. Among them is the Baltimore City Public School System, which employs 128 full-time school psychologists to serve 84,000 students — a ratio of about 1:656. Many of those students come from families of low socioeconomic status and often experience social and emotional difficulties, and school personnel are extremely committed to helping students overcome those difficulties, says Rivka Olley, PhD, who supervises psychological services in the system.

“Unlike a lot of districts, we are known for the fact that our school psychologists are providing mental health services,” she says.

Baltimore’s school psychologists and social workers proactively work with teachers and establish student support teams to help students at the first signs of trouble. They also meet with families in their homes or churches, at coffee shops or local restaurants. “We want to make that connection because that’s what the research shows makes a difference for these kids. It’s really reaching out to the families and bringing them into the loop,” Olley says.

Ultimately, it’s hard to argue against making student mental health a priority. And school psychologists can take a leadership role in making that argument, Hughes says, by reaching out to both administrators and legislators to underscore the importance of investing in students’ mental well-being.

“The potential for impact is enormous,” she adds, “if we can get everyone working in the same direction.”

Kirsten Weir is a writer in Minneapolis.

Retrieved from: http://www.apa.org/monitor/2012/09/squeeze.aspx

musings on the madness…con’t.

In Education, School Psychology, School reform, School violence on Sunday, 16 December 2012 at 09:49

i truly believe that there were warning signs (especially in childhood, so more evidence that the schools are one of the BEST resources for this information). when someone does something like this, there is always hindsight about things that were “off” or not right. rarely, if ever, does someone do something this horrific in the absence of even some “signs” that something just isn’t right or this person is at risk. it’s just many people do not realize these correlations (and that would be the first step…education for all). but, with confidentiality and an extremely litigious society looking to blame, blame, blame…what can we (as school employees) do??? if we reported these incidents, could you not see the parents who would threaten to sue because of “confidentiality,” “predetermination of disability,” or some such nonsense?

not to mention how short-staffed and over-worked we are. i used to have regular “lunch bunches” with my kids. i can’t even recall the last time i took time out to eat lunch by myself, let alone ate with kids. i work straight through just trying to keep up with the paperwork, legal issues, meetings, and assessment (i won’t discuss how much time it took me on friday to fill out the needed information for my “brand new” evaluation process…), and trying to fulfill all my “duties and responsibilities.” i am not putting the blame directly on administration or “downtown” as what can they do when funds are cut and cut again, programs are eradicated, and we are doing the job of two or three people?

it’s a trickle down effect from the “reformers” and a society that would rather pay athletes than those who teach and work with their children. that said, this “education reform” has all the wrong priorities. instead of blaming the teachers, the unions, etc., cutting salaries and programs, inventing new curricula, money needs to be pouring into education and NOT for reform and new tests and ways to evaluate data.

instead of being able to give my email or number to a kid who may be in distress and alone and in need of a professional to speak to, I WOULD BE FIRED! we are not allowed. while we pour money into “celebrity” we take money away from the very place that turns these kids into celebrities, doctors, teachers, athletes, scientists, etc….the schools. the place children spend 8+ hours a day, 180 days a year. the place where we can identify and intervene in things before they become school shootings.

and we can. and we do. it is just to a much lesser extent because of time, money, and, of course, CYA. what if the shooter did have a trusted adult to call? i am not saying he would have or things would have been different, but i can tell you about times i have intervened (even going to the hospital with a suicidal child after school) and things changed. but, as i said, this is NOT allowed anymore. and, while i DO understand the reasons this is not allowed, i wonder if we were not trying so hard to CYA and keep things on a less personal level, would this have happened. if we weren’t afraid of “making waves” or the massive amounts of paperwork, new curricula every few years, or having so much to do that it stops us from connecting with the very kids we work with, would this have happened. we don’t need more criterion-referenced tests, we don’t need personal evaluation instruments that take 50 hours or more, we don’t need to blame the unions and the teachers…we need to take a hard look at our priorities AS A NATION and realize that something needs to change and it’s not the curriculum. instead of piling money into failing banks and auto companies, we need to save our schools and our kids. because, ultimately, the information you can get from those that spend hours every day with your kids…THAT is more important than ANY test score. we are reacting when we need to be intervening. hindsight is always 20/20, but i truly believe there were signs that went unnoticed or worse…unspoken.

musings on the madness…

In Education, Musings, School Psychology, School violence on Saturday, 15 December 2012 at 13:00

the real madness.  not the madness of the occurrences in newtown.  education madness.  how this MIGHT have been avoided.  or at least how i feel i could have done something…were we not focusing on the wrong things.

1.  he has “some” kind of mental illness…

there are only a handful of “mental illnesses” with a higher than average propensity toward violence or carrying out violence. and, even fewer to do something of this magnitude. i have my suspicions as to what, if any, diagnosis, this person has (and, let me give you a clue, it’s not an autism spectrum disorder (asd), a learning disability, or obsessive compulsive disorder (ocd). at any rate, while NO unstable person should have access to a gun, i don’t want people thinking that this boils down to some mental illness and that being an excuse.  unless you are saying “someone MUST have seen the signs” as they have been known and written about for YEARS.

2. we already know the “signs.”  research.  read the literature.  BE INFORMED!

to me, what this shows so very clearly (more than the talk of second amendment rights OR gun control)

3.  i am not advocating that we shouldn’t talk of such things, just not now.

is the need for EARLY INTERVENTION via better early mental health screenings and resources, more education regarding mental health, resources for help…i could go on and on. ironic (but in an horrifically tragic way) that the SCHOOL PSYCHOLOGIST was among those killed.  SHE would have been one of the most qualified to screen, support, and follow children such as these (and, we DO have them). as a school psychologist in the age of education funding cuts and one person doing the work of what was once divided by two or three positions, WE CAN’T DO IT ALL.

4.  you know, i keep asking for the to be one of my super powers, but no luck yet.  maybe i can make it one of my evaluative goals for next year…

unfortunately, things like just taking time to get to know the kids, spending time doing things like reaching out, mentoring, being a real part of a school (as opposed to your FOUR schools) are difficult to come by.  i am confident we (i am speaking as a school psychologist, but counselors, teachers, administrators, etc. can tell you A LOT about your kid/s) can be instrumental in screening and providing resources and intervention if we could just go back to doing all the other things we are good at

5. and, yes, we are good clinicians and do like our assessment, but we are not merely “testers” as much as we have been relegated to the role, we are not taking it gladly

i say this talk needs to be about stopping this crazy education-reform-value-added-data-driven madness and make education and mental health services (especially early INTERVENTION programs, NOT after the fact!) a priority in this country.  

6.  look i love sports and entertainment as much as the next, but there’s something off about a country that cares more about “reality” tv than the reality their kids face every day…the place they spend the majority of their time every week

PEOPLE! many times we are with your children more than you are! we mold YOUR most precious asset.

7.  it really should be.  if not, check yourself

why in the world would you want to CUT funding to education? why would you want LESS resources allotted? i don’t get it.  we pour money into entertainment, sports, alcohol…education should come first. these are kids. YOUR kids.

i just think we are focusing on the wrong things.  in the end, children and adults lost their lives.  other children will be haunted by this for days, weeks, months, and years to come.  how many kids need to be killed?  we can stop this now.

NOW is the time…

In Education, School Psychology, School violence on Saturday, 15 December 2012 at 09:14

Now Is the Time to Talk Guns, Mental Illness

By: Roland Martin


Editor’s note: Roland Martin is a syndicated columnist and author of “The First: President Barack Obama’s Road to the White House.” He is a commentator for the TV One cable network and host/managing editor of its Sunday morning news show, “Washington Watch with Roland Martin.”

(CNN) — Enough!

Enough with putting off tomorrow what we should be talking about today. Enough with being afraid to step on someone’s delicate sensibilities when it comes to the Second Amendment. Enough with elected leaders who are too cowardly to confront the National Rifle Association and their ardent supporters. Enough with moms and dads and brothers and sisters and aunts and uncles and pastors and deacons who are afraid to make public the private anguish of mental illness.

Enough! Enough! Enough!

Enough with just asking for thoughts and prayers. Enough with just hugging our children. Enough with leaving flowers and teddy bears at a makeshift memorial.

It’s time for action. It’s time for people of conscience to, in the words of the late civil rights activist Fannie Lou Hamer, be “sick and tired of being sick and tired.”

America, 20 of our children are dead, and we are all paralyzed, not knowing what to do or say. I’ve shed tears for the lives of the innocent children and adults at Sandy Hook Elementary School in Newtown, Connecticut. Many of you have likely done the same.

We witnessed the president of the United States, Barack Obama, stand before the country fighting back tears talking about the lives lost, reminding of us other tragedies involving guns and sick individuals behind the trigger.

And every time this happened, those who refuse to discuss gun control are quick to say, “Now is not the time.”

One day after Kansas City Chiefs linebacker Jovan Belcher shot and killed his girlfriend, Kasandra Perkins, NBC Sports anchor Bob Costas said it was time to talk about this nation’s fascination with guns. Instead of being hailed as an honest communicator, he was vilified for having the audacity to raise the subject at the halftime of a football game.

Have we become such a nation of cowards that we are desperate to not discuss a real issue, instead saying, “Please, shut up so I can watch the game?”

Yet today, we are glued to the television, unable to turn from the scene in Newtown, Connecticut, eager to find every new detail as to what led to the horrific mass murder of a classroom full of kindergartners.

It wasn’t time to talk about this when Rep. Gabby Giffords was shot in the head, and six others were killed in January 2011. It wasn’t time in July 2012 when 12 people were blown away in a movie theater in Colorado. Seven were killed at a Sikh temple near Milwaukee near August, and we were told then, “Now is not the time.”

So, please, exactly when is the time?

This nation, whether we want to admit it not, is one that is fascinated and enraptured with guns. It courses through our veins like heroin shooting through the arms of an addict. We love to see it in our movies, video games, on television, and then we’ll fiercely defend the right to bear arms, all while flagrantly waving the U.S. Constitution in the face of anyone who objects.

There is absolutely no reason why we need as many guns in America. None. It simply shouldn’t be the way of life others are so quick to defend. There is absolutely no doubt that we need tough and stringent gun control. Not solely to prevent murders like those in Connecticut, but to remove the option when someone is angered, depressed or in the case of too many, mentally ill.

And that’s the second issue that it’s time that we come to grips with in this country: We are a nation that has chosen to either medicate or ignore altogether.

“They have a few screws loose.” “You know he’s off his rocker.” We’ve heard all of the terms. We often laugh and dismiss the mentally ill in America, choosing to cross the street when we see the homeless veteran screaming and cussing at anyone who walks by. When it’s time for budget cuts, those most vulnerable often get thrown out first.

For years American cities, counties and states have shirked their responsibility when it comes to the mentally ill, choosing to abandon helping them, but quick to build a new prison to incarcerate them when a law is broken.

Now we wait to see if the Newtown, Connecticut, killer will be the latest Jared Lee Loughner (Gabby Giffords), Seung-Hui Cho (Virginia Tech), or James Holmes (Colorado movie theater all individuals who were described as mentally unstable.

Too often the warning signs were there, but ignored for one reason or another.

Could any of these tragedies have been prevented? No one knows for sure. But I sure as hell would rather try than have to be a first responder and look a parent in the eye and say, “Sir or ma’am, I’m sorry. But your baby is dead, killed in the classroom along with 19 other classmates.”

See, now is the time that they are having that conversation. Now is the time those parents are grieving the loss of their babies. Now is the time parents in Newtown, Connecticut are eschewing Christmas plans to prepare for a funeral.

America, now is the time for us to stop living in denial. We must address guns. We must address mental illness. We must have the courage and conviction to put aside our political views and deal with the task at hand.


Retrieved from: http://www.cnn.com/2012/12/14/opinion/martin-gun-control/index.html

Early identification for individuals at risk for antisocial personality disorder

In General Psychology, School Psychology on Saturday, 15 December 2012 at 06:39

Early identification for individuals at risk for antisocial personality disorder

Jonathan Hill, MRCPsych


Background Antisocial personality disorder is usually preceded by serious and persistent conduct problems starting in early childhood, and so there is little difficulty in identifying an at-risk group.

Aims To address six key areas concerning the relationship between early conduct problems and antisocial personality disorder.

Method Review of recent research into early identification of and intervention in child conduct problems, following up to possible adult antisocial behaviour.

Results Conduct problems are predictive of antisocial personality disorder independently of the associated adverse family and social factors. Prediction could be aided through identification of subtypes of conduct problems. There is limited evidence on which children have problems that are likely to persist and which will improve; children who desist from early conduct problems and those with onset in adolescence are also vulnerable as adults.

Conclusions The predictive power of the childhood precursors of antisocial personality disorder provides ample justification for early intervention. Greater understanding of subgroups within the broad category of antisocial children and adults should assist with devising and targeting interventions.

The identification of childhood precursors of adult psychiatric disorders offers the possibility of early intervention and hence prevention. In the case of antisocial personality disorder the early indicators are remarkably clear. Starting with Robins’ (1966) classic follow-up of children referred to a clinic for conduct problems, numerous studies have shown that persistent and pervasive aggressive and disruptive behaviours seen before the age of 11 years are strongly associated with persistence of antisocial behaviours through adolescence and into adult life. As Robins described, the risk extends far beyond antisocial behaviours to unstable relationships, unreliable parenting and underachievement in education and at work (Moffitt et al, 2002). This broad constellation of difficulties is reflected in DSM—IV antisocial personality disorder (American Psychiatric Association, 1994). Furthermore, children who do not have conduct problems are very unlikely to subsequently develop antisocial personality disorder (which is rare without a history of conduct problems). Conduct disorder is a specific diagnosis within DSM—IV, which requires antisocial acts seen generally in older children and adolescents. In this paper the terms ‘conduct problems’ and ‘the conduct disorders’ are used to denote serious oppositional, aggressive or antisocial behaviours whether or not they meet DSM criteria for conduct disorder.


Selective review of findings published over the past 10 years in childhood predictors of antisocial personality disorder, and consideration of issues still to be addressed in relation to early identification of individuals at risk.


Clinical policy

From a clinical and policy perspective, the strength of the continuity from conduct problems to antisocial personality disorder is ample grounds for making strenuous efforts to prevent the appearance of aggressive and disruptive behaviours in young children, and to intervene early once they have been identified. It is not the purpose of this paper to review the evidence for the effectiveness of prevention programmes and of early interventions for conduct problems, but a brief summary highlights the need for further refinements in early identification. A small number of adequately designed randomised controlled trials of preventive programmes to reduce conduct problems have been carried out, some of which have yielded promising results. Equally, whereas there have been some significant improvements, often the effects have been quite small; and some studies have shown no benefits (LeMarquand et al, 2001). There is substantial support for the effectiveness of parent management training programmes in reducing overall levels of conduct problems in children (Kazdin, 2000), and for the effectiveness of stimulants where conduct problems are associated with attention-deficit hyperactivity disorder (ADHD) (Swanson et al, 2001). Nevertheless, there has been considerable variability in outcomes. Parent training has been found to be less effective for the higher-risk families characterised by socio-economic disadvantage, marital discord or single parent status, high parental stress and maternal unresolved loss or trauma (Routh et al, 1995Kazdin, 1997). Children with more severe or chronic problems or with comorbid conditions are less likely to do well (Ruma et al, 1996). Evidence of the long-term effectiveness of psychosocial treatments for conduct problems, and of stimulants for conduct problems comorbid with ADHD, is lacking.

Early identification

It may be that the problem will be solved simply through better treatment techniques; however, attention to six issues in early identification may also be of value in generating ideas for the development of interventions. First, conduct problems in young children are associated with many other adverse factors such as ineffective parenting practices, discordant and unstable families, poor peer relationships and educational failure. It is important to clarify whether it is the child’s disorder that requires early identification, or these associated factors or both. Second, conduct problems in childhood are generally identified on the basis of a broad cluster of behaviours. The identification of subtypes may lead to a better understanding of underlying mechanisms, and hence to improved matching of treatment to clinical needs. Third, in approximately 50% of children with early conduct problems these do not persist into adolescence and adult life. Ways of distinguishing persisters and desisters are needed. Fourth, given the intractability of behaviour problems in some young children, we need to ask whether identification at an earlier age is possible. Fifth, the adult outcomes of children who show early conduct problems and then desist, and of those whose problems start in adolescence, need to be considered. Finally, we need to attend to the adult outcomes that we are attempting to anticipate. It may be that specific antisocial outcomes have different antecedents from those of antisocial personality disorder.

What is predictive?

It is possible that, because conduct problems are associated with a wide range of adverse individual, family and social factors, the conduct problems per seare not the antecedents of antisocial personality disorder but are markers for these other difficulties that are the true antecedents. In general, the evidence supports conduct problems as true antecedents (Farrington et al, 1990). For example, studies that have assessed both conduct problems and quality of peer relationships, and then followed children over several years, have consistently found that early conduct problems predict later antisocial behaviours (Tremblay et al, 1995Woodward & Fergusson, 1999). By contrast, the role of peer relationships has been less clear. This should not, however, be interpreted to mean that the associated factors are unimportant. For example in the Dunedin Multidisciplinary Health and Development Study, violent crime at the age of 18 years was predicted by the combination of temperamental lack of control (quick to show negative emotions when frustrated, poor impulse control) and number of changes of parental figure before the age of 13 years, which probably reflected a range of family adversities (Henry et al, 1996).

Sources of heterogeneity in the conduct disorders

Longitudinal studies from childhood to adulthood have used a wide range of ways to characterise conduct problems. Generally they have made use of summary scores generated from a range of questionnaires completed by teachers and parents (Farrington et al, 1990Fergusson et al, 1996Moffitt et al, 1996). The consistency of the findings may suggest that it does not matter much how the problem is defined. Equally, there are pointers to potentially important kinds of heterogeneity. Children with conduct problems and hyperactivity/inattention differ from those with ‘ pure’ conduct disorder in that their problems are more severe and likely to persist, and they are more likely to have neuropsychological deficits (Lynam, 1996). Lynam (1998) has argued that children with attention-deficit hyperactivity problems are ‘fledgling psychopaths’, implying that they are more likely to show in adult life the combination of callousness, superficial charm and antisocial behaviour that characterises a sub-group of adults with antisocial personality disorder. Frick and colleagues give priority to callous—unemotional traits in childhood. In a series of studies they have demonstrated that children with antisocial problems who exhibit these traits differ from other children with antisocial problems (Barry et al, 2000) in apparently having fewer verbal deficits (Loney et al, 1998) and in coming from families that are not characterised by dysfunctional parenting practices seen generally in the conduct disorders (Wootton et al, 1997). Children exhibiting callous—unemotional traits may also have a deficit in processing behavioural evidence of distress in others. Associations between scores assessing callous and unemotional characteristics and a reduced ability to recognise fear and sadness have been shown in young adolescents recruited in mainstream schools and children with identified emotional and behavioural problems (Blair & Coles, 2003;Stevens et al, 2001).

Loeber et al (1993) have proposed that three contrasting patterns of childhood antisocial problems reflect different pathways for different behaviour patterns: an ‘overt’ pathway characterised by bullying, followed by early fighting and proceeding to more serious violence; a ‘covert’ pathway starting with lying and stealing, and going on to more serious damage to property; and an ‘ authority conflict’ pathway in which oppositional and defiant behaviours are prominent.

A further distinction, between ‘reactive’ and ‘ proactive’ antisocial behaviours, cuts across this three-category typology. Reactive acts occur in response to actual or perceived threat from others, whereas proactive behaviours are initiated by the individuals (Dodge & Coie, 1987). Reactive aggression is thought to involve angry retaliation, in contrast to the cold unprovoked calculation of proactive aggression. Dodge et al (1997) reported that, compared with children showing proactive aggression, ‘reactive’ children were more likely to have been physically abused, to have poor peer relationships, to have shown aggression from an earlier age and to have attention-deficit and hyperactivity symptoms. A central idea in Dodge’s model is that reactive aggression is mediated by a readiness to perceive hostile intent in the actions of others. However, the evidence for this is inconsistent. At this stage these can be considered as promising subtypes that may lead to a more precise specification of mechanisms, and hence provide pointers to different kinds of intervention. Longitudinal studies to determine whether they differ in course are needed.

Who are the persisters and desisters?

We have already referred to the poor outlook of children with both conduct disorder and ADHD symptoms. On the basis of retrospective reports within a large epidemiological study, Robins & Price (1991) found that the number of childhood antisocial problems is associated with risk of antisocial personality disorder. Studies within childhood provide some further clues regarding risk of persistence. Loeber et al (2000) found that early fighting and hyperactivity predicted persistence of antisocial behaviours over a 6-year period among boys referred for conduct problems. In a prospective study of a representative general population sample from ages 7-9 years to 14-16 years, persisters had the highest levels of family adversity and lower IQ and self-esteem (Fergussonet al, 1996). Children with early conduct problems that did not persist had levels of these risk factors that were intermediate between those of persisters and of children who lacked early behavioural problems. Persisters were more likely than those whose early antisocial behaviours had remitted to have a deviant peer group in adolescence. Whether this was a reflection or a cause of persistence is not clear; however, it is consistent with Sampson and Laub’s argument that a key factor in determining persistence may be the presence or absence of social bonds and controls (Sampson & Laub, 1994).

Earlier predictors

We might suppose that, given the stability of conduct problems from the age of 3 years onwards, earlier precursors should be readily identifiable. However, the findings have been inconsistent. For example, the idea has been extensively investigated that early ‘difficult’ temperament, comprising traits such as predominantly negative emotions and ready frustration, contributes to irritable parenting, which in turn increases the risk for conduct problems. Studies using assessments of temperament based on parental reports have yielded some positive findings, but these are vulnerable to parental attributions. Recent studies have failed to demonstrate consistently that observational measures of temperament made in the first year of life predict later conduct problems (Belsky et al, 1998Aguilar et al, 2000). Early attachment difficulties might be expected to increase the risk for later conduct problems. Here again the evidence is not convincing (Hill, 2002). It is likely that the quality of parenting in infancy is predictive of later conduct problems (Belsky et al, 1998) and it may be that the most promising approaches to the identification of early predictors will examine specific interactions between infant characteristics and early social experience (Shaw et al, 1996Belsky et al, 1998).

Desisters and later onsets

We have focused so far on boys who show early conduct problems that persist into adult life. It has generally been assumed that those whose conduct problems remit have ‘recovered’. However, recent evidence from the Dunedin Study suggests that although these children are not at increased risk for antisocial outcomes, they are by no means free of difficulties (Moffitt et al, 2002). At the age of 26 years they had higher rates of depression and anxiety disorders, both self- and informant-rated, and they were socially isolated, with few friends. They shared the poor educational and work records of the life-course persistent group who were antisocial as adults. Likewise, those with onset in adolescence, provisionally termed by Moffitt ‘ adolescence limited’, were not free of problems by the age of 26 years. Compared with those who were not significantly antisocial in childhood or adolescence, these young men had higher rates of documented and self-reported drug and property crimes, and their informants reported more depression and anxiety symptoms.

Heterogeneity within antisocial personality disorder

Thus far in this paper the assumption has been made that the DSM-IV antisocial personality disorder category best summarises the antisocial outcomes of interest. There is little doubt that it succeeds as a broad-brush characterisation of antisocial behaviour and associated wider social dysfunction. However, it lacks specificity. In common with all DSM diagnoses, it requires the presence of a number of maladaptive behaviours or mental states identified from a larger set. Hence, the requirements can be met in numerous ways. This may limit the investigation of more specific causal factors, and so a more precise specification of the adult antisocial outcomes may be needed.

The identification of ‘psychopathic disorder’ makes the point. DSM-IV antisocial personality disorder is present in 50-80% of convicted offenders, but a much smaller group of 15-30% are judged to have characteristics such as grandiosity, callousness, deceitfulness, shallow affect and lack of remorse (Hart & Hare, 1989). These individuals are more likely than other offenders to have a history of severe and violent offences, and they may also have a distinctive deficit in interpersonal sensitivity. In a comparison of prisoners with and without psychopathic disorder, the groups did not differ in their ability to attribute correctly happiness, sadness and embarrassment to protagonists in short stories. However, in response to guilt stories, those with psychopathic disorder were more likely to attribute happiness or indifference to the protagonists (Blair et al, 1995). It has been proposed that psychopathy is associated with a failure to inhibit aggression in response to signs of distress in others, arising from a deficit in processing behavioural evidence of that distress (Blair et al, 1997). There is supportive evidence that, compared with other offenders, adults with psychopathic disorder have reduced autonomic responses to distress cues (Chaplin et al, 1995Blair et al, 1997). As we saw earlier, a subgroup of children with antisocial problems who exhibit callous—unemotional traits has been identified that may parallel adults with psychopathic disorder. No studies have yet tested for continuity between child and adult psychopathic traits by following these children into adult life.


Children at risk for future antisocial personality disorder are readily identified, but evidence on the long-term effectiveness of prevention and treatment programmes is limited. Some progress has been made in identifying subgroups of children with antisocial problems in which different causal processes operate, and therefore for which there are different treatment needs. The available research does not yet tell us whether differences in the patterning, or associated features, of childhood conduct problems are predictive of distinctive adult outcomes. If is possible that this review was subject to selection bias.

Clinical Implications and Limitations


  • The identification and treatment of conduct problems in early childhood are central to the prevention of antisocial personality disorder.
  • The conduct disorders are heterogeneous in the patterning and course of symptoms, with implications for matching treatment to type of problem.
  • There is considerable heterogeneity within antisocial personality disorder, so that there is a need to identify specific early indicators of particular adult antisocial outcomes.


  • Most of the research reviewed in the article refers to antisocial personality disorder in males.
  • Few longitudinal studies of general populations have included sufficient numbers of antisocial children to explore heterogeneity.
  • Little is known about very early indicators of children at risk for the development of conduct problems.


  • * Paper presented at the second conference of the British and Irish Group for the Study of Personality Disorders (BIGSPD), University of Leicester, UK, 31 January to 3 February 2001.


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  1. Moffitt, T. E., Caspi, A., Dickson, N., et al (1996) Childhood-onset versus adolescent-onset antisocial conduct in males: natural history from 3 to 18. Development and Psychopathology8, 399 -424.
  1. Moffitt, T. E., Caspi, A., Harrington, H., et al (2002) Males on the life-course persistent and adolescence-limited antisocial pathways: follow-up at age 26. Development and Psychopathology14, 179 -207.
  1. Robins, L. N. (1966) Deviant Children Grown-Up: A Sociological and Psychiatric Study of Sociopathic Personalities. MD: Williams and Wilkins.
  1. Robins, L. N. & Price, R. K. (1991) Adult disorders predicted by childhood conduct problems: results from the NIMH Epidemiological Catchment Area Project. Psychiatry542, 116 -132.
  1. Routh, C. P., Hill, J. W., Steele, H., et al (1995) Maternal attachment status, psychosocial stressors and problem behaviour: follow-up after parent training courses for conduct disorder. Journal of Child Psychology and Psychiatry36, 1179 -1198.
  1. Ruma, P. R., Burke, R. V. & Thompson, R. W. (1996) Group parent training: is it effective for children of all ages? Behavior Therapy27, 159-169.
  1. Sampson, R. J. & Laub, J. H. (1994) Urban poverty and the family context of delinquency: a new look at structure and process in a classic study. Child Development65, 523 -540.
  1. Shaw, D. S., Owens, E. B., Vondra, J. I., et al (1996) Early risk factors and pathways in the development of early disruptive behavioural problems.Development and Psychopathology8, 679 -700.
  1. Stevens, D., Charman, T. & Blair, R. J. R. (2001) Recognition of emotion in facial expressions and vocal tones in children with psychopathic tendencies. Journal of Genetic Psychology162, 201 -211.
  1. Swanson, J. M., Kraemer, H. C., Hinshaw, S. P., et al (2001) Clinical relevance of the primary findings of the MTA: success rates based on severity of ADHD and ODD symptoms at the end of treatment. Journal of the American Academy of Child and Adolescent Psychiatry40, 168 -179.
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i have no words right now…

In General Psychology, School Psychology, School violence, Uncategorized on Friday, 14 December 2012 at 17:14



DSM-V…out with the old and in with the new…

In Autism Spectrum Disorders, General Psychology, Psychiatry, School Psychology on Thursday, 6 December 2012 at 11:20


inclusion for all?

In Autism Spectrum Disorders, School Psychology, Special Education on Tuesday, 27 November 2012 at 15:36

Study Questions Benefits of Inlcusion for Autism

By: Lee Wilkinson, Ph.D.

The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) (P.L. 108-446) (idea.ed.gov/) guarantees a free and appropriate public education (FAPE) in the least restrictive environment (LRE) for every student with a disability. The LRE provision mandates that “to the maximum extent appropriate, children with disabilities, including children in public or private institutions or other care facilities, are educated with children who are not disabled, and special classes, separate schooling, or other removal of children with disabilities from the regular educational environment occurs only when the nature or severity of the disability of a child is such that education in regular classes with the use of supplementary aids and services cannot be achieved satisfactorily.” In general,inclusion (or inclusive education) with typical peers is often considered to be the best placement option for students with disabilities. However, a study published in Pediatrics, the official journal of the American Academy of Pediatrics, calls into question whether or not inclusive education actually leads to better outcomes in the long term for children with autism.

The Study

Researchers from the University of Alabama at Birmingham and Johns Hopkins University sought to determine whether the proportion of time spent in an inclusive educational setting, a process indicator of the quality of schooling for children with autism, improves key outcomes. The participants were 484 children and youth educated in special education with a primary diagnosis of autism in the National Longitudinal Transition Study-2 (NLTS2). The NLTS2 is a 10-year study of youth with disabilities who were receiving special education services in public or state-supported special schools. The NLTS2 uses a nationally representative sample of youth in special education who were between the ages of 13 and 16 on December 1, 2000.

The primary exposure of interest in this analysis was the proportion of time the youth spent in a general education classroom. A school program questionnaire was used to collect data on the courses that each student took during the 2003 school year and whether each course was taken in a general education or special education classroom. The proportion of time spent in an inclusive setting was categorized as 0%, 1% to 74%, or 75% to 100% of courses taken in a general education classroom.

Key Outcomes

Three outcomes were assessed in the study’s analysis: (1) not dropping out of high school, (2) any college attendance, and (3) a cognitive functional scale. Youth were coded as not dropping out if the parent reported that they graduated, received a certificate or General Educational Development certificate, or were still in high school at the time of data collection. Any college attendance was based on parent report of whether the youth attended any type of postsecondary school in the previous 2 years, including postsecondary classes to earn a high school degree, a 2-year or 4-year college, or postsecondary vocational school. The functional cognitive scale measured a combination of parent-reported cognitive, sensory, and motor skills used in performing daily activities (such as counting change). Parents rated their child on a scale of 1 (“not at all well”) to 4 (“very well”) for each of these skills. The rating for each skill was added to create the functional cognitive scale, which ranged from 4 (not at all well for any of the skills) to 16 (very well for all of the skills).


Compared with children with autism who were not educated in an inclusive setting, children with autism who spent 75% to 100% of their time in a general education classroom were no more likely to attend college, not drop out of high school, or have an improved functional cognitive score after controlling for key confounders. The researchers state that “In general, our analyses suggest that inclusivity does not improve educational or functional outcomes for children with autism.” They also note that although the link between inclusivity and outcome remains weak, “inclusive education” that is well implemented and supported might have substantial benefits. Recommendations for further research include investigation of educational and functional outcomes from data on large samples of children in real-world settings. There is also a need for developing future indicators to measure the “quality” of special education for children with autism. This includes a careful description of the learning environment and experiences within and between communities as well as key measures specific to the characteristics and education of children with autism. The authors conclude that the study illustrates the challenges of understanding the effect of real-world services and treatments and that a “A fuller understanding of inclusively and other potential measures of educational quality may have to wait for better data and methods.”

Foster, E. M., & Pearson, E. (2012). Inclusivity an Indicator of Quality of Care for Children With Autism in Special Education? Pediatrics, 130, S179-S184.

Lee A. Wilkinson, PhD is the author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome from Jessica Kingsley Publishers.

Dr. Wilkinson can be reached at bestpracticeautism.com.

Retrieved from: http://www.examiner.com/article/study-questions-benefits-of-inclusion-for-autism

Court Decision on Independent Educational Evaluations

In Education, School Psychology, Special Education on Tuesday, 27 November 2012 at 15:29

Court Upholds IDEA Rule on Independent Evaluations

By Mark Walsh

A federal appeals court has upheld a longtime U.S. Department of Education regulation requiring school districts, under certain circumstances, to reimburse parents for independent educational evaluations of their children with disabilities.

A three-judge panel of the U.S. Court of Appeals for the 11th Circuit, in Atlanta, ruled unanimously to uphold the regulation promulgated under the Individuals with Disabilities Education Act, the main federal special education law. The rule requires districts or other public agencies to pay for independent evaluations when parents disagree with the public agency’s initial assessment of their child.

The regulation has been in place in various forms since 1977, two years after the passage of the precursor to the IDEA.

The challenge to the rule comes in the case of Alabama parents who squabbled with the Jefferson County school district over the education of their son, identified as A.C., who has a disability not specified in court papers. In 2005, the parents disagreed with the district’s evaluation of their son and obtained an independent evaluation. The district refused to reimburse the parents, who then pursued relief through administrative channels and then the federal courts.

In court, the Jefferson County district challenged the authority of the U.S. secretary of education to promulgate the regulation requiring that parents be reimbursed for independent evaluations. The board argued that the regulation exceeded the scope of the IDEA because the statute itself did not authorize such reimbursements. The U.S. Department of Justice, in a friend-of-the-court brief filed in the 11th Circuit on the parents’ side, argued that the regulation was valid and was entitled to deference.

A federal district court rejected the board’s arguments, and in its Nov. 21 decision in Phillip C.v. Jefferson County Board of Education, the 11th Circuit appeals panel affirmed.

The appeals court noted that Congress, in effect, endorsed the earliest version of the independent evaluation regulation in a 1983 reauthorization of the special education law, and that lawmakers have further renewed the IDEA in 1990, 1997, and 2004 “without altering a parent’s right to a publicly funded [independent educational evaluation].”

“Under the re-enactment doctrine, Congress is presumed to be aware of an administrative or judicial interpretation of a statute and to adopt that interpretation when it re-enacts a statute without change,” the 11th Circuit court said. “Accordingly, Congress has clearly evinced its intent that parents have the right to obtain an IEE at public expense.”

Retrieved from: http://blogs.edweek.org/edweek/school_law/2012/11/court_upholds_idea_rule_on_ind.html?intc=bs&cmp=SOC-SHR-GEN

autism grows up…

In Autism Spectrum Disorders, School Psychology on Friday, 23 November 2012 at 17:19

Experts Brace for a Wave of Autistic Adults

by: Erin Allday

Guido Abenes appreciates their concern, but he’d really like his parents to stop worrying about him.

He’s 25, he says, and he’s doing fine. But he’s also autistic, part of the generation of young adults who were born during the first big wave of autism cases in the United States two decades ago and are now struggling to strike out on their own.

“I tell them sometimes, ‘Stop it, I’m doing things, I’m resourceful,’ ” said Abenes, who is a student at Cal State East Bay. “They’re getting the message, I think. But they still worry.”

Abenes, who wants to be a therapist someday and travel the world, is fortunate. He joined the College Internship Program in Berkeley, which provides him with a two-bedroom apartment he shares with a roommate, along with intensive, daily academic and developmental support to help him continue to thrive into adulthood.

But Abenes’ situation is unusual, say autism advocates and experts, who are bracing for a flood of adults with autism who lack the support they had as children, and are entering a world that isn’t ready for them.

Skyrocketing rates

It was in the late 1980s and early ’90s that rates of autism started skyrocketing in the United States. A condition that once was considered rare, with fewer than 2 cases per 1,000 births in the United States, is now thought to afflict 1 in 88 children, according to the Centers for Disease Control and Prevention. It’s unclear exactly what has caused the increase, but factors could include greater awareness and better diagnosing of the condition, as well as an actual rise in cases, perhaps related to environmental factors.

For those born in that first wave and now entering adulthood, it’s a tough, uncertain future. Some, like Abenes, will go to college or find jobs and eventually move out on their own.

But most will not, studies show. Most will continue to live at home and will, at best, find part-time, minimum-wage work – or no work at all. Many will suffer setbacks in their condition. Two recent studies found that only about a third of autistic young adults had jobs or went to school.

“A majority of our adults are underserved or not served at all. They can’t access the same services as adults that they had as children,” said Jim Ball, board chairman of the Autism Society, a national advocacy group. “We are doing a lot for our kids, but these kids are going to live to 80 or 90 years old – they’re going to live the majority of their lives as adults. What are we doing for them in that realm?”

Twenty-two years old is an important turning point for many young people with autism. That’s when they officially age out of the public school system that offered them educational and other supportive services.

Kids in the middle

Kids with intellectual disabilities – most notably, an IQ under 70 – often have post-high school opportunities for continued improvement and some measure of independent living. Most of them will continue to get supportive care daily for the rest of their adult lives from state and federal programs.

And the young people at the opposite end of the spectrum – the ones identified as having Asperger’s syndrome, a mild form of autism, who may have above-average IQs or skills that will aid them in college and careers – often manage adult life just fine.

It’s the ones in the middle who suffer the most, autism experts said. They don’t have enough of a disability to get major supportive care, but they’re clearly disabled enough that they have a hard time finding, and keeping, jobs or attending college classes.

“These are kids who seem like they could do things and be successful, and they just end up staying at home because there are very few resources for them,” said Dr. Carl Feinstein, director of the Stanford Autism Center at Lucile Packard Children’s Hospital.

“Their parents are frustrated because they don’t know how to help and they aren’t so happy with their kids living in their home,” he said. “Meanwhile, these kids grew up thinking they would have a driver’s license and an apartment of their own, and they’d get married and have all these things that aren’t happening.”

That’s where something like Berkeley’s College Internship Program comes in. The program was started in the 1980s on the East Coast by a man who was diagnosed with Asperger’s in his 50s. It serves young adults ages 18 to 26 who have autism or other types of learning disabilities, many of whom fall in that middle range of needing support.

Preparation for life

The goal of the program is to provide the support services these young people may need to be successful in school and start a career, as well as teaching life skills to help them become independent adults.

The students live in housing provided by the program in downtown Berkeley, and they usually attend classes at nearby community colleges. At the program center, students get lessons in cooking and banking and other basic living skills. They learn how to budget their time, how to apply for jobs and how to get along with co-workers and bosses.

But it’s expensive: The program costs $30,000 to $70,000 a year, not including housing or tuition at other academic institutions. Scholarships are available and insurance may cover some or all of the expenses.

For those who can afford it, or whose parents have the time and energy to seek the help, there are other, similar programs. Many college campuses, including Cal State East Bay, offer extra services for autistic students.

Some businesses are starting special programs for hiring autistic employees, especially if those employees possess skills like focus and an attention to detail that can come hand-in-hand with autism. One company, Palo Alto-based Semperical, is based entirely around a model of hiring high-functioning autistic employees as test engineers.

But those jobs and support programs aren’t large and there aren’t many of them. Meanwhile, the group of autistic adults needing these services is only going to grow. The first generation is entering its 20s – but they’ll be hitting middle age soon enough, and there are even larger generations on their heels.

Worried parents

It’s not just a problem for the autistic children and adults, but for their families – especially for the parents, many of whom worry they won’t be able to care for their adult children much longer.

“I hear from parents in the Baby Boomer generation who have kids in their 30s now,” said Kurt Ohifs, executive director of Pacific Autism Center for Education in Santa Clara. “They come to me and say, ‘I’m afraid to die, because who’s going to care for my son or daughter?’

Retrieved from: http://www.sfgate.com/health/article/Experts-brace-for-wave-of-autistic-adults-3921071.php#ixzz2D58PzgN2

Sensory Integration Therapy ineffective for Treatment of Autism, Study Finds

In Autism Spectrum Disorders, General Psychology, School Psychology on Wednesday, 21 November 2012 at 14:35

Sensory Integration Therapy ineffective for Treatment of Autism, Study Finds

By: Pasha Bahsoun

Parents of children with autism are faced with many options when it comes to therapy and education for their children, from applied behavior analysis (ABA) to floortime. A new study out of the University of Texas at Austin has found that one form of therapy, sensory integration therapy, is ineffective for the treatment of autism.

Many children on the autism spectrum experience sensitivities towards sensory stimuli such as sounds, light and touch. Those who practice sensory integration therapy seek to offer children small amounts of sensory input with the goal of improving how their nervous system reacts to certain stimuli. This is accomplished through objects such as weighted blankets, weighted vests and swings.

The researchers evaluated 25 studies on sensory integration therapy and found that there was no scientific evidence that symptoms of autism were improved. Three of the studies suggested that the treatment was effective and 14 studies reported no benefits. They went further to indicate that several of the studies, including the three studies reporting positive results, had serious methodological flaws. Therefore, based on this evaluation, they were not able to support sensory integration therapy for the treatment of children with autism.

The researchers noted that sensory integration therapy may even exacerbate the symptoms of autism because it provides reinforcement for unwanted behaviors by providing access to desirable activities, like bouncing on balls, and being allowed to escape tasks like homework. In addition, children who receive this form of therapy are oftentimes also receiving other behavioral interventions simultaneously, which would undermine their effectiveness.

Agencies providing services for children with autism, as well as insurance companies, are now mandating that only evidence and research-based practices be used in interventions, which at the moment is only applied behavior analysis.

If you enjoy my articles, you can follow me on Twitter:@ThePashaB.

Retrieved from: http://www.examiner.com/article/sensory-integration-therapy-ineffective-for-treatment-of-autism-study-finds


Sensory Integration Treatment for Autism Spectrum Disorders: A Systematic Review


Intervention studies involving the use of sensory integration therapy (SIT) were systematically identified and analyzed. Twenty-five studies were described in terms of: (a) participant characteristics, (b) assessments used to identify sensory deficits or behavioral functions, (c) dependent variables, (d) intervention procedures, (e) intervention outcomes, and (f) certainty of evidence. Overall, 3 of the reviewed studies suggested that SIT was effective, 8 studies found mixed results, and 14 studies reported no benefits related to SIT. Many of the reviewed studies, including the 3 studies reporting positive results, had serious methodological flaws. Therefore, the current evidence-base does not support the use of SIT in the education and treatment of children with autism spectrum disorders (ASD). Practitioners and agencies serving children with ASD that endeavor, or are mandated, to use research-based, or scientifically-based, interventions should not use SIT outside of carefully controlled research.


► Research involving sensory integration therapy to autism was reviewed. ► Out of 25 studies, three studies had positive results. ► Serious methodological flaws were found across studies. ► The evidence-base does not support the use of SIT in the treatment of autism.

Retrieved from: http://www.sciencedirect.com/science/article/pii/S1750946712000074

Girls with ADHD often diagnosed later than boys

In ADHD, ADHD Adult, ADHD child/adolescent, ADHD stimulant treatment, Child/Adolescent Psychology, Psychiatry, School Psychology on Saturday, 10 November 2012 at 11:06

Girls with ADHD often diagnosed later than boys.

the illustrious “IQ”

In Education, Neuropsychology, School Psychology on Saturday, 10 November 2012 at 10:52

the debate as to what is iq as well as whether or not it can be accurately measured has been around long before i got into this field and i do think it will be around long after i retire.  here is one side…

urther Evidence That IQ Does Not Measure Intelligence

By: Analee Newitz

Every ten years, the average IQ goes up by about 3 points. Psychologist James Flynn has spent decades documenting this odd fact, which was eventually dubbed the Flynn Effect. The question is, does the Flynn Effect mean we’re getting smarter? Not according to Flynn, who argues that the effect simply reveals that IQ measures teachable skills rather than innate ones. As education changed over time, kids got better at standardized tests like the IQ test. And so their scores went up.

But some thinkers cling to the idea that IQ measures an inborn intelligence that transcends culture and schooling. If that’s true, one would expect that the most abstract, “culture free” elements of IQ testing wouldn’t be subject to the Flynn Effect. But they are. And now two psychology researchers have shown why that is.

What Changed Our Minds?

I talked to Florida State psychology researcher Ainsley Mitchum, who has just published a studyin Journal of Experimental Psychology with his colleague Mark Fox. They looked at changes in how people scored the Raven’s Matrices parts of IQ tests, which measure people’s ability to think abstractly. Often these tests involve charts and pattern recognition, and are widely believed to be free of all cultural biases.

Mitchum and Fox were lucky enough to find a report detailing the scores of a group of young people who took the Raven’s Progressive Matrices test in the 1960s, and compared it to scores of young people taking the test now. The results were consistent with the Flynn Effect. “People who got average scores 50 years ago would be below average now,” Mitchum said. But how could this be?

In modern cultures, more emphasis is being placed on abstraction. Students learn algebra at an earlier age than they used to, for instance, but in addition our everyday lives are full of abstractions. Mitchum noted that simply using “folders” on your computer desktop requires a level of abstract thinking that people would rarely encounter in daily life fifty years ago. “This pattern makes you more comfortable breaking away from the surface level features of objects,” Mitchum explained. So a more high-tech culture, combined with differences in education, enhance people’s ability to engage in abstract reasoning.

Test your abstract thinking with a test very similar to Raven’s Progressive Matrices.

Abstraction Is Cultural

Over time, our ability to deal with abstract information is changing. What this means is that abstraction itself is cultural, and it changes over time just as many other aspects of our culture do. It’s very likely that previous generations were more literal-minded in their thinking. They dealt more often with objects in the real world, and had no need to understand things like avatars — icons that represent a real-world object — or how to translate a tiny flick of the wrist into movement on a screen.

Said Mitchum:

Psychologists want to tell you that intelligence measures an essential ability that’s native to people – a real quantity, not something that’s cultural. So they constructed these tests that were designed to not be sensitive to culture [like the Raven’s Progressive Matrices]. But intelligence can’t be looked at as something separate from culture. We argue that the changes in test scores don’t translate into changes in ability. It doesn’t mean we’re evolving into more intelligent people. The data suggest that what’s changing is knowledge. There’s a type of abstract knowledge that people have now in greater numbers. People on average didn’t have that 50 years ago.

Mitchum noted that you can see this transformation far beyond the boundaries of technology. Even the meta-humor you see on television, such as the referential humor on Community, is far more abstract than what people enjoyed in The Three Stooges half a century ago.

If there’s a substantial change in technology in the future, Mitchum believes we’ll see another shift in the way people learn and deal with information “It shouldn’t be surprising to people that when our environment changes rapidly, the way that people deal with information changes with it,” Mitchum said. “We map onto our environment. So what we’re seeing on IQ tests is the footprint of that.”

You Are Probably Not Much Smarter or Dumber Than Anybody Else

If your IQ is largely the result of your environment, what does that say about intelligence itself? Aren’t some of us born with more mental gifts than others? Probably not, said Mitchum. “Neurotypical adults probably don’t differ as much as it seems,” he said. Certainly some people have cognitive deficiencies from head injuries, neurochemical syndromes, and developmental disabilities. But people whose brains are in the typical range probably don’t differ very much in terms of innate mental abilities. What we measure as “intelligence” on IQ tests is mostly environment and experience.

That doesn’t mean IQ tests are useless. In fact, they are very helpful for tracking the way our cultures are shifting over time. These tests are helping us track the way modes of thought are passed on from one generation to the next, mutating as they go.


You can read a PDF of Mitchum and Fox’s paper on IQ scores here.

James Flynn, Are We Getting Smarter? Rising IQ in the Twenty-First Century (Cambridge: Cambridge University Press, 2012)

Retrieved from: http://io9.com/5959058/further-evidence-that-iq-does-not-measure-intelligence

Helping Your Child Study

In Education, Pedagogy, School Psychology on Saturday, 10 November 2012 at 08:56


By Claire Marketos

‘Tell me, I forget. Teach me, I remember. Involve me, I understand.’- Chinese proverb

Imagine you’re nine years old. Your first test is on Friday, and you have your book in front of you. Your mom tells you to revise your study material. Feeling helpless and ill-equipped, you stare at the pages, hoping that somehow you will remember something.  Soon, you lose interest and begin playing with the dog. It is not surprising that studying turns into a lonely, repetitive chore you dread – one that stifles your natural curiosity. In the words of a fifth grader, ‘Studying is not fun.’

While most schools teach learners how to study, they do so in isolated classes, instead of integrating studying skills in daily lessons and notes, so that it becomes a part of learning. It is extremely frustrating and difficult for a fourth grader to try to apply what he has learned about studying in general to specific subjects. Your child therefore depends on you for help.

Between a rock and a hard place

Instead of treating it as yet another chore, unleash your creativity and approach study time as a fun, inspiring opportunity to bond with your children. By adopting an innovative way of thinking, your child will feel more connected to you and you will empower him with an enquiring mind for life.

Children are curious and instinctively explore their environment to find out more about the world around them. By appealing to your child’s innate inquisitiveness, you can turn studying into an incidental part of his daily activities. Show him how studying can be an enjoyable way to find answers to questions. For example, use Zulu words while preparing the salad. And while driving, throw out a question “Why is it important for people to pay taxes?” This will stimulate critical thinking and lively discussion. By collaborating with your child, you will demonstrate positive ways of interacting with others to find solutions to problems. That’s a useful attribute for almost any career your child may choose later on in life.

Learning how to study effectively is a process that has to be modified according to your child’s needs. There are so many factors influencing the way children study and how well they recall the material later. Whether your child is tired after a long day at school or just battling to concentrate on the task at hand, physical and emotional well-being plays a big role as does personality.

Stumbling blocks

  • If you are going through a divorce and your child worries about this, he will struggle to apply himself.
  • If your child is physically unwell, he may need medical intervention before he is able to concentrate.
  • If your child has learning difficulties, he may require remedial assistance before he can study effectively.
  • If your child has experienced trauma or grief, his ability to retain and recall knowledge will be impaired. Play therapy, among other treatments, may be necessary to provide him with the support he needs.

How children learn

If you are going to be of any help, you need to understand how children learn and how their brains function.

Passively reading through notes, is not the most effective way to study. Research shows that children learn most efficiently by being actively involved in the learning experience. By involving your child personally through writing, speaking, or experiencing the material, you will enable him to recollect it better. Walking around while acting out their assignment helps some students retain information. Others require bright colourful pictures and concrete objects to stimulate their minds. Try different methods, until you find the best way for your child to study- the more memorable and pleasurable the experience, the better the recall.

Learning in a group also greatly improves children’s comprehension, Russian psychologist Lev Vygotsky discovered in his early twentieth century research. He also found that children who worked together were able to explain what they had learned in the context of their daily lives.

Studying with, you, his peers, or teacher, helps your child clarify ideas, ask questions, and understand the subject. Vygotsky calls this ‘reciprocal teaching’ and initially used it to teach reading. So, leaving your child to study alone in his bedroom is not the greatest way to help him retain knowledge. He will recall so much more if he can visualize the material while talking about it to you.

Sensory stimulation theorist Dugan Laird found that children can remember seventy-five percent of material presented in visual form such as pictures and diagrams, thirteen percent that is auditory and twelve percent through the other senses.

Have some fun

·        Help your child turn his study notes into colourful diagrams, mind maps, and cartoons.

·        Involve the whole family by using different voices to speak into a tape recorder, saying important facts. Let your child listen to the tape in the car or while taking a bath.

·        Use visual and auditory stimulus from the computer, to help your child remember more of his notes. A great idea is to use your child’s notes to  put together a PowerPoint presentation on the computer. It is time consuming, but as a visual aid it can be invaluable.

 Feeding and stimulating the brain  

The brain is the source not only of our intellect, but also of our emotions. It is who we are, and our moods influence our ability to concentrate. If your child is feeling pressured or frustrated, he will find it harder to retain information. We have all heard how we only use a small part of our brains and that we rarely reach our full potential. So how can you help stimulate your child’s brain to enhance learning and memory?

The brain comprise mainly fat, so it requires ‘good fats’ and protein to function efficiently. Eating a healthy meal of fish rich in omega-3 fatty acids before studying will help fuel the brain.  A favourite memory booster recommended by American Mensa supervisory psychologist Dr. Frank Lawliss is banana and chocolate, preferably eaten together. Other brain foods are water, raw or steamed fruits and vegetables, avocado, whole grains, eggs, nuts, and vitamin D.

Tips to kick start the brain

  • Play marching music and have your child chew gum containing the sugar substitute, xylitol, suggests Lawliss – but avoid gum containing aspartame and sugar.
  • Physical exercise not only relieves stress, it also helps your child breathe more deeply, resulting in more oxygen reaching the brain. Doing a moderate amount of exercise before study will stimulate your child’s brain into action. Too much exercise, on the other hand, will make him feel tired with little energy left to concentrate.
  • Games like chess, charades and building puzzles fires up the mind.
  • Devise games to help your child remember his notes.  Design a quiz show or modify 30 seconds as a revision aid. .
  • Sleep is essential to recharge the mind and help process information- eight to ten hours’ sleep a night is ideal.

Create the right environment

As a child how many times were you told to go and sit at your desk and study? We tend to believe that to study properly we should be seated at a table in a quiet room with good lighting. Good lighting is crucial to avoid eye strain, but children learn in different ways and can study in all sorts of environments. Your child may be able to concentrate better when he walks around or sits on a gym ball with music playing in the background.

Be sensitive and flexible in the way you approach your child’s method of studying. Almost any environment can provide an opportunity to learn, so experiment with different places in the home, until you find those best suited to study. Being able to relax and being comfortable will make the experience more beneficial and pleasant. Nevertheless, trying to study in a room with the television on and other children playing is probably too distracting for most children.


Children with learning difficulties learn more effectively in an environment that is free of clutter, well organised and structured. Have all the necessary stationery available, especially brightly coloured highlighters, dictionaries, and keep a file for notes and pictures. Don’t forget to use the computer as a visual and auditory study aid.

Recent research by Robert A. Bjork, a psychologist at the University of California, Los Angeles found that learning different content in different environments helps to remember the study material better. So learning maths while looking out on to the oak tree in the garden, or history while glancing at the lava lamp, gives the brain many associations with the subject which helps to retain it. “When the outside context is varied, the information is enriched, and this slows down forgetting,” said Dr. Bjork, author of ‘The two-room experiment.’

Instead of focusing on only one aspect of a subject when studying such as vocabulary, Bjork suggests combining various aspects of the subject in one study session as athletes or musicians would. For example: while learning a language alternate between “speaking, vocabulary, and reading.”

Nate Kornell states: “What seems to be happening is that the brain is picking up deeper patterns. It’s picking up what’s similar and what’s different.”

Establish a routine

Routine makes children feel safe and secure. Children like to know with absolute certainty what is expected of them. Having a study routine will do away with questions like, ‘Do I have to study now?’ Remember to also chat about the subject in an informal way outside of study time while grocery shopping, watching the news, or when an interesting fact occurs to you. .

Most children become irritable when they are tired, so it is best not to schedule study time just before bed. Negotiate a time for studying with your child that you know is best suited to your child’s temperament. Some children study well in the afternoon after lunch and free play, while others study better after supper. Try to schedule it for the same time every day, but accommodate extra-murals and playtime. Your child needs a balanced lifestyle- time to pursue other interests and to relax in order to be successful.

Studying for hours on end is not productive. Your child will become tired and de-motivated. Memory and concentration also decrease after a while. Stick to the allotted time, and stop when that time is up. Focus instead on managing the set times efficiently. Allow short breaks to maintain concentration and to let the brain process the information. Tomorrow will provide another opportunity to study. If your child continues to spend hours doing homework and learning, it may be necessary to evaluate your expectations of him, or chat to the teacher to find out whether the workload is too heavy. If he is experiencing difficulties with some of the material, provide him with additional help.

Managing stress

Aspire to stimulating curiosity in your child along with the desire to know more about himself and the world around him, instead of merely aiming for higher grades. Children who leave school with passion and energy are motivated to seize the challenges faced in adulthood, whereas overachievers who tried to please their parents throughout their childhood may feel burned out, stressed and disinclined to pursue their ambitions.

Stressing over homework and studying is counterproductive. A stressed child can’t concentrate or remember what he is studying. Choose to stop stressing about studying and your child will most likely develop a more positive attitude towards it. Waking up early to study on the day of a test is likely to create additional stress- and it will probably be ineffective, since the brain will not have sufficient time to process the crammed information. Sleep is more important at this age than studying at the last minute.

Pressuring your child to obtain higher marks, criticising him, and making him redo work over and over again, is discouraging. Not only is your child less likely to do well, he may also develop feelings of resentment, and rebel by underachieving. Avoid comparing your children, especially across the sexes, since boys and girls learn in different ways. Research shows that children who have controlling, strict parents, tend to have lower self esteem, as they learn that they cannot be trusted to manage themselves. Avoid living vicariously through your children, and make sure your intentions are to help him find his true purpose in life.

Show your child how to relax. Deep breathing, visualizations, yoga, swaying and meditation, are all ways to deal with stress, and so focus better. Explain to your child how to concentrate in class, call on the teacher for help, and get guidelines for tests- this way much of the knowledge needed can be gained in the classroom.

What to avoid

  • putting pressure on your child to get higher marks
  • being overly critical
  • making your child redo work over and over again
  • comparing him to others, particularly a girl to a boy, or a boy to a girl
  • being too controlling
  • living vicariously through a child

What to do

  • Teach your child relaxation techniques such as deep breathing, visualizations, yoga, swaying and meditation
  • encourage your child to concentrate in class
  • teach your child to ask teachers for help
  • make sure your child gets guidelines for tests and exams
  • approach your child’s school notes with a positive attitude and cultivate this attitude in him
  • allow your child to take control of his schedule, helping where necessary
  • give praise where it is due ,without allowing the praise to turn into added pressure

Keeping your child motivated

‘Aw! Why do I have to study?’ moans a sixth grader. Few children are motivated to study. How do you turn this around? What can you do to inspire your child to enjoy studying? Children watch their parents all the time and your child will copy what you do. If you’re positive and enthusiastic and have a probing mind, your child is likely to be more curious and interested in studying. Watching you read or study will encourage them to do the same.

Research shows that the children of loving parents whose expectations are reasonable have higher self- esteem, and are more motivated when it comes to studying. In contrast, the children of parents who pay attention only when they do well tend to have lower self-esteem and less confidence in their own abilities.

We all enjoy being affirmed and praised for our achievements, and you should be generous in your praise. However, research by theorist William Damon from Stanford University shows that constant praise, especially when nothing has really been achieved, actually limits a child’s abilities. Instead, he says, we should ‘guide them towards worthwhile activities and goals that result in credible self esteem.’

Create opportunities for your child to learn from his mistakes, be persistent in the face of adversity, and accomplish things on his own. Imagine the sense of satisfaction he will feel when he takes control of his notes, and rearranges them to be easier to remember. Setting realistic goals and taking steps to achieve them will help motivate your child.

Children have vivid imaginations and can come up with fabulous ideas to help them remember study material. Inspire your child to think laterally as he tackles his notes. Your curiosity and interest in his subjects will stimulate intellectual thought and conversation- a much more enjoyable proposition than merely studying for tests.

We all know how infectious it can be to be around someone who is upbeat and who has a high self esteem. Teach your child the power of positive thinking. Believing in himself, defining who he is and what his abilities are will give him the confidence to overcome stress, especially when studying.

Get creative 

Think outside the box. Engage your child in thinking of novel ways to remember his study notes.

  • When talking with your child about his study notes, add in tidbits of interesting information from your readings and travels. Children love to hear stories, and if you can tell stories relevant to their study material, it will provide a hook to help jog his memory, for example, ‘Mom saw Tutankhamen’s sarcophagus in the British Museum…..’
  • Explain how their notes are relevant to their daily lives, and how as we develop as a society we build on knowledge from the past. Ask ‘what if’ questions to stimulate thinking- for example, ‘What if Thomas Edison hadn’t been curious, and hadn’t kept experimenting to find answers? We may never have discovered electricity. Then there would be so many things we wouldn’t be able to do like……”Challenge your child to come up with uses for electricity.
  • Teach your child to organise his study material, and tackle difficult information first. He doesn’t need to learn work he already knows.
  • Children learn best from notes and diagrams transcribed in their own words and in age-appropriate language. If your child finds his study notes difficult to understand, encourage him to summarise it in his own words. Help him draw mind maps and spider diagrams.
  • Take time to teach your child to read his notes critically. Scan the material to find the most important points. Pose questions and find the answers in the study notes. Write down important points. Being able to read and take notes effectively will be of immense help once your child goes to high school.
  • One picture paints a thousand words, the saying goes. This is especially true when it comes to studying. Always look for a way to represent notes visually. Help your child turn his study notes into colourful pictures and diagrams. For example, if you are studying surface and subsurface water sources, let him draw a diagram showing where the water sources are. These diagrams or pictures can be simple stick figures which don’t take a long time to draw. Use colour to make it more memorable.
  • Use different coloured cards on which to write important information, such as dates. Post the cards behind the toilet door, the car seat, or on the fridge, so that your child can see the information often. Make associations like, ‘Red is 1361BC when people began to settle along the Nile River.’
  • Ask your child to teach you, a teddy, a pet, or other members of the family. To teach, he will need to understand the subject material. Let him use his notes initially, but as the week goes by, let them try without notes. Or as one mother found to her delight, her daughter had rediscovered the karaoke function on the family’s music system. ‘She’s been lecturing to a phantom audience all week,” the mother said.
  • Invent silly rhymes, acronyms and mnemonics with your child to help him remember difficult dates and facts.
  • If your child is musically inclined, he may even make up a rap song from his notes.
  • If your child has good ball skills, let him pin the answers to questions to a wall, and throw tennis balls at the correct answer.
  • Putting on a puppet show for the family can help your child commit information to memory.
  • Film them as they make a documentary on their assignment. They can watch it later for further reinforcement.
  • Drumming is often used these days to help children with learning difficulties. Beating out facts on a drum can make them easier to recall – drumming is relaxing and helps to stimulate the brain.
  • If you can actually visit the place they are learning about, do the experiment, or see the artifact in a museum, your children will easily recall it later.
  • Give your child strategies and tips on how to do well on tests: “Read the questions carefully, underlining key words. Look at the mark allocation. Always answer the question even if you have to make an educated guess.”
  • Guide your child to watch programmes on TV or DVD, and read newspaper articles which show how their study notes are relevant to everyday life, and to reinforce the material they have studied.

For many of us parents studying evokes unpleasant memories, which we wouldn’t want our children to experience. Throw out those old methods that didn’t work for you, and strive to replace them with inspirational ideas that make the learning experience enjoyable and memorable for your children. It is possible to show them that the world provides so many amazing opportunities that they can be part of.

Note to parents: I specifically didn’t use the word ‘work’ when referring to the child’s school notes or study notes as studying should not be viewed as ‘work’ but rather as a means of finding answers to questions.


The IQ Answer  by Dr. Frank Lawliss

Child Development 5th Edition by Laura Berk

This article was first published in the book “Happy Years: A guide for paqrents’ by Abraham Kriel Childcare. The copyright remains with the author Claire Marketos.

This page is sponsored by BLUEKEY– – small & medium business accounting software. Specialists in SAP Business One. info@bluekey.co.za. Toll free 0800 258 3539.

Retrieved from: http://www.inspiredparenting.co.za/NewsCast.aspx?NID=76

Children With Autism Developmentally Normal at 6 Months

In Autism Spectrum Disorders, Neuropsychology, School Psychology, Special Education on Tuesday, 6 November 2012 at 15:24

Children With Autism Developmentally Normal at 6 Months

Pam Harrison

Infants who go on to develop autism spectrum disorder (ASD) are developmentally normal by the age of 6 months, and the earliest signs of developmental disruption are subtle and not specific to autism, prospective, longitudinal data show.

In the largest prospective, longitudinal study to date comparing children with early and later diagnosis of ASD with children without ASD, Rebecca Landa, PhD, Kennedy Krieger Institute, Baltimore, Maryland, and colleagues found that the earliest signs of developmental disruption in children with ASD are likely to be nonspecific to ASD, such as communication or motor delay.

At 6 months, development within both the early-onset ASD children and those with later-onset ASD was comparable both to each other and to non-ASD control children.

“The standard clinical tools that we use to assess early development are not identifying abnormalities in babies midinfancy that go on and have autism,” Dr. Landa told Medscape Medical News.

“So the assumption that any infant who is going to have autism would be obviously autistic in midinfancy is a myth because this just isn’t happening.”

The study was published online October 30 in Child Development.

Developmental Trajectory

Studying the developmental trajectory of multiple systems — motor, cognitive, social, and language — in the first 3 years of life in children with and without ASD could shed light on the susceptibility of the developing brain to the impact of genetic, epigenetic, and environmental factors in children with ASD.

Therefore, the investigators examined language and motor development in children aged 6 to 36 months and social development from 14 to 24 months, the time during which ASD regression usually occurs.

Participants included 204 infant siblings of children with autism as well as 31 infants with no family history of autism.

The Mullen Scales of Early Learning provided measures of motor and language functioning, and the Communication and Symbolic Behavior Scales Developmental Profile provided measures of 2 social functions related to the diagnostic criteria for ASD.

By 14 months, the early-onset group exhibited significantly lower expressive language and shared positive affect scores than the later ASD group (P < .001 for both endpoints).

By 18 months, the early ASD group also had greater delays in receptive (P < .001) and expressive language development (P = .001) compared with the later-onset group.

Gap Closes

At 24 months, however, “the gap between the Early- and Later-ASD groups had closed, and no differences from the Later-ASD group were detected at subsequent ages,” the investigators write.

These findings indicate that the early-ASD group manifested earlier development disruption, especially as it affected language and social functioning, than children with later-onset ASD but that they were no more severely affected than later-onset ASD children at either 30 or 36 months.

“There are different developmental pathways to ASD,” said Dr. Landa.

Children who manifest symptoms by their first birthday are more globally impaired at 14 months than children who have later manifestations of ASD.

On the other hand, children with later-onset ASD do have some signs of developmental delay at 14 months, but these signs are not specific to ASD and include motor and communications delays.

However, by 36 months, both groups are comparable in their social and developmental characteristics, she added.

“Many pediatricians screen for autism at around 18 months, as the American Academy of Pediatrics recommends, but they don’t continue screening after that,” Dr. Landa said.

“But screening should be repeated through early childhood, and if concerning signs of delay associated with ASD are observed in a child who scores normally on standardized tests, further assessment is warranted.”

Need for Early Intervention

Deborah Fein, PhD, University of Connecticut, in Storrs, told Medscape Medical News that it is important to appreciate that the ASD children included in this study were infant siblings of children with ASD.

As such, “this is not the population at large, so these findings might not be generalizable,” Dr. Fein said

On the other hand, infant siblings of children with ASD are a small enough population that they could be followed very closely throughout their preschool years, and subtle delays in motor or social communication development could be identified.

Other children at risk for ASD, including premature infants or infants who have had obstetric complications, are also at risk for ASD and could be similarly followed, she added.

“There are preclinical signs of ASD, but in a sense, it doesn’t matter because if you know a child has some mild delay in cognitive or motor or social communication function, you still want to deliver early interventions,” she said.

“Then if full-blown autism does emerge, you’ll be on top of it.”

The authors and Dr. Fein have disclosed no relevant financial relationships.

Child Dev. Published online October 30, 2012. Abstract

Retrieved from: http://www.medscape.com/viewarticle/773990?src=nl_topic

common core…another educational phase or here to stay?

In Education, Education advocacy, Pedagogy, School Psychology, School reform, Special Education on Saturday, 3 November 2012 at 08:23

Scores Drop on Ky.’s Common Core-Aligned Tests

By Andrew Ujifusa

Results from new state tests in Kentucky—the first in the nation explicitly tied to the Common Core State Standards—show that the share of students scoring “proficient” or better in reading and math dropped by roughly a third or more in both elementary and middle school the first year the tests were given.

Kentucky in 2010 was the first state to adopt the common core in English/language arts and mathematics, and the assessment results released last week for the 2011-12 school year are being closely watched by school officials and policymakers nationwide for what they may reveal about how the common standards may affect student achievement in coming years. So far, 46 states have adopted the English/language arts common standards; 45 states have done so in math.

Two federally funded consortia are working on assessments based on the common standards, and those tests are not slated to be fully ready for schools until 2014-15. But Kentucky’s tests are generally understood to be linked to the common core.

“What you’re seeing in Kentucky is a predictor of what you’re going to see in the other states, as the assessments roll out next year and the year after,” said Gene Wilhoit, the executive director of the Washington-based Council of Chief State School Officers, which spearheaded the common-core initiative along with the National Governors Association. Mr. Wilhoit was also previously Kentucky’s education commissioner.

Falling Scores

The drop in Kentucky’s scores conform to what state education officials had expected: that students in grades 3-8 taking the new, more-rigorous Kentucky Performance Rating of Education Progress, or K-PREP, would not be able to reach their achievement levels of prior years. Kentucky began implementing the common standards in the 2011-12 school year.

The biggest drop came at the elementary level. On the previous Kentucky Core Content Tests, 76 percent of elementary students scored proficient or higher in reading in the 2010-11 school year. That percentage plunged to 48 percent for the K-PREP results in the 2011-12 school year, a drop-off in proficiency of more than a third.

In 2010-11, 73 percent of elementary students were proficient or better in math, but that fell to 40.4 percent. That drop represents a 45 percent decline in the share of proficient students.

Middle schoolers’ decline was a little less steep. In reading, they dropped from a 70 percent proficiency level in 2010-11 to 46.8 percent in 2011-12, a decline of a third. In math, proficiency-or-better levels declined slightly more than that, from 65 percent in 2010-11 to 40.6 percent in 2011-12.

Overall, students in grades 3-8 demonstrated somewhat higher proficiency levels in reading than in math.

When new tests are introduced, states can expect scores to fall in most cases, said Douglas McRae, a retired assessment designer who helped build California’s testing system. “When you change the measure, change the tests, then you interrupt the continuity of trend data over time. That’s the fundamental thing that happens,” he said.

Kentucky developed its tests in conjunction with Pearson, the New York City-based education and testing company, which is also crafting curricula for the common core.

K-PREP does not represent the final, polished version of common-core assessments. The Partnership for Assessment of Readiness for College and Careers, or PARCC, and theSmarter Balanced Assessment Consortium are designing the tests that most states have signed on to for gauging students’ mastery of the common standards nationwide beginning in the 2014-15 school year. (Kentucky belongs to the PARCC consortium.)

But Mr. Wilhoit said K-PREP represents the state’s best effort, along with Pearson’s, “to develop an assessment that was representative of the common core.”

Proficiency drops also occurred in the end-of-course tests in reading and math Kentucky administered to high school students. But those declines were smaller than those in the earlier grades, and a state study shows that while the K-PREP tests are completely aligned with the common standards, the high school end-of-course tests (from the ACT QualityCore program) are only about 80 percent to 85 percent aligned to the standards.

The proficiency level in high school reading dropped from 65 percent to 52.2 percent (a figure 6 percentage points higher than the state’s prediction), based on the end-of-course tests, while proficiency in math fell from 46 percent to 40 percent on the Algebra 2 test, beating the state’s prediction by 4 percentage points.

Commissioner’s Take

Kentucky Education Commissioner Terry Holliday said that students beat the state’s predictions for both the K-PREP and end-of-course exams. Using a statistical model that predicted ACT performance based on academic results in reading and math in 2011, for example, the state estimated a 36 percentage-point drop in elementary reading scores in 2011-12, instead of the actual 28-point drop.

“We’re just a little bit above our prediction, which I think is a pretty good testament to our teaching,” Mr. Holliday said.

Earlier exposure to the common standards, he suggested, would help younger students at first.

“It’s going to take a little longer to see middle and high school growth on these tests,” Mr. Holliday said. “It’ll take about five years to see an overall growth of significance at all levels.”

But based on national benchmarks, the new K-PREP tests may not have been rigorous enough, said Richard Innes, an education policy analyst at the Bluegrass Institute, a conservative-leaning Lexington, Ky.-based think tank.

In a report released the week of Oct. 29 for the institute, Mr. Innes compared the K-PREP math scores for 8th graders this year (41.5 percent proficient or better) with the results on the ACT Explore test this year (30.5 percent) and the National Assessment of Educational Progress proficiency levels in 2011 (31 percent).

“There are questions in my mind as to whether they are rigorous enough in several areas,” he said. Different subject tests appeared to have been more rigorous in different grade levels, Mr. Innes said. The math in middle schools appears to be the subject where K-PREP is less rigorous than NAEP or Explore tests, he noted. He drew the same conclusion about K-PREP reading results at the elementary school level.

One number that went up: the proportion of students qualifying as college and/or career ready, which rose to 47 percent in 2011-12, from 38 percent the previous year. Mr. Holliday attributed that rise to the state creating more career pathways and bringing more introductory college courses to high school seniors to prevent the need for postsecondary remediation.

“To get that much improvement in the first year is extraordinary, I think,” said Bob King, the president of the Kentucky Council on Postsecondary Education, based in Frankfort, Ky.

Preparing the Public

To combat a potential public backlash from the lower scores, Mr. Holliday noted that he had enlisted the Kentucky Chamber of Commerce as part of a yearlong public relations campaign.

Florida schools earlier this year endured a significant backlash when proficiency rates on its state writing tests dropped by two-thirds after a tougher grading system was introduced, forcing the state school board to change the test’s cutoff score retroactively.

“We knew the scores were going to drop, but this is the right thing for our kids, our schools,” he said. “You’re going to see quite a different reaction in Kentucky because we watched what happened everywhere else,” Mr. Holliday said.

But the transition for schools can be disappointing for some, especially in the short term. Carmen Coleman, the superintendent of the Danville Independent district, said she was proud of how the school system had progressed over the past three years from a ranking of 110th to 24th among the state’s 174 districts, only to tumble back to the middle of the pack in the newest rankings of school districts.

“It’s a tough blow for teachers and students,” she said.

The Kentucky PTA has received grant money from the National PTA to educate parents and others about the new standards, but the state group’s president, Teri Gale, said it doesn’t mean people won’t be caught off guard by the lower-than-usual results.

“They’ve heard us talk about it. They’ve seen the newscasts and everything,” Ms. Gale said. “But until they actually see the scores, I don’t think it’s going to hit home that this is what we were talking about.

Coverage of the implementation of the Common Core State Standards and the common assessments is supported in part by a grant from the GE Foundation, atwww.ge.com/foundation.

Retrieved from: http://www.edweek.org/ew/articles/2012/11/02/11standards.h32.html?tkn=MUUFgXKG6BeBJ5plrgNFi1pr%2BpWNe%2BzfFckH&cmp=clp-edweek&utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+EducationWeekWidgetFeed+%28Education+Week%3A+Free+Widget+Feed%29


adhd and exercise…more positive evidence of benefits

In ADHD, ADHD Adult, ADHD child/adolescent, Education, Fitness/Health, School Psychology on Friday, 2 November 2012 at 06:49

A Little Exercise May Help Kids With ADHD to Focus

Published November 01, 2012


Twenty minutes of exercise may help kids with attention-deficit hyperactivity disorder (ADHD) settle in to read or solve a math problem, new research suggests.

The small study, of 40 eight- to 10-year-olds, looked only at the short-term effects of a single bout of exercise. And researchers caution that they are not saying exercise is the answer to ADHD.

But it seems that exercise may at least do no harm to kids’ ability to focus, they say. And further studies should look into whether it’s a good option for managing some children’s ADHD.

“This is only a first study,” said lead researcher Matthew B. Pontifex, of Michigan State University in East Lansing.

“We need to learn how long the effects last, and how exercise might combine with or compare to traditional ADHD treatments” like stimulant medications, Pontifex explained.

He noted that there’s been a lot of research into the relationship between habitual exercise and adults’ thinking and memory, particularly older adults’. But little is known about kids, even though some parents, teachers and doctors have advocated exercise for helping children with ADHD.

So for their study, Pontifex and his colleagues recruited 20 children with diagnosed or suspected ADHD, and 20 ADHD-free kids of the same age and family-income level.

All of the children took a standard test of their ability to ignore distractions and stay focused on a simple task at hand – the main “aspect of cognition” that troubles kids with ADHD, Pontifex noted. The kids also took standard tests of reading, spelling and math skills.

Each child took the tests after either 20 minutes of treadmill exercise or 20 minutes of quiet reading (on separate days).

Overall, the study found, both groups of children performed better after exercise than after reading.

On the test of focusing ability, the ADHD group was correct on about 80 percent of responses after reading, versus about 84 percent after exercise. Kids without ADHD performed better – reaching about a 90 percent correct rate after exercise.

Similarly, both groups of kids scored higher on their reading and math tests after exercise, versus post-reading.

It’s hard to say what those higher one-time scores could mean in real life, according to Pontifex, who published his results in The Journal of Pediatrics.

One of the big questions is whether regular exercise would have lasting effects on kids’ ability to focus or their school performance, he said.

And why would exercise help children, with or without ADHD, focus? “We really don’t know the mechanisms right now,” Pontifex said.

But there is a theory that the attention problems of ADHD are related to an “underarousal” of the central nervous system. It’s possible that a bout of exercise helps kids zero in on a specific task, at least in the short term.

Parents and experts alike are becoming more and more interested in alternatives to drugs for ADHD, Pontifex noted. It’s estimated that 44 percent of U.S. children with the disorder are not on any medication for it.

And even when kids are using medication, additional treatments may help them cut down their doses. Pontifex said future studies should look at whether exercise fits that bill.

“We’re not suggesting that exercise is a replacement, or that parents should pull their kids off of their medication,” Pontifex said.

But, he added, they could encourage their child to be active for the overall health benefits, and talk with their doctor about whether exercise could help manage ADHD specifically.

“Exercise is beneficial for all children,” Pontifex noted. “We’re providing some evidence that there’s an additional benefit on cognition.”

Retrieved from: http://www.foxnews.com/health/2012/11/01/little-exercise-may-help-kids-with-adhd-focus/?utm_source=twitterfeed&utm_medium=twitter#ixzz2B3qU8bOp

asd…intervene early, see positive changes.

In Autism Spectrum Disorders, Psychiatry, School Psychology, Special Education on Friday, 2 November 2012 at 06:04

Early Autism Intervention Normalizes Brain Activity

Pam Harrison

Early behavioral intervention is associated with normalized patterns of brain activity along with improvements in social behavior in young children with autism spectrum disorder (ASD), a new nationwide study shows.

The multicentre study conducted by investigators at the University of North Carolina, Chapel Hill, showed that 73% of children who received the Early Start Denver Model (ESDM) intervention showed greater brain activation when viewing faces than when viewing objects.

This was very similar to typically developing children, 71% of whom showed the same brain activation pattern when viewing faces rather than objects.

In contrast, 64% of ASD children who received the control community intervention showed a greater response to objects than to faces, the opposite response from that seen in ESDM recipients.

Previous research has shown that ASD children typically respond more to nonsocial than to social stimuli.

“Those of us in the intervention field always assumed that improving children’s learning had to change brain function — that is how we learn,” Sally Rogers, PhD, University of California, Davis, MIND Institute, told Medscape Medical News.

“This evidence confirms how we understand learning — it’s not a surface change [but rather] a change in brain activation and patterns of brain connection.

“So I think behavioral intervention can be seen as a biological intervention because it changes the biology of brain activity.”

The study is published in the November issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

Intensive Therapy

A previous report from a randomized trial indicated that ESDM, a developmental behavioral intervention, resulted in gains in IQ, language, and adaptive behavior in children with ASD (Pediatrics 2010;125:e17-e23).

The current report describes electroencephalographic (EEG) activity, a secondary outcome measurement from the same study.

A total of 48 children aged 18 to 30 months who had been diagnosed with ASD were randomly assigned to receive ESDM or referral to community intervention for 2 years.

Children randomly assigned to ESDM received the intervention for 2 hours, twice a day, 5 days a week for 2 years.

The community intervention group received comprehensive diagnostic evaluations, interventional recommendations, and community referrals.

The children enrolled in the study represented the full range of severity of ASD in early childhood, and as Dr. Rogers emphasized, they were not picked because they had mild symptoms.

Two types of brain activity measurements were collected in response to social (faces) and nonsocial (toys) stimuli.

“The first reflected early-stage perceptual processing of faces versus objects,” the authors state, “[and] the second set of measurements reflected the degree of attention engagement…and active cognitive processing of the stimulus.”

Children randomly assigned to either intervention arm did not differ from typical children in early-stage perceptual face processing, the researchers point out.

In contrast, EEG measurements reflecting patterns of attention engagement and active cognitive processing of social stimuli showed that children who received the ESDM intervention exhibited brain activity that was comparable to age-matched typical children in that both allotted greater attentional and cognitive resources during viewing of social stimuli than to nonsocial stimuli.

These patterns were different from patterns observed in children who received the community intervention, who allotted greater attentional and cognitive resources to viewing of nonsocial stimuli than to social stimuli.

Powerful Intervention

“This is a very powerful intervention,” Dr. Rogers emphasized. For example, almost none of the children had speech prior to the ESDM intervention.

The average IQ prior to the intervention was only 65, she added.

Following the intervention, the average IQ was in the 80s.

“This means that these children no longer had intellectual disability as a group, so it was a huge change, and almost all of the children were able to use language effectively and functionally as well,” Dr. Rogers said.

Children with good EEG data who received the ESDM intervention also differed significantly on behavioral outcomes in autism symptoms, IQ, language, and adaptive and social behavior.

“Many public services provide interventions for young ASD children, but too many children are getting a hodgepodge of interventions,” Dr. Rogers observed.

“But national standards require we use evidence-based intervention, and what this study demonstrated is the importance of using evidence-based interventions and delivering them with enough intensity so they can have maximal effect.”

New Target, Potential Biomarker

Thomas Insel, MD, National Institute of Mental Health, noted in a press release on the study that this may be the first demonstration that a behavioral intervention for autism is associated with changes in brain function as well as positive changes in behavior.

“By studying changes in the neural response to faces, Dawson and her colleagues have identified a new target and a potential biomarker that can guide treatment development,” Dr. Insel added.

The study was funded by the National Institute of Mental Health. Dr. Dawson and Dr. Rogers are authors of the book Early Start Denver Model for Young Children with Autism, from which they receive royalties. Dr. Insel has disclosed no relevant financial relationships.

J Am Acad Child Adolesc Psychiatry. 2012:51:1150-1160. Abstract

Retrieved from: http://www.medscape.com/viewarticle/773641

Early Behavioral Intervention Is Associated With Normalized Brain Activity in Young Children With Autism 






A previously published randomized clinical trial indicated that a developmental behavioral intervention, the Early Start Denver Model (ESDM), resulted in gains in IQ, language, and adaptive behavior of children with autism spectrum disorder. This report describes a secondary outcome measurement from this trial, EEG activity.


Forty-eight 18- to 30-month-old children with autism spectrum disorder were randomized to receive the ESDM or referral to community intervention for 2 years. After the intervention (age 48 to 77 months), EEG activity (event-related potentials and spectral power) was measured during the presentation of faces versus objects. Age-matched typical children were also assessed.

ResultsThe ESDM group exhibited greater improvements in autism symptoms, IQ, language, and adaptive and social behaviors than the community intervention group. The ESDM group and typical children showed a shorter Nc latency and increased cortical activation (decreased α power and increased θ power) when viewing faces, whereas the community intervention group showed the opposite pattern (shorter latency event-related potential [ERP] and greater cortical activation when viewing objects). Greater cortical activation while viewing faces was associated with improved social behavior.


This was the first trial to demonstrate that early behavioral intervention is associated with normalized patterns of brain activity, which is associated with improvements in social behavior, in young children with autism spectrum disorder.

Retrieved from: http://www.jaacap.com/article/S0890-8567(12)00643-0/abstract

Homework Help, Timing is Vital: Setting Yourself and Your Child Up for Success

In ADHD, ADHD child/adolescent, Education, School Psychology, Special Education on Friday, 2 November 2012 at 05:59

Homework Help, Timing is Vital: Setting Yourself and Your Child Up for Success

Every household and every student is different so we ask that when you are reviewing these guidelines think about what might need to be adjusted in your household to be sure that we are setting up for success! First off, if you are reading this you are already on your way because step 1 is being committed to improving. Whether this is the first year of homework or a teen or college student, creating new habits takes consistency and commitment; if this sounds like too much work or not the easy answer you were hoping keep reading, it is still a start!

Timing is key:  Most people with ADHD are pros at putting off things that are more difficult or take longer to complete. You will hear and may have heard almost every excuse, this isn’t about excuses, this is about accomplishment.We work on upfront contracting and positive reinforcement and reward systems. Work with the student to set the intention in advance and then stick to it. Discuss with the student the expectations of homework such as how and when you  will review daily assignments before and after they are completed. Then set a time frame for which they need to be completed by. It has to be specific and it has to fit your household. Try to use events that occur daily rather than a specific time on the clock to ensure the child has a clear understanding of what that timeframe means.

Here is one example: Child arrives home from school and they show you their work from the day and what assignments they have as soon as they walk in the door. They then have 20 minutes for snack and free time. Once the 20 minutes is up all work  must be completed before any extra activities or electronics are used including cell phone, TV and video games.

Dinner is typically not a priority for most children and even teens/adults, it is a necessity, so avoid using the “finish your homework before dinner” because that affects you and the family time not the students needs, wants or desires. Most often this upsets the person making dinner and turns into an argument and dinner time a negotiation rather than much-needed family time.

During the childs snack/free time try to estimate in your mind what they will need help with more than other things and prepare yourself to be an active observer and helper as needed so that they feel both supported and monitored. Let them  know that you are there if they need help with a certain area and if you have something to accomplish discuss that with the student before their snack.

Example: Student has some geography work that you know they typically struggle with and some reading and math that looks like they should handle with minimal guidance and you have dinner to make. “It looks like the countries you have to identify and the geography assignment is something that might be new to you. I have to make dinner, but am happy to work with you on it or be here for questions if you need, would this help? Could we work on that assignment first so then I can get dinner going while you finish up the rest of your work?”

If a child has something going on that you are aware of in the evening, remind them in the morning that because of the event they will have to skip free time and have their snack while they do their homework so that they can still make the special event.Giving them a heads up helps them to prepare rather than meltdown or feel unexpectedly rushed.

We talked about removing electronics before homework is completed, YOU HAVE TO STICK TO THIS! Set up the students space or their launch pad is vital. We will talk more about how to accomplish this in future posts but the key is to stick with it!

If your child is completing homework at after school or a relatives house be sure and still have guidelines set up for when they walk in the door at home. Is there remediation of a particular subject that they should do a few times a week? Be sure you are at least reviewing the work first thing and then coming up with your strategies from there. The more consistent your expectations and behavior the less likely you will have blow ups and missed work. Your child wants to please you and be successful even if they don’t let you know that!

Retrieved from: http://focusmdblog.com/2012/10/18/homework-help-timing-is-vital-setting-yourself-and-your-child-up-for-success/


important information regarding child abuse

In Child/Adolescent Psychology, Psychiatry, School Psychology on Wednesday, 31 October 2012 at 08:12

please be proactive if you suspect child abuse.  you are not determining that there is definitive abuse if you report, that determination is made by the respective agencies responsible for child welfare.  ignoring it will not make the problem go away and can have deleterious effects for children.

How Child Abuse Primes the Brain for Future Mental Illness

By: Maia Szalvitz

Child maltreatment has been called the tobacco industry of mental health. Much the way smoking directly causes or triggers predispositions for physical disease, early abuse may contribute to virtually all types of mental illness.

Now, in the largest study yet to use brain scans to show the effects of child abuse, researchers have found specific changes in key regions in and around the hippocampus in the brains of young adults who were maltreated or neglected in childhood. These changes may leave victims more vulnerable to depression, addiction and post-traumatic stress disorder (PTSD), the study suggests.

Harvard researchers led by Dr. Martin Teicher studied nearly 200 people aged 18 to 25, who were mainly middle class and well-educated. They were recruited through newspaper and transit ads for a study on “memories of childhood.” Because the authors wanted to look specifically at the results of abuse and neglect, people who had suffered other types of trauma like car accidents or gang violence were excluded.

MORE: Study: How Chronic Stress Can Lead to Depression

Child maltreatment often leads to conditions like depression and PTSD, so the researchers specifically included people with those diagnoses. However, the study excluded severely addicted people and people on psychiatric medications, because brain changes related to the drugs could obscure the findings.

Overall, about 25% of participants had suffered major depression at some point in their lives and 7% had been diagnosed with PTSD. But among the 16% of participants who had suffered three or more types of child maltreatment  — for example, physical abuse, neglect and verbal abuse — the situation was much worse. Most of them — 53% — had suffered depression and 40% had had full or partial PTSD.

The aftermath of that trauma could be seen in their brain scans, whether or not the young adults had developed diagnosable disorders. Regardless of their mental health status, formerly maltreated youth showed reductions in volume of about 6% on average in two parts of the hippocampus, and 4% reductions in regions called the subiculum and presubiculum, compared with people who had not been abused.

That’s where this study begins to tie together loose ends seen in prior research. Previous data have suggested that the high levels of stress hormones associated with child maltreatment can damage the hippocampus, which may in turn affect people’s ability to cope with stress later in life. In other words, early stress makes the brain less resilient to the effects of later stress. “We suspect that [the reductions we saw are] a consequence of maltreatment and a risk factor for developing PTSD following exposure to further traumas,” the authors write.

Indeed, brain scans of adults with depression and PTSD often show reductions in size in the hippocampus. Although earlier research on abused children did not find the same changes, animal studies on early life stress have suggested that measurable differences in the hippocampus may not arise until after puberty. The new study suggests that the same is true for humans.

MORE: Nurturing Moms May Boost Children’s Brain Growth

The findings also help elucidate a possible pathway from maltreatment to PTSD, depression and addiction. The subiculum is uniquely positioned to affect all of these conditions. Receiving output from the hippocampus, it helps determine both behavioral and biochemical responses to stress.

If, for example, the best thing to do in a stressful situation is flee, the subiculum sends a signal shouting “run” to the appropriate brain regions. But the subiculum is also involved in regulating another brain system that, when overactive during chronic high stress such as abuse, produces toxic levels of neurotransmitters that kill brain cells — particularly in the hippocampus.

It can be a counterproductive feedback loop: high levels of stress hormones can lead to cell death in the very regions that are supposed to tell the system to stop production.

What this means is that chronic maltreatment can set the stress system permanently on high alert. That may be useful in some cases — for example, for soldiers who must react quickly during combat or for children trying to avoid their abusers — but over the long term, the dysregulation increases risk for psychological problems like depression and PTSD.

MORE: Boxer Quanitta Underwood’s Inspiring Fight Against Sexual Abuse — and for Olympic Gold

The subiculum also regulates the stress response of a key dopamine network, which may have implications for addiction risk. “It is presumably through this pathway that stress exposure interacts with the dopaminergic reward system to produce stress-induced craving and stress-induced relapse,” the authors write.

In other words, dysregulation of the stress system might lead to intensified feelings of anxiety, fear or lack of pleasure, which may in turn prompt people to escape into alcohol or other drugs.

With nearly 4 million children evaluated for child abuse or neglect in the U.S. every year — a problem that costs the U.S. $124 billion in lost productivity and health, child welfare and criminal justice costs — child maltreatment isn’t something we can afford to ignore.

Even among the most resilient survivors, the aftereffects of abuse may linger. Not only are such children at later risk for mental illness, but because of the way trauma affects the stress system, they are also more vulnerable to developing chronic diseases like diabetes, high blood pressure, heart attack and stroke.

We can do better for our kids.

The study was published in the Proceedings of the National Academy of Sciences.

Maia Szalavitz is a health writer at TIME.com. Find her on Twitter at @maiasz. You can also continue the discussion on TIME Healthland’s Facebook page and on Twitter at @TIMEHealthland.
Retrieved from: http://healthland.time.com/2012/02/15/how-child-abuse-primes-the-brain-for-future-mental-illness/#ixzz2AsTNhYSB

adhd…under and over diagnosed.

In ADHD, ADHD Adult, ADHD child/adolescent, Psychiatry, School Psychology on Sunday, 21 October 2012 at 09:47

Attention Deficit Hyperactivity Disorder is Both Under and Over Diagnosed, Study Suggests

ScienceDaily (Oct. 19, 2012)

Attention Deficit Hyperactivity Disorder is both under and over diagnosed. That’s the result of one of the largest studies conducted on ADHD in the United States, published in the Journal of Attention Disorders.

A substantial number of children being treated for ADHD may not have the disorder, while many children who do have the symptoms are going untreated, according to the 10-year Project to Learn about ADHD in Youth (PLAY) study funded by the National Center on Birth Defects and Developmental Disabilities of the Centers of Disease Control and Prevention

“Childhood ADHD is a major public health problem. Many studies rely on parent reporting of an ADHD diagnosis, which is a function of both the child’s access to care in order to be diagnosed, and the parent’s perception that there is a problem,” said Robert McKeown, of the University of South Carolina’s Arnold School of Public Health, who led the South Carolina portion of the study.

“Further complicating our understanding of the prevalence of ADHD and its treatment is that the diagnosis often is made by a clinician who has little experience assessing and diagnosing mental disorders. As a result, ADHD is both under and over diagnosed,” said McKeown, distinguished professor emeritus in the department of epidemiology and biostatistics.

The study, conducted between 2002-2012, was a collaborative research project with the University of South Carolina’s Arnold School and School of Medicine and the University of Oklahoma’s Health Sciences Center.

“To our knowledge, this is the largest community-based epidemiologic study of ADHD to date,” McKeown said.

The study found that 8.7 percent of children in the community sample in South Carolina had enough symptoms to fit the ADHD diagnosis at the time of the initial assessment. The percentage was 10.6 in Oklahoma.

The report also revealed that the number of parents in the community sample who reported that their children were taking ADHD medication was 10.1 percent in South Carolina and 7.4 percent in Oklahoma. Yet, of the children taking ADHD medication, only 39.5 percent in South Carolina and 28.3 percent in Oklahoma actually met the case definition of ADHD.

“ADHD is not a snap diagnosis. It requires data from several sources and across several domains and considerable expertise to diagnose accurately and differentiate from other possible problems,” McKeown said.

The CDC reports that ADHD is one of the most common neurobehavioral disorders of childhood. Often first diagnosed in childhood, ADHD affects a child’s ability to do well in school and his or her ability to make and keep friends. While many children “outgrow” the disorder, ADHD can continue into adulthood, impacting the individual’s ability to work and function in society.

McKeown said the study found that many children taking ADHD medication did not meet the ADHD diagnostic criteria.

“These children had more ADHD symptoms, on average, than the other comparison children. Many children meeting case criteria had not been previously identified and were not receiving medication treatment, suggesting that the condition remains underdiagnosed,” he said.

The study was designed to follow children from elementary school through adolescence (ages 5 — 13) and investigate the short- and long-term outcomes of children with ADHD. Teachers screened 10,427 children in four school districts across the two states where the study was conducted. ADHD ratings by teacher and parent reports of diagnosis and medication treatment were used to determine whether children were high or low risk for ADHD.

Study questions focused on the prevalence and treated prevalence of ADHD in children; the existence of other health problems in children with ADHD, and the types and rates of health risk behaviors in children with ADHD. The study also looked at treatment patterns, both past and current, of children with ADHD.

“The findings of our study suggest that a fair number of children are being treated who do not meet case criteria and that there are children who do meet criteria but are not being treated,” McKeown said. “ADHD is not a snap diagnosis. It requires data from several sources and across several domains and considerable expertise to diagnose accurately and differentiate from other possible problems.”

Children and adolescents with ADHD also were found to have high rates of other disorders, including oppositional defiant disorder and conduct disorder. They also were more likely to engage in risky or impulsive behaviors, he said.

“We will follow up on these initial reports as the children age to determine what, if any, changes have occurred in the symptom patterns, as well as in the types of health risk behaviors,” McKeown said.

“We hope that this will shed light on the prevalence and the treatment of ADHD and will lead practitioners to seek consultation if they are not trained to assess, diagnose and treat ADHD,” he said. “We also hope it will lead parents and practitioners to assess all the treatment options to determine what works best for each child.”

USC researchers involved in the study included Dr. Steven Cuffe of the University of Florida College of Medicine-Jacksonville, formerly of the USC School of Medicine; Arnold School doctoral student Lorie L. Geryk; and Matteo Botai of the Karolinska Institutet in Sweden and Joseph R. Holbrook of the CDC, both formerly at the Arnold School.

University of South Carolina (2012, October 19). Attention deficit hyperactivity disorder is both under and over diagnosed, study suggests.ScienceDaily. Retrieved October 21, 2012, from http://www.sciencedaily.com­ /releases/2012/10/121019141124.htm

Retrieved from: http://www.sciencedaily.com/releases/2012/10/121019141124.htm

exercise and adhd…

In ADHD, ADHD Adult, ADHD child/adolescent, Fitness/Health, Neuropsychology, Psychiatry, School Psychology, Special Education on Sunday, 21 October 2012 at 09:43

Exercise May Lead to Better School Performance for Kids with ADHD

ScienceDaily (Oct. 16, 2012)

A few minutes of exercise can help children with attention deficit hyperactivity disorder perform better academically, according to a new study led by a Michigan State University researcher.

The study, published in the current issue of the Journal of Pediatrics, shows for the first time that kids with ADHD can better drown out distractions and focus on a task after a single bout of exercise. Scientists say such “inhibitory control” is the main challenge faced by people with the disorder.

“This provides some very early evidence that exercise might be a tool in our nonpharmaceutical treatment of ADHD,” said Matthew Pontifex, MSU assistant professor of kinesiology, who led the study. “Maybe our first course of action that we would recommend to developmental psychologists would be to increase children’s physical activity.”

While drugs have proven largely effective in treating many of the 2.5 million school-aged American children with ADHD, a growing number of parents and physicians worry about the side effects and costs of medication.

In the study, Pontifex and colleagues asked 40 children aged 8 to 10, half of whom had ADHD, to spend 20 minutes either walking briskly on a treadmill or reading while seated. The children then took a brief reading comprehension and math exam similar to longer standardized tests. They also played a simple computer game in which they had to ignore visual stimuli to quickly determine which direction a cartoon fish was swimming.

The results showed all of the children performed better on both tests after exercising. In the computer game, those with ADHD also were better able to slow down after making an error to avoid repeat mistakes — a particular challenge for those with the disorder.

Pontifex said the findings support calls for more physical activity during the school day. Other researchers have found that children with ADHD are less likely to be physically active or play organized sports. Meanwhile, many schools have cut recess and physical education programs in response to shrinking budgets.

“To date there really isn’t a whole lot of evidence that schools can pull from to justify why these physical education programs should be in existence,” he said. “So what we’re trying to do is target our research to provide that type of evidence.”

Pontifex conducted the study for his doctoral dissertation at the University of Illinois before joining the MSU faculty. His co-investigators included his adviser, kinesiology professor Charles Hillman, and Daniel Picchietti, a pediatrician at the Carle Foundation Hospital in Champaign, Ill. The research was funded by the National Institute of Child Health and Human Development.

Michigan State University (2012, October 16). Exercise may lead to better school performance for kids with ADHD. ScienceDaily. Retrieved October 21, 2012, from http://www.sciencedaily.com­ /releases/2012/10/121016132109.htm

Retrieved from: http://www.sciencedaily.com/releases/2012/10/121016132109.htm

Homework Help, Timing is Vital: Setting Yourself and Your Child Up For Success!

In ADHD, ADHD Adult, ADHD child/adolescent, Education, School Psychology, Special Education on Friday, 19 October 2012 at 15:52

Homework Help, Timing is Vital: Setting Yourself and Your Child Up For Success!.

a mother’s letter to the principal…

In Education, Education advocacy, School Psychology, Special Education on Friday, 19 October 2012 at 15:47


another piece on teacher evaluations…

In Education, Education advocacy, Pedagogy, School Psychology, School reform, Special Education on Wednesday, 17 October 2012 at 08:25

Seeking Aid, More Districts Change Teacher Evaluations

By: Motoko Rich

LONGMONT, Colo. — In an exercise evoking a corporate motivation seminar, a group of public school teachers and principals clustered around posters scrawled with the titles of Beatles songs. Their assignment: choose the one that captured their feelings about a new performance evaluation system being piloted in their district.

Jessicca Shaffer, a fifth-grade teacher in this suburban community northeast of Boulder, joined the group assembled around “Eight Days a Week.” (Other options: “We Can Work It Out” and “Help!”)

“If we truly had 52 weeks of school a year, we still would not have enough time to do everything we have to do,” Ms. Shaffer said, sounding a common note of exasperation. “I am supersaturated.”

An elementary school literacy coach wondered whether the evaluations would produce anything other than extra paperwork. “Are they going to be giving us true feedback?” she asked. “Or are they just going to be filling out a form?”

The teachers and administrators, who gathered last month in the boardroom of the St. Vrain Valley School District for a daylong training session on evaluating teachers through classroom observations, echoed anxieties that are rippling through faculty lounges across the nation.

Fueled in part by efforts to qualify for the Obama administration’s Race to the Top federal grant program or waivers from the toughest conditions of No Child Left Behind, the Bush-era education law, 36 states and the District of Columbia have introduced new teacher evaluation policies in the past three years, according to the National Center on Teacher Quality, a nonprofit research and advocacy group. An increasing number of states are directing districts to use these evaluations in decisions about how teachers are granted tenure, promoted or fired.

Proponents say that current performance reviews are superficial and label virtually all teachers “satisfactory.” “When everyone is treated the same, I can’t think of a more demeaning way of treating people,” Arne Duncan, the secretary of education, said in a telephone interview. “Far, far too few teachers receive honest feedback on what they’re doing.”

So far, attention has focused mainly on one element of the new evaluation systems, the requirement that districts derive a portion of a teacher’s rating from student performance on standardized tests. Anger over the use of test results exploded during the strike by the Chicago Teachers’ Union last month. But most of the new state policies also include a component based on classroom observations by principals, peers or outside evaluators.

Advocates of the new evaluations, including Secretary Duncan, have repeatedly emphasized the importance of professional reviews including “multiple measures” of performance.

During the St. Vrain seminar, officials from the Colorado Department of Education walked administrators and teachers through a model rubric for classroom observations that the Education Department had developed to guide principals in assessing teachers. At 24 pages, the rubric serves as a checklist of broad ideals, asking whether a teacher “motivates students to make connections to prior learning” or “provides instruction that is developmentally appropriate for all students.”

The new Colorado evaluation system was developed in response to a 2010 bill requiring that all principals, teachers and other licensed school staff be reviewed annually. Half of a teacher’s score is determined by student achievement on a range of tests; the other half is based on an evaluation of “professional practice” — what can be observed in class as well as gleaned from lesson plans and other instructional materials.

Even those who are skeptical about the value of using test scores to rate teachers say that classroom observations, done well, can help teachers improve.

“It can be very powerful and it is more stable and reliable” than measures that look at test scores, said Linda Darling-Hammond, an education professor at Stanford University. But, she added, “one of the big challenges we have is to create systems that are manageable, doable and not overwhelming.”

For teachers, the biggest fear is that a poor evaluation could lead to job loss. Under the new Colorado law, teachers can be rated highly effective, effective, partially effective or ineffective. Starting in the 2014-15 school year, anyone who receives an “ineffective” or “partially effective” rating for two consecutive years will be stripped of the state’s equivalent of tenure status, said Katy Anthes, the executive director of educator effectiveness at the state Education Department. To qualify for tenure, a new teacher must be rated at least “effective” for three consecutive years.

During the St. Vrain training session, officials from the state Education Department sought to tamp down fears that the new evaluations were designed to weed out or shame underperforming teachers. “It is not about a ‘gotcha’ game,” Mike Gradoz, a consultant with the department, told the teachers and principals. “It is about elevating the game so you get better at what you already do.”

To help acquaint the principals and teachers with the state’s rubric, Mr. Gradoz and another trainer walked them through a mock scoring exercise. In one case study, the phantom teacher earned a “partially proficient” rating for failing to establish a “safe, inclusive and respectful learning environment” and showing weak evidence of lesson planning.

Mr. Gradoz asked the group how they would respond to such a rating. Joe Mehsling, a veteran principal, got right to the point. “If it is a rookie, there is hope,” he said. “If it is a veteran, time to start counseling out.”

During a break, Mr. Mehsling said the new system — and the mandated consequences — would indeed make it easier for principals to fire low-performing teachers. “The elephant in the room that we are dancing around is the fact that public education has not done a good job on our own dismissing ineffective teachers,” Mr. Mehsling said.

But, he added, such teachers represented only 1 or 2 percent of those in classrooms. The new systems, he said, could subject the best teachers to onerous observation and bureaucracy so that principals could justify firing a few bad eggs. “It is taking a sledgehammer where an ice pick would have been effective,” he said.

Still, Mr. Mehsling said the new evaluation systems could result in more objective reviews. “I think it is going to be more work,” he said. “But I think it is going to be more meaningful.”

In that, he was joined by many principals and teachers at the training session.

“The current system has no rubric so it is harder to know what you are checking for,” said Janis Hughes, a principal who attended the training.

The following day, Ms. Hughes, who has been the principal for more than a decade at Burlington Elementary, a diverse neighborhood school where about 41 percent of the students qualify for free and reduced-price lunches, dropped by to observe Brian Huey, a fourth-grade teacher.

Mr. Huey, who shaves his head and wears a tiny silver hoop in each ear, began by asking the children to define the word of the day: “disposition.”

Quietly segueing into a math lesson, he wrote a multiplication word problem on a whiteboard. The students worked independently, and then Mr. Huey helped guide them through several strategies that would help them arrive at the right answer.

Next the class gathered on the rug for a review of geometry concepts. “What are the dimensions of that rectangle?” Mr. Huey asked one boy.

The boy paused. A girl who had piped up several times during the lesson was eager to showcase her knowledge again. “It is also known as a perimeter!” she blurted.

“Let’s not cheat his thinking,” Mr. Huey said gently.

Ms. Hughes, watching from the back of the room, noticed. “He engaged Janelle but did it in a respectful, nice way,” she said. “But it also let her know she can’t dominate the conversation.”

Such observations, Ms. Hughes said, would easily fit into the state’s model rubric. (Page 10: The teacher “ensures that all students participate with a high level of frequency.”)

In general, Mr. Huey said, “when I looked over what the criteria are, they sound fair.”

“It’s just good teaching,” he added.

Retrieved from: http://www.nytimes.com/2012/10/16/education/seeking-aid-more-districts-change-teacher-evaluations.html?src=un&feedurl=http%3A%2F%2Fjson8.nytimes.com%2Fpages%2Fnational%2Findex.jsonp&_r=0&pagewanted=all


Raising a Child with Special Needs…the Psychic Toll on Families

In School Psychology, Special Education on Tuesday, 16 October 2012 at 08:36

The Psychic Toll Paid in a Special Needs House

Ron Leiber

October 12, 2012

Most people caring for a family member with special needs eventually assemble a financial checklist of sorts.

They put together a team of health, legal and financial experts who understand their family member’s condition. Then comes the estate plan and making sure they understand the eligibility rules for any state or federal benefits.

Checking these items off, however, as I did in a column last week, often proves to be the easier part of special needs planning. The harder part springs from two challenges that are ultimately rooted in emotion and behavior. It’s the psychological side, after all, that often plays a big role in just about every major financial decision.

The first is the question of where a special needs child or sibling should live. The second is not letting the stress of managing the affairs of a special needs family member contribute to the end of a marriage or other long-term romantic partnership.

When Alice Walther’s son was small and experiencing developmental delays, she and her husband took him to a major children’s hospital in the St. Louis area. A top doctor there told them that he was severely retarded. “He said to put him in a home, that it will ruin your family,” she recalled.

Her son Sean is now 43 and he never left his family’s home. He works part time at a library and pursues his passion for golf in his spare time, watching tournaments on television and maintaining a collection of scorecards from all over the world that is so large it takes up three bookshelves.

“He’s gotten so used to his own room and his own bathroom that he wouldn’t fit into a group home, quite honestly,” Ms. Walther said.

Mary Anne Ehlert, a financial planner in Lincolnshire, Ill., who specializes in advising people with family members who have special needs, has heard versions of this before. Her own late sister, who had cerebral palsy, lived with her parents as an adult before her parents finally decided to have her move out.

“You want to keep them totally in a bubble,” she said. “But it’s not in their best interest, and it’s not what they want. The problem is, if the parents die, then what?”

Ms. Walther’s other son Michael, a financial planner himself, has thought through every angle of his younger brother’s situation. He sees things as Ms. Ehlert does and thinks his brother should move out of his parents’ home sooner rather than later.

“Change is not something he does well with,” he said. “If we were to introduce it at the same time as the loss of a parent, that’s going to be an awful lot to swallow. ”Their parents have a plan for this. “The minute one of us goes, the two who are left will move into assisted living,” Ms. Walther said. Meanwhile, they’re building a financial war chest for that moment, in part by living in the same house they have been in for 45 years.

Once Sean’s other parent dies or is close to death, Mike plans to move his brother to the Chicago area where he lives. He’s made peace, more or less, with his parents’ decision about where Sean will do best in the meantime. “They’re going to win this argument while they’re alive,” he said. “And I’m going to win it when they’re dead.”

The elder Walthers will celebrate their 49th wedding anniversary next month, but not every couple is so lucky. Just how many couples never make it that long while caring for a family member with special needs is a bit uncertain, though. Families I’ve spoken to in the last two weeks have repeated a statistic that about 75 percent of parents with a special needs child end up getting divorced or splitting up.

There does not seem to be any data backing this up, but it’s clear why people may fear the financial consequences of a divorce in a family that is caring for a child or live-in relative with special needs.

Christopher Currin, a financial planner in Dallas who has an 18-year-old son with Down syndrome, knows of a family that ended up paying for three residences after a divorce. One is for the mother, one for the father and one is the house they used to share. They didn’t think their child with special needs could easily move back and forth from one residence to another, so the parents trade off moving back in.

Mr. Currin’s marriage is intact, but as someone who has counseled many families with special needs relatives, he understands why many partnerships do not. “One person in a couple with a child whose disability was unexpected may have difficulty accepting it,” he said. “A deeper wellspring of love may open up in one of them, while the other goes to that well and finds it empty.”

Some people also turn to a higher power when faced with a different sort of parenting challenge. “It can reinforce or cause someone to rediscover religious feelings,” he said. “But others might be cast into doubt that can lead to losing faith.”

The one advantage to frightening, if exaggerated, divorce data is that it might nudge people into some preventive marriage counseling. Or if not that, the persistent, low-grade fear of a failed partnership may at least encourage people to invest in some quality time as a couple.

Mr. Currin said he was particularly grateful for the respite programs that Methodist churches in his area have offered over the years. There, special needs children and their siblings can spend an evening with others like them while their parents get a few hours alone.

“We don’t ever use the D word,” said Matt Syverson, a financial planner in Overland Park, Kan. He and his wife have twins and a younger daughter, Lily, who has Down syndrome. “We don’t ever need to go there. We make the best with what we’ve been dealt, and with God’s help we keep getting through it.”

In fact, now that Lily is in kindergarten, the Syversons have decided to add another child to their family. In the spring, they hope to adopt a boy they’ve named Levi and bring him home from China. He has a severe heart ailment, and once he’s moved in, they will cross their fingers when the time comes for the surgery that will give him the best chance at a long life.

Retrieved from: http://www.nytimes.com/2012/10/13/your-money/the-psychic-toll-paid-in-a-special-needs-house.html?smid=li-share&_r=0

adhd…a longitudinal follow-up

In ADHD, ADHD Adult, ADHD child/adolescent, ADHD stimulant treatment, Brain imaging, Brain studies, Neuropsychology, Neuroscience, Psychiatry, School Psychology on Tuesday, 16 October 2012 at 07:34

Men Diagnosed with ADHD as Children had Worse Outcomes as Adults, Study Says

ScienceDaily (Oct. 15, 2012) — Men who were diagnosed as children with attention-deficit/hyperactivity disorder (ADHD) appeared to have significantly worse educational, occupational, economic and social outcomes in a 33-year, follow-up study that compared them with men without childhood ADHD, according to a report published Online First by Archives of General Psychiatry, a JAMA Network publication.

ADHD has an estimated worldwide prevalence of 5 percent, so the long-term outcome of children with ADHD is a major concern, according to the study background.

Rachel G. Klein, Ph.D., of the Child Study Center at NYU Langone Medical Center in New York, and colleagues report the adult outcome (follow-up at average age of 41 years) of boys who were diagnosed as having ADHD at an average age of 8 years. The study included 135 white men with ADHD in childhood, free of conduct disorder (probands), and a comparison group of 136 men without childhood ADHD.

“On average, probands had 2½ fewer years of schooling than comparison participants … 31.1 percent did not complete high school (vs. 4.4 percent of comparison participants) and hardly any (3.7 percent) had higher degrees (whereas 29.4 percent of comparison participants did). Similarly, probands had significantly lower occupational attainment levels,” the authors note. “Given the probands’ worse educational and occupational attainment, their relatively poorer socioeconomic status at [follow-up at average age of 41 years] is to be expected. Although significantly fewer probands than comparison participants were employed, most were holding jobs (83.7 percent). However, the disparity of $40,000 between the median annual salary of employed probands and comparisons is striking.”

In further comparisons of the two groups, the men who were diagnosed with ADHD in childhood also had more divorces (currently divorced, 9.6 percent vs. 2.9 percent, and ever been divorced 31.1 percent vs. 11.8 percent); and higher rates of ongoing ADHD (22.2 percent vs. 5.1 percent, the authors suspect the comparison participants’ ADHD symptoms might have emerged during adulthood), antisocial personality disorder (ASPD, 16.3 percent vs. 0 percent) and substance use disorders (SUDs, 14.1 percent vs. 5.1 percent), according to the results.

During their lifetime, the men who were diagnosed with ADHD in childhood (the so-called probands) also had significantly more ASPD and SUDs but not mood or anxiety disorders and more psychiatric hospitalizations and incarcerations than comparison participants. And relative to the comparison group, psychiatric disorders with onsets at 21 years of age or older were not significantly elevated in the probands, the study results indicate.

The authors note the design of their study precludes generalizing the results to women and all ethnic and social groups because the probands were white men of average intelligence who were referred to a clinic because of combined-type ADHD.

“The multiple disadvantages predicted by childhood ADHD well into adulthood began in adolescence, without increased onsets of new disorders after 20 years of age. Findings highlight the importance of extended monitoring and treatment of children with ADHD,” the study concludes.

Retrieved from: http://www.sciencedaily.com/releases/2012/10/121015162407.htm



Brain Gray Matter Deficits at 33-Year Follow-up in Adults With Attention-Deficit/Hyperactivity Disorder Established in Childhood

Erika Proal, PhD; Philip T. Reiss, PhD; Rachel G. Klein, PhD; Salvatore Mannuzza, PhD; Kristin Gotimer, MPH; Maria A. Ramos-Olazagasti, PhD; Jason P. Lerch, PhD; Yong He, PhD; Alex Zijdenbos, PhD; Clare Kelly, PhD; Michael P. Milham, MD, PhD; F. Xavier Castellanos, MD

Arch Gen Psychiatry. 2011;68(11):1122-1134. doi:10.1001/archgenpsychiatry.2011.117.


Context  Volumetric studies have reported relatively decreased cortical thickness and gray matter volumes in adults with attention-deficit/hyperactivity disorder (ADHD) whose childhood status was retrospectively recalled. We present, to our knowledge, the first prospective study combining cortical thickness and voxel-based morphometry in adults diagnosed as having ADHD in childhood.

Objectives  To test whether adults with combined-type childhood ADHD exhibit cortical thinning and decreased gray matter in regions hypothesized to be related to ADHD and to test whether anatomic differences are associated with a current ADHD diagnosis, including persistent vs remitting ADHD.

Design  Cross-sectional analysis embedded in a 33-year prospective follow-up at a mean age of 41.2 years.

Setting  Research outpatient center.

Participants  We recruited probands with ADHD from a cohort of 207 white boys aged 6 to 12 years. Male comparison participants (n = 178) were free of ADHD in childhood. We obtained magnetic resonance images in 59 probands and 80 comparison participants (28.5% and 44.9% of the original samples, respectively).

Main Outcome Measures  Whole-brain voxel-based morphometry and vertexwise cortical thickness analyses.

Results  The cortex was significantly thinner in ADHD probands than in comparison participants in the dorsal attentional network and limbic areas (false discovery rate < 0.05, corrected). In addition, gray matter was significantly decreased in probands in the right caudate, right thalamus, and bilateral cerebellar hemispheres. Probands with persistent ADHD (n = 17) did not differ significantly from those with remitting ADHD (n = 26) (false discovery rate < 0.05). At uncorrected P < .05, individuals with remitting ADHD had thicker cortex relative to those with persistent ADHD in the medial occipital cortex, insula, parahippocampus, and prefrontal regions.

Conclusions  Anatomic gray matter reductions are observable in adults with childhood ADHD, regardless of the current diagnosis. The most affected regions underpin top-down control of attention and regulation of emotion and motivation. Exploratory analyses suggest that diagnostic remission may result from compensatory maturation of prefrontal, cerebellar, and thalamic circuitry.

Retrieved from: http://archpsyc.jamanetwork.com/article.aspx?articleid=1107429

Depression 101…

In Mood Disorders, Psychiatry, School Psychology on Tuesday, 16 October 2012 at 07:15

Depression 101: Treatment & Tips To Ward Off Depression

Depression is a common mental health illness in the US and around the world. In fact, the Center for Disease Control and Prevention states that 1 in 10 adults in the US report experiencing depression. What is most troubling to me is that only about 51% of those people suffering from depression seek out treatment according to the National Institute of Mental Health. Depression may begin at any age and may be caused by any number of triggers such as bullying, parental or marital conflict, sense of isolation, loss, seasonal causes, etc.

As a result, I wanted to write a blog post specifically on depression, its treatment, and offer wellness tips to ward off depression. Please note that depression is one of several mood disorders and is different than bipolar, dysthymia, and other mood disorders. This blog post will focus on depression technically known as Major Depressive Disorder. I also want to make it very clear that depression is a treatable illness but, like many illnesses, it can require ongoing “maintenance.”

First let me review the symptoms of depression, followed by the treatment, and then offer some tips to ward off depression.

Symptoms of Depression: To meet criteria, five or more symptoms must be present for at least a 2 week period according to the Diagnostic and Statistical Manual of Mental Disorders. It is also very important to rule out physiological effects of a substance/drug, other psychiatric disorders such as bereavement, and medical conditions such as thyroid problems that may cause depressive symptoms.

  Sad or depressed mood most of the day, almost every day.

  Anhedonia, which is loss of interest in previously enjoyed activities.

  Sleep problems, usually hypersomnia but can also be insomnia.

  Weight gain or loss not due to diet or exercise.

  Low of energy or fatigue even with sufficient rest.

  Psychomotor agitation or retardation, which is usually moving or talking slower.

  Poor concentration or ability to think.

  Feeling of worthlessness or excessive guilt.

  Thoughts of death or suicide, which could be the most serious of all the symptoms and must be taken seriously even in children.

Here are some other symptoms to look for that are frequently present in depression:

  Thoughts of helplessness

  Thoughts of hopelessness

  Isolation

  Changes in appetite

  Irritability

  Crying

  Decrease in sex drive

Treatment for Depression

Treatment for depression begins with an evaluation by a licensed mental health professional to determine severity of depression, to rule out other possible issues, and to refer for appropriate services. Treatment usually entails either counseling or psychotropic medication or a combo of both, depending on severity. Severe depression usually requires a psychiatric evaluation by a psychiatrist for psychotropic medication to help improve symptoms enough for counseling to be effective, while mild to moderate depression can usually be treated with counseling alone. It is important to know there are a countless approaches to counseling such as cognitive behavior, psychodynamic, humanistic, and many more. Many approaches explore the person’s feelings, thoughts, and behaviors. The trust developed between the client-therapist relationship is what many approaches have in common and what research has found to be an essential ingredient to effective treatment. That is why it is imperative that one choose a therapist that is a good fit.

In addition, there are other interventions or activities such as exercise and meditation that have been found to be effective treatment for mild to moderate depression. Family therapy can also be helpful at alleviating tensions at home that may be impacting one’s depression and hindering treatment progress.

Tips to Ward Off Depression

  Exercise Regularly as it has been found to be fantastic not only for managing stress and preventing physical problems but also at reducing depression and anxiety.

  Be Present is where people often report being happy while being in the future can create anxiety and being in the past can lead to feelings of regret, guilt, and depression. Focus on being more mindful about how you are feeling right now rather than how you felt weeks or years ago.

  Seek Support from licensed mental health professionals, friends, family and even animals, whom can be helpful. Surround yourself with people that are positive and validating.

  Know the Signs of depression so that you know when you or someone you in your life needs help.

  Know your Depression and be proactive. If you know that you happen to be extra susceptible to depression during the winter months, prepare for it by scheduling regular activities or seeking extra support during this time.

  Get Outside because sunlight can be helpful and so can nature. Experiencing the grandeur nature can help put one’s problems into perspective and when our problems seem small they don’t bother us as much.

  Find Meaning or a reason for living as it can be a powerful motivation to keep living. One’s meaning can be their partner, children, or even a cause.

  Sleep is vital to good health and mental functioning. Avoid sleep problems by having a regular bedtime even on weekends, keeping distractions from the bedroom (e.g., TV), and creating a bedtime that is conducive for relaxation.

  Visit Your Primary Care Doctor regularly to prevent, catch, or treat medical illnesses early that can create depressive symptoms.

  Eat Healthy meals to improve physical, mental, and emotional functioning. Eating unhealthy foods erodes your physical health, impairs cognitive functioning, and also impacts how you feel about yourself.

  Respect your Emotions rather than stuffing them. Bottling your feelings can be toxic to your body while expressing how you feel can be very relieving especially when your feelings are validated.

Author: Yoendry Torres, Psy.D., Clinical Psychologist

Retrieved from: http://www.intuitionwellness.com/blog/2012/10/12/depression-101-treatment-tips-to-ward-off-depression/

more awesomeness in neuroscience…

In Education, Neurogenesis, Neuropsychology, Neuroscience, School Psychology on Saturday, 13 October 2012 at 09:30

Brain Scans Can Detect Children’s Reading Ability


Stanford researchers say that brain scans can help detect whether or not a child will develop reading-related problems in the future, a discovery that opens up possibility of intervention programs for helping children improve their reading ability.  In a study, conducted over a period of three years, researchers at Stanford University assessed children’s reading skills with the help of standardized tests. They observed and analyzed the participants’ brain scans taken during the study.

Researchers found that in each of the 39 children, the rate of development in the white matter region accurately predicted the child’s score on a reading test. The white matter regions of the brain are associated with reading; the rate of development in the brain region is measured by fractional anisotropy, or FA.

Further, children who displayed above-average reading skills had FA in two regions, the left hemisphere arcuate fasciculus and the left hemisphere inferior longitudinal fasciculus. Interestingly, in children who develop good reading skills, the initial FA was lower but increased over time. In children that had lower reading abilities, the FA was higher initially but declined afterwards.

According to researchers, a child’s ability to read at seven years of age can predict hisor her reading ability at 17 years of age. But, detecting if the child has problems with reading can be a challenge. “By the time kids reach elementary school, we’re not great at finding ways of helping them catch up,” said Jason D. Yeatman, a doctoral candidate in psychology at Stanford and the lead author on the study.

The great news is the study could one day lead to an early warning system for struggling students and this could help children improve their reading ability as the brain is young and is still developing.

“Once we have an accurate model relating the maturation of the brain’s reading circuitry to children’s acquisition of reading skills, and once we understand which factors are beneficial, I really think it will be possible to develop early intervention protocols for children who are poor readers, and tailor individualized lesson plans to emphasize good development. Over the next five to 10 years, that’s what we’re really hoping to do,” Yeatman said.

The study was published in the Proceedings of the National Academy of Sciences.

Retrieved from: http://www.medicaldaily.com/articles/12666/20121012/brain-scans-detect-childrens-reading-ability.htm#go5H3ZzSAe1jtK0g.99

Development of white matter and reading skills

PNAS Plus – Biological Sciences – Psychological and Cognitive Sciences

Jason D. Yeatman, Robert F. Dougherty, Michal Ben-Shachar, and Brian A. Wandell

White matter tissue properties are highly correlated with reading proficiency; we would like to have a model that relates the dynamics of an individual’s white matter development to their acquisition of skilled reading. The development of cerebral white matter involves multiple biological processes, and the balance between these processes differs between individuals. Cross-sectional measures of white matter mask the interplay between these processes and their connection to an individual’s cognitive development. Hence, we performed a longitudinal study to measure white-matter development (diffusion-weighted imaging) and reading development (behavioral testing) in individual children (age 7–15 y). The pattern of white-matter development differed significantly among children. In the left arcuate and left inferior longitudinal fasciculus, children with above-average reading skills initially had low fractional anisotropy (FA) that increased over the 3-y period, whereas children with below-average reading skills had higher initial FA that declined over time. We describe a dual-process model of white matter development comprising biological processes with opposing effects on FA, such as axonal myelination and pruning, to explain the pattern of results.

PNAS Plus: Development of white matter and reading skillsPNAS 2012 ; published ahead of print October 8, 2012,doi:10.1073/pnas.1206792109

Retrieved from: http://www.pnas.org/search?fulltext=reading&go.x=0&go.y=0&go=GO&submit=yes



Occurrence and Family Impact of Elopement in Children With Autism Spectrum Disorders

In Autism Spectrum Disorders, School Psychology, Special Education on Thursday, 11 October 2012 at 11:58

Running Away Common with Autism

By Genevra Pittman

NEW YORK (Reuters Health) Oct 08 – Almost half of children with autism in a new study had run away at least once – and many of them were missing long enough to cause concern.

Researchers found that kids most often wandered off from their home, school or a store, and some tried to run away multiple times a day.

But rather than being confused about where they were, kids typically left to find a place they enjoyed, to explore or to avoid an anxious or uncomfortable situation, based on their parents’ reports.

“It’s rooted in the very nature of autism itself,” said Dr. Paul Law, who worked on the study.

“Kids don’t have the social skills to check in with their parents, and to have that communication and social bond that most children have when they’re approaching a road or at a park.”

Dr. Law directs the Interactive Autism Network Project at the Kennedy Krieger Institute in Baltimore. With funding from a number of autism research and advocacy groups, he and his colleagues used their registry to survey the parents of 1,218 kids with an autism spectrum disorder.

Of those kids, 598 – or 49% – had tried to run away at least once, their parents reported. And 316 were missing long enough to cause concern – an average of more than 40 minutes.

In comparison, the same parents reported 13% of their non-autistic children had ever wandered off after age four.

Most of the kids with autism who went missing were in danger of getting hit by cars, and others could have drowned. Police had to be called for one-third of missing children.

“Amongst the families we did interview, there were many reports of injuries, close calls with drowning (and) close calls with traffic accidents,” Dr. Law told Reuters Health.

“There’s an enormous burden that all families are undergoing to keep their families safe. The amount of diligence, and not going out in public, and staying up late at night… just the general anxiety that families live under because of concerns with this is just torturous.”

Children with more severe autism were more likely to have bolted, according to findings published Monday in Pediatrics.

Autism researcher Russell Lang from Texas State University-San Marcos said the prevalence of running away or “eloping” in children with autism “absolutely surprised” him.

“It’s a very dangerous behavior, and it’s a little bit deceptive because it can seem somewhat benign compared to other challenging behaviors,” Lang, who wasn’t involved in the new study, told Reuters Health.

Those other “challenging behaviors” common in kids with autism include self-injury and property destruction, he said. They often get lumped together with running away, which is why researchers haven’t had a good estimate of the prevalence of elopement until now.

The new study couldn’t estimate how many children with autism die every year due to running away and getting into danger, the researchers said.

“This is not simply a case of parents being remiss in some way regarding their supervision of their children,” Lang said. “The child with autism doesn’t realize what danger they’re putting themselves in. They have a propensity to elope, it seems, regardless of parental care.”

He said therapy that rewards kids for not wandering off may help prevent them from disappearing in the future.

Dr. Law advises parents to reach out to advocacy groups to learn about safe locks for their doors and tracking devices for kids. And emergency responders can be better prepared for getting the call when a child with autism goes missing.

Still, he added, “we haven’t totally come to consensus on what some of the best practices are” to prevent running away.

SOURCE: http://bit.ly/RLrO7s

Retrieved from: http://www.medscape.com/viewarticle/772243?src=nl_topic

Occurrence and Family Impact of Elopement in Children With Autism Spectrum Disorders

Connie Anderson, PhDaJ. Kiely Law, MDa,bAmy Daniels, PhDa,c Catherine Rice, PhDdDavid S. Mandell, ScDeLouis Hagopian, PhDa,b, and Paul A. Law, MD, MPHa,b


OBJECTIVES: Anecdotal reports suggest that elopement behavior in children with autism spectrum disorders (ASDs) increases risk of injury or death and places a major burden on families. This study assessed parent-reported elopement occurrence and associated factors among children with ASDs.

METHODS: Information on elopement frequency, associated characteristics, and consequences was collected via an online questionnaire. The study sample included 1218 children with ASD and 1076 of their siblings without ASD. The association among family sociodemographic and child clinical characteristics and time to first elopement was estimated by using a Cox proportional hazards model.

RESULTS: Forty-nine percent (n = 598) of survey respondents reported their child with an ASD had attempted to elope at least once after age 4 years; 26% (n = 316) were missing long enough to cause concern. Of those who went missing, 24% were in danger of drowning and 65% were in danger of traffic injury. Elopement risk was associated with autism severity, increasing, on average, 9% for every 10-point increase in Social Responsiveness Scale T score (relative risk 1.09, 95% confidence interval: 1.02, 1.16). Unaffected siblings had significantly lower rates of elopement across all ages compared with children with ASD.

CONCLUSIONS: Nearly half of children with ASD were reported to engage in elopement behavior, with a substantial number at risk for bodily harm. These results highlight the urgent need to develop interventions to reduce the risk of elopement, to support families coping with this issue, and to train child care professionals, educators, and first responders who are often involved when elopements occur.

Retrieved from: http://pediatrics.aappublications.org/content/early/2012/10/02/peds.2012-0762.abstract


ADHD…a “made up” disorder???

In ADHD, ADHD Adult, ADHD child/adolescent, ADHD stimulant treatment, Medication, Neuropsychology, Psychiatry, Psychopharmacology, School Psychology on Thursday, 11 October 2012 at 10:37

while i do think adhd is the “diagnosis of the day” and it may be over-diagnosed, i DO NOT agree that it is a “made up”  disorder or “an excuse.”  you only have to look at the latest studies that compare treated and untreated brains of those diagnosed with adhd to see that there are real neurological and neuroanatomical deficits that can arise if adhd is left untreated (for one example, see: Adult ADHD: New Findings in Neurobiology and Genetics ; Scott H. Kollins, Ph.D.  http://www.medscape.org/viewarticle/765528).  

if you think you or someone you know has adhd, the following lists suggestions to make sure you receive a valid diagnosis and what to help to facilitate that*:

A good evaluation may consist of many of the following:

  • Collection of rating scales and referral information before or during the evaluation  
  • An interview with the student and parents
  • A review of previous records that may document impairments (i.e. problems in school, socially, or at home that you believe can be attributed to ADHD.  A good doctor knows exactly what questions to ask.
  • A general medical examination when medication might be part of treatment or coexisting medical conditions need to be evaluated (if the physician hasn’t already done this). 

 What to take along to facilitate these steps:  

  • Any records from schools you.your child attended and any other documentation of problems that could be related to ADHD or another disorder 
  • A list of family members with mental health known disorders
  • A description of impairments during childhood (i.e. elementary school), as well as more recent ones (i.e. middle school).  This can be done via SST notes, progress reports, psychological evaluations, IEP’s, etc.

*adapted from: Barkley, Russell A. (2011-04-04). Taking Charge of Adult ADHD (Kindle Locations 464-483). Guilford Press. Kindle Edition.

Attention Disorder or Not, Pills to Help in School

Alan Schwarz

CANTON, Ga. — When Dr. Michael Anderson hears about his low-income patients struggling in elementary school, he usually gives them a taste of some powerful medicine: Adderall.

The pills boost focus and impulse control in children with attention deficit hyperactivity disorder. Although A.D.H.D is the diagnosis Dr. Anderson makes, he calls the disorder “made up” and “an excuse” to prescribe the pills to treat what he considers the children’s true ill — poor academic performance in inadequate schools.

“I don’t have a whole lot of choice,” said Dr. Anderson, a pediatrician for many poor families in Cherokee County, north of Atlanta. “We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.”

Dr. Anderson is one of the more outspoken proponents of an idea that is gaining interest among some physicians. They are prescribing stimulants to struggling students in schools starved of extra money — not to treat A.D.H.D., necessarily, but to boost their academic performance.

It is not yet clear whether Dr. Anderson is representative of a widening trend. But some experts note that as wealthy students abuse stimulants to raise already-good grades in colleges and high schools, the medications are being used on low-income elementary school children with faltering grades and parents eager to see them succeed.

“We as a society have been unwilling to invest in very effective nonpharmaceutical interventions for these children and their families,” said Dr. Ramesh Raghavan, a child mental-health services researcher at Washington University in St. Louis and an expert in prescription drug use among low-income children. “We are effectively forcing local community psychiatrists to use the only tool at their disposal, which is psychotropic medications.”

Dr. Nancy Rappaport, a child psychiatrist in Cambridge, Mass., who works primarily with lower-income children and their schools, added: “We are seeing this more and more. We are using a chemical straitjacket instead of doing things that are just as important to also do, sometimes more.”

Dr. Anderson’s instinct, he said, is that of a “social justice thinker” who is “evening the scales a little bit.” He said that the children he sees with academic problems are essentially “mismatched with their environment” — square pegs chafing the round holes of public education. Because their families can rarely afford behavior-based therapies like tutoring and family counseling, he said, medication becomes the most reliable and pragmatic way to redirect the student toward success.

“People who are getting A’s and B’s, I won’t give it to them,” he said. For some parents the pills provide great relief. Jacqueline Williams said she can’t thank Dr. Anderson enough for diagnosing A.D.H.D. in her children — Eric, 15; Chekiara, 14; and Shamya, 11 — and prescribing Concerta, a long-acting stimulant, for them all. She said each was having trouble listening to instructions and concentrating on schoolwork.

“My kids don’t want to take it, but I told them, ‘These are your grades when you’re taking it, this is when you don’t,’ and they understood,” Ms. Williams said, noting thatMedicaid covers almost every penny of her doctor and prescription costs.

Some experts see little harm in a responsible physician using A.D.H.D. medications to help a struggling student. Others — even among the many like Dr. Rappaport who praise the use of stimulants as treatment for classic A.D.H.D. — fear that doctors are exposing children to unwarranted physical and psychological risks. Reported side effects of the drugs have included growth suppression, increased blood pressure and, in rare cases, psychotic episodes.

The disorder, which is characterized by severe inattention and impulsivity, is an increasingly common psychiatric diagnosis among American youth: about 9.5 percent of Americans ages 4 to 17 were judged to have it in 2007, or about 5.4 million children, according to the Centers for Disease Control and Prevention.

The reported prevalence of the disorder has risen steadily for more than a decade, with some doctors gratified by its widening recognition but others fearful that the diagnosis, and the drugs to treat it, are handed out too loosely and at the exclusion of nonpharmaceutical therapies.

The Drug Enforcement Administration classifies these medications as Schedule II Controlled Substances because they are particularly addictive. Long-term effects of extended use are not well understood, said many medical experts. Some of them worry that children can become dependent on the medication well into adulthood, long after any A.D.H.D. symptoms can dissipate.

According to guidelines published last year by the American Academy of Pediatrics, physicians should use one of several behavior rating scales, some of which feature dozens of categories, to make sure that a child not only fits criteria for A.D.H.D., but also has no related condition like dyslexia or oppositional defiant disorder, in which intense anger is directed toward authority figures. However, a 2010 study in the Journal of Attention Disorders suggested that at least 20 percent of doctors said they did not follow this protocol when making their A.D.H.D. diagnoses, with many of them following personal instinct.

On the Rocafort family’s kitchen shelf in Ball Ground, Ga., next to the peanut butter and chicken broth, sits a wire basket brimming with bottles of the children’s medications, prescribed by Dr. Anderson: Adderall for Alexis, 12; and Ethan, 9; Risperdal (an antipsychotic for mood stabilization) for Quintn and Perry, both 11; and Clonidine (a sleep aid to counteract the other medications) for all four, taken nightly.

Quintn began taking Adderall for A.D.H.D. about five years ago, when his disruptive school behavior led to calls home and in-school suspensions. He immediately settled down and became a more earnest, attentive student — a little bit more like Perry, who also took Adderall for his A.D.H.D.

When puberty’s chemical maelstrom began at about 10, though, Quintn got into fights at school because, he said, other children were insulting his mother. The problem was, they were not; Quintn was seeing people and hearing voices that were not there, a rare but recognized side effect of Adderall. After Quintn admitted to being suicidal, Dr. Anderson prescribed a week in a local psychiatric hospital, and a switch to Risperdal.

While telling this story, the Rocaforts called Quintn into the kitchen and asked him to describe why he had been given Adderall.

“To help me focus on my school work, my homework, listening to Mom and Dad, and not doing what I used to do to my teachers, to make them mad,” he said. He described the week in the hospital and the effects of Risperdal: “If I don’t take my medicine I’d be having attitudes. I’d be disrespecting my parents. I wouldn’t be like this.”

Despite Quintn’s experience with Adderall, the Rocaforts decided to use it with their 12-year-old daughter, Alexis, and 9-year-old son, Ethan. These children don’t have A.D.H.D., their parents said. The Adderall is merely to help their grades, and because Alexis was, in her father’s words, “a little blah.”

”We’ve seen both sides of the spectrum: we’ve seen positive, we’ve seen negative,” the father, Rocky Rocafort, said. Acknowledging that Alexis’s use of Adderall is “cosmetic,” he added, “If they’re feeling positive, happy, socializing more, and it’s helping them, why wouldn’t you? Why not?”

Dr. William Graf, a pediatrician and child neurologist who serves many poor families in New Haven, said that a family should be able to choose for itself whether Adderall can benefit its non-A.D.H.D. child, and that a physician can ethically prescribe a trial as long as side effects are closely monitored. He expressed concern, however, that the rising use of stimulants in this manner can threaten what he called “the authenticity of development.”

“These children are still in the developmental phase, and we still don’t know how these drugs biologically affect the developing brain,” he said. “There’s an obligation for parents, doctors and teachers to respect the authenticity issue, and I’m not sure that’s always happening.”

Dr. Anderson said that every child he treats with A.D.H.D. medication has met qualifications. But he also railed against those criteria, saying they were codified only to “make something completely subjective look objective.” He added that teacher reports almost invariably come back as citing the behaviors that would warrant a diagnosis, a decision he called more economic than medical.

“The school said if they had other ideas they would,” Dr. Anderson said. “But the other ideas cost money and resources compared to meds.”

Dr. Anderson cited William G. Hasty Elementary School here in Canton as one school he deals with often. Izell McGruder, the school’s principal, did not respond to several messages seeking comment.

Several educators contacted for this article considered the subject of A.D.H.D. so controversial — the diagnosis was misused at times, they said, but for many children it is a serious learning disability — that they declined to comment. The superintendent of one major school district in California, who spoke on the condition of anonymity, noted that diagnosis rates of A.D.H.D. have risen as sharply as school funding has declined.

“It’s scary to think that this is what we’ve come to; how not funding public education to meet the needs of all kids has led to this,” said the superintendent, referring to the use of stimulants in children without classic A.D.H.D. “I don’t know, but it could be happening right here. Maybe not as knowingly, but it could be a consequence of a doctor who sees a kid failing in overcrowded classes with 42 other kids and the frustrated parents asking what they can do. The doctor says, ‘Maybe it’s A.D.H.D., let’s give this a try.’ ”

When told that the Rocaforts insist that their two children on Adderall do not have A.D.H.D. and never did, Dr. Anderson said he was surprised. He consulted their charts and found the parent questionnaire. Every category, which assessed the severity of behaviors associated with A.D.H.D., received a five out of five except one, which was a four.

“This is my whole angst about the thing,” Dr. Anderson said. “We put a label on something that isn’t binary — you have it or you don’t. We won’t just say that there is a student who has problems in school, problems at home, and probably, according to the doctor with agreement of the parents, will try medical treatment.”

He added, “We might not know the long-term effects, but we do know the short-term costs of school failure, which are real. I am looking to the individual person and where they are right now. I am the doctor for the patient, not for society.

Retrieved from: http://www.nytimes.com/2012/10/09/health/attention-disorder-or-not-children-prescribed-pills-to-help-in-school.html?pagewanted=all&pagewanted=print

Special Ed complaints to Office of Civil Rights reach new heights

In Education, Education advocacy, School Psychology, School reform, Special Education on Thursday, 11 October 2012 at 08:49

Special Ed complaints to Office of Civil Rights reach new heights

OCTOBER 7, 2012


The federal Office of Civil Rights (OCR)has just released a new report, Disability Rights Enforcement Highlights, and it reveals among other interesting findings that during the three year period from 2009-2011, it received more disability complaints than during any other three year period in its history. During this time, OCR received over 11,700 disability complaints, which comprised 55% of the total overall complaints received. The other 45% of the claims received were related to other areas of OCR enforcement in areas such as national origin, race, age, and sex.

Based on the report, it is clear that the vast majority of disability complaints were in the area of FAPE, Free and Appropriate Public Education. FAPE questions concern whether a district has offered a special needs child an educational program from which the student can obtain at least some minimal benefit. If not, the student has been denied FAPE. Of the 11,700 disability complains, 4678 were devoted to FAPE questions, or roughly 40%. Other high complaint areas were exclusion, retaliation, and academic adjustment. During this three year span, the OCR launched 15 FAPE related investigations of its own.

Another important function that OCR noted it played over this same time span was protecting the educational rights of “wounded warriors.,” our nation’s soldiers who have returned home from battle with permanent injuries that qualify them for educational protection. OCR noted that often these former soldiers are not familiar with the educational protections provided for them under federal law.

Similarly, educational institutions are not uniformly prepared to serve an influx of veterans with combat-related disabilities such as Traumatic Brain Injury and Post-Traumatic Stress Disorder. OCR’s technical assistance has informed veterans, educators and service providers from institutions such as the Veterans Administration about how the protections afforded to post-secondary students with disabilities apply to those returning from war.

Here are examples of some of the investigations based on complaints received by OCR.

Academic Adjustment: An HIV positive student alleged that his college discriminated against him by dismissing him from its medical office technology program. One of the required classes for it mandated that the students draw blood from one another, and the school dropped the young man due to safety concerns. In order to resolve the complaint, the school agreed to re-enroll the student, consider the student’s request for the academic adjustment of not having other students draw his blood, and provide the college’s staff with training on the necessity of providing academic adjustments to disabled students.

FAPE: OCR facilitated Early Complaint Resolution where parents alleged that a school district had not faithfully implemented their child’s IEP (individualized educational program) who qualified for services due to a mood disorder. Based on these efforts, the district agreed to schedule an IEP to discuss the parent’s concerns and to provide notice to the teachers of the requirement that they implement the IEP.

Harassment: Parents filed a complaint based on harassment they alleged their student had received due to a disability related body odor issue. The child had been previously diagnosed due to Fragile X Syndrome, ADD, Asperger’s Syndrome, and Tourette’s Syndrome. The complaint alleged that based on the body odor issue, the student had been detained by school staff who made her take a shower prior to attending class, had staff spray air freshener on her in front of other students, and be sent home prior to the end of the day due to her body odor. After OCR facilitated Early Complaint Resolution, the school district agreed to train staff regarding the student’s disabilities, enroll the student in its Senior Life Skills course, offer weekly social work services, and assist the student in finding community employment.

Retrieved from: http://www.examiner.com/article/special-ed-complaints-to-office-of-civil-rights-reach-new-heights

in honor of bullying prevention month

In Education, School Psychology on Tuesday, 9 October 2012 at 06:54

Dealing with bullying: What parents and teachers can do to help


When a child reports a problem with teasing or bullying, it can leave both parents and teachers feeling frustrated and helpless. Parents may feel helpless because they are not with their child all day at school and they cannot be there to protect their child. Teachers and other school staff such as school psychologists, teacher aides and special education teachers are in a position to intervene, however, school staff cannot always be there to witness every interaction and instance of bullying. Children with disabilities in particular are more likely to be bullied because they are physically different or because they have learning or behavioral difficulties.

Adams County School District 50 in Westminster, CO, began a district-wide bully prevention program during the 2011-2012 school year which features three steps: Stop, walk and talk. The program, Bully Prevention in Positive Behavior Support, is one anti-bullying program that teaches students how to deal with teasing, bullying and gossip. The program relies partially on bystanders, those students who witness the bullying, to step in and help when appropriate. Students learn to tell the bully to stop (paired with a stop hand signal) as a first defense, and then if the bullying or teasing continues they are taught to walk away calmly and confidently to remove the attention that the bully is seeking. As a last step, the students are taught to talk to an adult to report the problem if the other strategies fail and the bullying continues.

The most effective bully prevention program involves students, teachers, parents and communities. Parents can encourage their child not to take the teasers comments personally. Teasers and bullies are out for power, control and attention. Walking away or ignoring the comments takes away the attention that they are seeking. It is important to note that ignoring is taught only as a first strategy and the student should report the problem to an adult if the bullying continues.

Parents can also talk to their child about being assertive and dealing with peers in a confident manner. Bullies are more likely to pick on students who look intimidated and who seem unable to stand up for themselves. Talk to your child about choosing appropriate friends and encourage them to stay close to friends who treat them with respect. Many instances of bullying can be prevented when the child is surrounded by friends who can stick up for them and tell the bully to stop.

Teachers can increase supervision in areas of the school where bullying incidents are more likely to happen such as hallways, lunchrooms and buses. Reassure students that they can report bullying and that they will remain confidential. Adults should respond immediately to reports of teasing or bullying and should follow up with students to determine whether the bullying has stopped or if it is continuing.
Organizations such as the U.S. Department of Health and Human Services and Kidpower have excellent bullying prevention resources and tips for parents and professionals.

Retrieved from: http://www.examiner.com/article/dealing-with-bullying-what-parents-and-teachers-can-do-to-help?cid=db_articles


School psychologists and autism training

In Autism Spectrum Disorders, Education, School Psychology on Tuesday, 9 October 2012 at 06:47

no matter how good we think we are, how many ‘letters’ are behind our names, or  long we have been practicing, in this ever-evolving field, we ALWAYS need to keep up with the latest research and literature and adapt.  when we stop learning, we stop living.  there are lessons all around us…

School Psychologists Need More Training to Meet the Needs of Students with Autism Spectrum Disorders (ASD)

Lee Wilkinson, Ph.D.

More children than ever before are being diagnosed with autism spectrum disorders (ASD). The U.S. Centers for Disease Control and Prevention (CDC) now estimates that 1 in 88 eight year-old children has an ASD. The occurrence of autism is also evident in the number of students with ASD receiving special educational services. Data collected for the Department of Education indicate that the number of children ages 6 through 21 identified with autism served under the Individuals With Disabilities Act (IDEA) quadrupled between 2000-01 and 2009-10; rising from 93,000 to 378,000 students and increasing from 1.5 to 5.8 percent of all identified disabilities.

Given the dramatic increase in ASD, school psychologists and other school-based professionals are now more likely to be asked to participate in the screening, identification, and educational planning for students with ASD than at any other time in the past. Moreover, the call for greater use of evidence-based practice has increased demands that school psychologists be knowledgeable about evidence-based assessment and intervention strategies for students with ASD. Guidelines and standards have been developed recommending best practice procedures for the assessment and treatment of ASD. There is a large and expanding scientific literature base that documents the existence of two major elements of evidence-based practice: assessments shown to be psychometrically sound for the populations on whom they are used and interventions with sufficient evidence for their effectiveness. Although school psychologists are often called on to assume a leadership role in evaluating, identifying, and providing interventions for students with ASD in our schools, there is little research to show how closely school psychologists align their practices with the parameters of best practice. Due to the increase in the number of children receiving special education services under the classification of autism, research is needed regarding the preparedness of school psychologists and schools to address the needs of children with ASD.

Recent Surveys

Although there is a paucity of research focusing on the delivery of school psychological services for students with ASD, there are several national and state-wide surveys which provide exploratory information regarding school psychologists’ level of knowledge in the area of autism assessment and intervention; assessment methods, measures, and techniques; level of training; and perceived level of preparation and confidence.

  • Aiello & Ruble (2011) investigated school psychologists’ knowledge and skills in identifying, evaluating, and providing interventions for students with ASD. A total of 402 participants from 50 states completed their survey. Results indicated that despite a limited amount of training received during their graduate education or pre-service training for working with the autism population, most school psychologists’ self-reported knowledge of ASD was in the expected direction for agreement. However, there were gaps in knowledge regarding the differences between emotional and behavioral disorders and autism, developmental delays and autism, and special education eligibility versus DSM-IV diagnoses that need to be addressed through more training. The survey also indicated the need for additional training opportunities in providing interventions, strategies, and supports for students with autism in the following areas: developing family-centered educational plans; training peer mentors; and translating assessment information into teaching goals and activities.
  • Rasmussen (2009) also completed a national survey of school psychologists to determine their level of knowledge in the area of autism assessment; level of training; and perceived preparation and confidence in providing services to children with ASD. Results indicated that training positively affected school psychologists’ knowledge about autism; their levels of involvement with students with autism; and their perceived levels of preparation to work with this population. Of the 662 participants, the majority accurately identified diagnostic features and true and false statements about autism, suggesting an adequate understanding of autism. Participants with more training reported an increased level of involvement on multidisciplinary teams and an ability to diagnose autism when compared to those with less training. Brief rating scales were among the most commonly used instruments, while more comprehensive and robust instruments were among the least-often employed, suggesting school psychologists are either not trained or are limited in the time and resources needed to use evidence-based instruments. Participants felt more prepared to provide consultation and assessment services and less prepared to provide interventions. Although a majority (96.5%) of the respondents reported they had attended workshop presentations or in-service trainings on autism, less than half (43.7%) had completed formal course work in autism in their training program and less than one third (32.3%) had internship or residency experience with autism. These data and previous research suggest school psychologists need more formal training and experience in meeting the needs of individuals identified with autism.
  • Singer (2008) surveyed 199 school psychologists regarding the frequency with which they were called upon to provide services to students with an autism spectrum disorder (ASD); services they actually provided to those students; and their perceptions of the training and experience they had pertaining to the assessment and treatment of ASD. Additionally, the study surveyed 72 graduate programs in school psychology to determine the extent to which these programs prepared new school psychologists to work with children who have ASD. A majority of respondents (64%) reported using only brief screening instruments to identify students. Although able to identify the “red flag” indicators of ASD, very few school psychologists perceived their training as adequate. Only 12.6 % of respondents indicated that they had sufficient coursework in ASD and only 21% indicated that they had sufficient practicum experience. Just 15% indicated that their overall training with ASD was “completely adequate.” Only 5 of the 72 (16.9%) school psychology programs surveyed offered a specific course in ASD; most indicating that the topic was addressed in other courses. According to the author, the survey data suggest that school psychologists lack adequate knowledge about evidence-based instruments and procedures available to screen, assess, and intervene for ASD.
  • Pearson (2008) surveyed a group of Pennsylvania school psychologists regarding their training, knowledge and evaluation practices when assessing and diagnosing ASD. The aim of the study was to determine the extent to which school psychologists are prepared to meet the rapidly increasing demand for using best practice procedures when assessing and diagnosing ASD. An electronic survey was sent to 1,159 certified school psychologists with 243 completed surveys returned. Survey results found the majority of respondents indicated that they rely on the use of brief screening instruments and do not use or recommend “gold standard” instruments with students suspected of having ASD. Only 32.2% of the respondents reported they were very much prepared to recommend an IDEA classification of Autism. Less than 5% of the school psychologists surveyed received formal training in ASD at graduate institutions or internships. The overwhelming majority of school psychologists surveyed believed there is         a need for more training for school psychologists concerning the characteristics of ASD, best practice in the assessment of ASD, and differentiating ASD from other developmental or coexisting disorders.
  • Small (2012) used an online survey of 100 members of the Massachusetts School Psychology Association (MSPA) to obtain information pertaining to demographics, participants’ experiences with the ASD population, participants’ knowledge of ASD, as well as their use, competency, and feelings of usefulness of various assessment techniques and treatments/interventions. The results indicated that overall, school psychologists demonstrated adequate knowledge of ASD, felt competent conducting assessments, and reported that the assessment tools were useful. School psychologists spent less time on treatment/intervention and while they considered many of the treatments/interventions helpful, they did not feel competent implementing them. The results suggest that school psychologists need more training in ASD, especially regarding treatments/interventions, at the pre-service level through graduate school training and experiences (e.g., practica and internships), as well as at the practitioner level through professional development opportunities.

Conclusion and Recommendations

As more and more children are being identified with ASD and placed in general education classrooms, school psychologists will play an ever increasingly important role in identification and intervention, as well as offer support, information, consultation, and recommendations to teachers, school personnel, administration, and families. Therefore, it is essential that they be knowledgeable about evidence-based assessment and intervention strategies for this population of students.  Despite the limitations inherent in survey research, the data from these studies suggest that school psychologists are not adequately prepared to provide evidence-based assessment and intervention services to children with ASD. The survey research illustrates a significant discrepancy between best practice (evidence-based) parameters and reality when it comes to the practice of school psychology and ASD in the schools. Federal statutes require that school districts ensure that comprehensive, individualized evaluations are completed by school professionals who have knowledge, experience, and expertise in ASD. Although surveys indicate sufficient knowledge of the signs and symptoms associated withASD, there is a critical need for school psychologists to be trained and develop competency in evidence-based assessment and identification practices with children who have or may have an ASD. For example, a majority of survey respondents reported using brief screening measures such the GARS and/or GADS in assessment and identification, both of which are not recommended for use in decision-making (Brock, 2004; Norris, M., & Lecavalier, 2010; Pandolfi, Magyar & Dill, 2010; Wilkinson, 2010). In contrast, evidence-based tools such as the ADOS, ADI-R, CARS, and SCQ were used less a third of the time in ASD assessment. Thus, while evidence-based instruments are available for the reliable, thorough assessment of students with ASD, school psychologists either do not have access or lack sufficient training to make them a part of their practice in the schools.

Because the knowledge base in ASD is changing so rapidly, it is imperative that school psychologists remain current with the research and up to date on scientifically supported approaches that have direct application to the educational setting. School psychologists can help to ensure that students with ASD receive an effective educational program by participating in training programs designed to increase their understanding and factual knowledge about best practice assessment and intervention /treatment approaches. Recommendations culled from the survey findings include the following: (a)school psychologists need more in-depth, formal training complete with supervision and consultation; (b) school psychology training programs should focus more energy on teaching intervention strategies for students with autism and include a separate course in ASD as part of the curriculum; (c) increase the use of more psychometrically sound autism instruments such as the ADOS and ADI-R in schools to provide better identification and more complete intervention strategies; (d) consider resident ASD specialists within the school and train teams of school professionals to work as a unit with the autism-related cases to ensure that the personnel are well-trained and have the experience necessary to conduct reliable and valid assessments and treatment planning; (e) provide training for all school psychologists on best practice guidelines for screening and assessment of ASD and identify measures with and without empirical support; and (g) develop closer relationships with ASD experts and service providers in the community. School districts may also want to consider levels of training, levels of education, and years of experience when assigning school psychologists who work with children who have ASD.  Finally, the National Association of School Psychologists (NASP) may consider developing guidelines and recommendations regarding the minimal competencies needed in order to work with special populations such as students with ASD.

Aiello, R., & Ruble, L. A. (2011, February). Survey of school psychologists’ autism knowledge, training, and experiences. Poster presented at the annual convention of the National Association of School Psychologists, San Francisco, CA.

Brock, S. E. (2004). The identification of autism spectrum disorders: A primer for the school psychologist. California State University, Sacramento, College of Education, Department of Special education, Rehabilitation, and School Psychology.

Norris, M., & Lecavalier, L. (2010). Screening accuracy of level 2 autism spectrum disorder rating scales: A review of selected instruments. Autism, 14, 263-284.

Pandolfi V., Magyar C. I., & Dill C. A. (2010). Constructs assessed by the GARS-2: factor analysis of data from the standardization sample. Journal of Autism & Developmental Disorders, 40, 1118-30.

Pearson, L. M. (2008). A survey of Pennsylvania school psychologists’ training, knowledge and evaluation practice for assessing and diagnosing autism spectrum disorders. PCOM Psychology Dissertations. Paper 112. http://digitalcommons.pcom.edu/psychology_dissertations/112

Rasmussen, J. E. (2009). Autism: Assessment and intervention practices of school psychologists and the implications for training in the united states. Ball State University). ProQuest Dissertations and Theses, 192. UMI Number: 3379197

Small, S. H. (2012). Autism spectrum disorders (ASD): Knowledge, training, roles and responsibilities of school psychologists. University of South Florida). ProQuest Dissertations and Theses, 220. ISBN: 9781267519658 UMI Number 3308958

Wilkinson, L. A. (2010). A best practice guide to assessment and intervention for autism and Asperger syndrome in schools. London: Jessica Kingsley Publishers.

© Lee A. Wilkinson, PhD

Posted by Lee A. Wilkinson Lee Wilkinson at Sunday, October 07, 2012

Retrieved from: http://bestpracticeautism.blogspot.com/2012/10/school-psychologists-need-more-training.html


autism and schizophrenia…a collision

In Autism Spectrum Disorders, Psychiatry, School Psychology on Tuesday, 9 October 2012 at 06:35

When the autism and schizophrenia spectrums collide

Spectrum. The name conjures up white light separating out through a prism, the multi-coloured rainbow, and even that wonderful 8-bit computer made by Sir Clive Sinclair (yes, I had one of those you Commodore people).

When it comes to autism and schizophrenia,the concept of a spectrum invokes similar ideas of different variations or colours on a theme, separate but linked, patterns of symptoms which stem from a single source but diffuse outwards with fuzzy boundaries. It almost sounds a little bit ‘Sixties’ if I’m truly honest.

For quite a few people, including those on the DSM-V ‘how are we going to redefine autism‘ committee, spectrum is something really being taken on board as the ever-approaching deadline for revision comes closer and closer into view. That’s not to say everyone is particularly happy with the formal spectrum-ing of autism as per this recent review by Luke Tsai* (open-access) who prefers the term ‘autism continuum disorder’, but there you go. Indeed scroll down to the descriptor of autism at the bottom of this blog and I use the word ‘tapestry’ which also might be a good description of the heterogeneity present. (Note to self: this description will need updating next year).

You’re probably wondering why I’m going on about spectrum; well its all to do with this paper by Prof. Kenneth Gadow** and how the autism spectrum and the schizophrenia spectrum might be colliding a little more than we perhaps first thought.

This is not the first time that I’ve talked about autism and schizophrenia overlapping as per this post on some very interesting research indicating that around about 40% of one cohort of people with schizophrenia also presented with symptoms congruent with an autism diagnosis.

Prof. Gadow reports a few interesting things from the other direction insofar as his cohort of children diagnosed with an autism spectrum disorder (ASD) presenting with quite a few characteristics more usually associated with the schizophrenia spectrum disorders (SSDs). In a little more detail (sorry that I can’t link to the full-text paper):

  • Building on previous research by the author***, the aim of the study was multi-fold primarily looking at the risk of SSD symptoms in ASD and also looking at how a comorbid diagnosis of ADHD may moderate that risk of SSD symptoms.
  • Consecutive child referrals (aged 6-12 years) to a developmental or child psychiatry outpatient clinic were included for study.
  • Samples were divided up as follows: Autism (N=147) of which n=50 were diagnosed with an ASD only and n=97 diagnosed with ASD & attention-deficit hyperactivity disorder (ADHD). Controls (N=335) included n=146 asymptomatic and n=188 (I assume the missing participant was excluded for some important reason).
  • The primary schedule of choice was the Child and Adolescent Symptom Inventory-4R (CASI-4R) completed by mums and teachers of participants. In particular, the subscales on Schizoid Personality and Schizophrenia and their combining to form a global SSD score were a focus for this study.
  • Results (a few of them anyway): well, mums and teachers showed some overlap in their scoring of participants (always a relief for a questionnaire) bearing in mind contextual differences. Both children with ASD with and without ADHD “had more severe global SSD ratings than their respective controls” but as with many things linked to autisms, there was quite a bit of variability among participant scores.
  • A diagnosis of ADHD whether associated with ASD or not, seemed to confer a greater risk of SSD symptoms pointing to a likely link between ADHD and SSD.
  • An interesting finding this one: the combination of ASD and ADHD and the pattern of SSD symptoms appearing (e.g. disorganised behaviour and negative symptoms – inappropriate laughter, crying and little interest in doing things) “supports the more general notion that certain combinations of disorders may be better conceptualized as unique clinical conditions“. Now think back to that spectrum – continuum argument and the DSM-5 move away from discrete diagnoses….?
  • Another quote from the paper: “findings provide additional support for an interrelation between ASD and SSD symptoms“.

A few things come to mind from these results. First is this suggestion that some cases of childhood ASD present with patterns of symptoms more readily tied into SSD. As per my previous post on this ‘overlap’, the great scientific machine seems to be doing yet another revolution as autism, once considered to be pretty ‘similar’ to schizophrenia (remember childhood schizophrenia) then departed on it’s own journey, and now appears to be heading back towards schizophrenia or at least SSD.

I’m making no value judgements either way on this process given the likely opinions that might be raised on this matter in terms of diagnostic identity, management options and indeed how autism and schizophrenia have tended to become represented among the general population. If there is an upside to this partial reunification, I suppose it is that shared genetics (and epigenetics), biochemistry (see this post for example) and other areas might open up some interesting avenues for further study. With my own research hat on, I’m thinking Dohan and his hypotheses on gluten in cases of schizophrenia and autism. There are most likely going to be others.

Second is this issue of discrete clinical conditions potentially being present from the current study. Again its all about historical trends in science, and whether people talk about specific clinical entities (diagnostic boxes with names and formal criteria) or ‘lumping things together’ as per the use of terms like spectrum. I admit also to being pretty intrigued by the suggestion of a possible new clinical entity represented by ASD, ADHD and SSD symptoms. I’m no expert, and please don’t take my word as Gospel, but there seem to be some hints of diagnoses like pathological demand avoidance (PDA) also being detailed here. Just a thought.

Finally bearing in mind the Gadow study was based on a paediatric population, one has to wonder how this complex pattern of symptoms will eventually play out into adulthood. Bearing in mind that autism is seemingly protective of nothing when it comes to comorbidity, I think many working at the coalface will know of people diagnosed with autism who seem to develop clinical signs and symptoms more readily associated with the schizophrenia spectrum disorders as maturity sets in. The question is whether the criteria used in the current study could somehow be predictive of those who are at greater risk and whether plans and processes could be set in place to moderate this risk.

I’m going to stop there save any charges of over-analysing the paper from Prof. Gadow and its important findings. Reiterating the complex nature of both ASD and SSD and the areas of overlap which seem to be present, how we understand such conditions and indeed label them actually might turn out to be an important point not just from a identity point of view but also conceptually, onward to planning for / mitigating risk and improving overall quality of life.

Without trying to make light of spectrums, may be you remember this theme tune by the Spectrum?

*Tsai L. Sensitivity and specificity: DSM-IV versus DSM-5 criteria for autism spectrum disorder. Am J Psychiatry. 2012; 169: 1009-1011.

** Gadow KD. Schizophrenia spectrum and attention-deficit/hyperactivity disorder symptoms in autism spectrum disorder and controls. J Am Acad Child Adolesc Psychiatry. 2012; 51: 1076-1084.

*** Gadow KD. & Devincent CJ. Comparison of children with autism spectrum disorder with and without schizophrenia spectrum traits: gender, season of birth, and mental health risk factors. JADD. February 2012.

Gadow KD (2012). Schizophrenia spectrum and attention-deficit/hyperactivity disorder symptoms in autism spectrum disorder and controls. Journal of the American Academy of Child and Adolescent Psychiatry, 51 (10), 1076-84 PMID: 23021482

Retrieved from: http://questioning-answers.blogspot.co.uk/2012/10/when-autism-and-schizophrenia-spectrums.html

The Energetic Brain…a great reference for ADHD

In ADHD, ADHD Adult, ADHD child/adolescent, ADHD stimulant treatment, Medication, Neuropsychology, Psychiatry, Psychopharmacology, School Psychology on Sunday, 7 October 2012 at 09:27

everything you ever wanted to know about adhd. a wonderful reference!


Background TV…when you’re not even actively watching.

In Education, School Psychology, Special Education, Uncategorized on Sunday, 7 October 2012 at 07:22

U.S. kids exposed to 4 hours of background TV daily

By Michelle Healy

A number of studies have found evidence that too much television is bad for children’s development, even when it’s playing in the background and kids are not watching. Now a study has tracked just how much background TV kids get and it’s a lot — 232.2 minutes or nearly 4 hours worth every day.

The average amount is even greater among some, especially children who are younger, African-American or from the poorest families, finds the study in today’sPediatrics.

The nearly four hours of background TV exposure “easily dwarfs” the 80 minutes of active TV viewing the average child in this age group absorbs daily, says the study.

“You’re looking at three times the amount, which is enormous,” says Matthew Lapierre, one of the study authors, an assistant professor of communication studies at the University of North Carolina-Wilmington. “It’s really kind of shocking,” he says.

The study was presented in May at a meeting of the International Communication Association. It was conducted using a nationally representative telephone survey of 1,454 parents with at least one child between the ages of 8 months and 8 years old.

Among questions that parents were asked: how often their TV was on when no one was watching; whether their child had a TV in their bedroom and the number of TVs in the home.

It found that in addition to actual TV viewing, children under age 2 and African-American children were exposed to an average of 5.5 hours a day of a TV playing in the background; children from the poorest families were exposed to nearly 6 hours per day.

The finding among African-Americans “wasn’t unexpected,” says Lapierre noting that statistically, their households “are often found to be more TV-centric,” compared with other groups, with more TVs per household and more of those TVs in bedrooms.

He suspects that the high rate of background TV among very young children may have to do with parents and caregivers leaving the television on, even when they’re not actively watching, to “break up the monotony” of being with an infant or toddler for long stretches of the day.

The study notes that background television exposure has been “linked to lower sustained attention during playtime, lower quality parent-child interactions, and reduced performance on cognitive tasks.”

Heather Kirkorian, an assistant professor of human development and family studies a researcher at the University of Wisconsin-Madison who has published studies on background television’s impact on both parent-child interaction and children’s play patterns, says “until now we could only guess at the extent of the impact in children’s day-to-day lives.” The new study “documents just how great the real-world impact may be, particularly for very young children.”

The American Academy of Pediatrics recommends that children under age 2 not be exposed to any television.

To reduce background TV exposure, the study recommends turning off the TV when no one is watching and at key points during a child’s day, such as bedtime and mealtime.

Retrieved from: http://www.usatoday.com/story/news/nation/2012/10/01/background-tv-viewing-pediatrics/1599995/

television exposure and kids

In School Psychology, Special Education on Wednesday, 3 October 2012 at 05:57

U.S. kids exposed to 4 hours of background TV daily

By Michelle Healy

A number of studies have found evidence that too much television is bad for children’s development, even when it’s playing in the background and kids are not watching. Now a study has tracked just how much background TV kids get and it’s a lot — 232.2 minutes or nearly 4 hours worth every day.

The average amount is even greater among some, especially children who are younger, African-American or from the poorest families, finds the study in today’s Pediatrics.

The nearly four hours of background TV exposure “easily dwarfs” the 80 minutes of active TV viewing the average child in this age group absorbs daily, says the study.

“You’re looking at three times the amount, which is enormous,” says Matthew Lapierre, one of the study authors, an assistant professor of communication studies at the University of North Carolina-Wilmington. “It’s really kind of shocking,” he says.

The study was presented in May at a meeting of the International Communication Association. It was conducted using a nationally representative telephone survey of 1,454 parents with at least one child between the ages of 8 months and 8 years old.

Among questions that parents were asked: how often their TV was on when no one was watching; whether their child had a TV in their bedroom and the number of TVs in the home.

It found that in addition to actual TV viewing, children under age 2 and African-American children were exposed to an average of 5.5 hours a day of a TV playing in the background; children from the poorest families were exposed to nearly 6 hours per day.

The finding among African-Americans “wasn’t unexpected,” says Lapierre noting that statistically, their households “are often found to be more TV-centric,” compared with other groups, with more TVs per household and more of those TVs in bedrooms.

He suspects that the high rate of background TV among very young children may have to do with parents and caregivers leaving the television on, even when they’re not actively watching, to “break up the monotony” of being with an infant or toddler for long stretches of the day.

The study notes that background television exposure has been “linked to lower sustained attention during playtime, lower quality parent-child interactions, and reduced performance on cognitive tasks.”

Heather Kirkorian, an assistant professor of human development and family studies a researcher at the University of Wisconsin-Madison who has published studies on background television’s impact on both parent-child interaction and children’s play patterns, says “until now we could only guess at the extent of the impact in children’s day-to-day lives.” The new study “documents just how great the real-world impact may be, particularly for very young children.”

The American Academy of Pediatrics recommends that children under age 2 not be exposed to any television.

To reduce background TV exposure, the study recommends turning off the TV when no one is watching and at key points during a child’s day, such as bedtime and mealtime.

Retrieved from: http://www.usatoday.com/story/news/nation/2012/10/01/background-tv-viewing-pediatrics/1599995/


Schools and ADHD…an “F” grade

In ADHD, ADHD Adult, ADHD child/adolescent, Education, School Psychology, Special Education on Thursday, 27 September 2012 at 07:25

How schools (even great ones) fail kids with ADHD

By Valerie Strauss

 There’s a group of students struggling through school rd to navigate that gets little attention in the media or in the debate about how to fix schools: Children with ADHD.

ADHD, or Attention Deficit Hyperactivity Disorder, is a brain condition that makes it especially hard for children to focus and concentrate in school and has a number ofother symptoms. It is too often misunderstood by teachers, parents and even the students themselves. According to the Centers for Disease Control, about 9.5% or 5.4 million children 4-17 years of age, had been diagnosed with ADHD, as of 2007. Many others who have the disorder haven’t had the benefit of a diagnosis.

Here is a powerful post by David Bernstein, a nonprofit executive who lives in Gaithersburg, Md., writing about the difficulties that his two sons, ages 7 and 15, have confronted in school as a result of ADHD.

By David Bernstein

When I was in fourth grade in the mid-1970s, my teacher pronounced that I was going to be an artist. The truth was that she didn’t think I had any academic talent to speak of. I was an “ADHD” boy who couldn’t follow directions, figure out what page we were on in the book, or turn my work in on time. With a severely limited understanding of the mind, the teacher simultaneously overestimated my artistic talent and underestimated my intellectual gifts.

School, particularly elementary school, was not for boys like me. And, 25 years later, even the very best schools have only changed slightly.
Like so many others who deviated from the norm, I learned much more from exploring my passions than I ever did from a structured school setting. With the help of numerous mentors, I taught myself how to write op-eds, lead teams, speak, and advocate. I actually cared about ideas, not primarily because of school, but despite it.  The Washington area, alive with political discourse, was the perfect place to give expression to my passions, and I moved here in my early twenties to take a job in the world of advocacy.

Now I have two boys of my own, neither of whom possesses a normative learning style. My teenage son goes to what is widely considered an excellent private school in the area with numerous wonderful, committed teachers. But like nearly every other educational institution in America, it’s built on an outmoded educational model.

Ironically, I first began to question the current model of education when the headmaster of my son’s school showed a video clip at a graduation ceremony of creativity guru Ken Robinson discussing how education kills creativity. Robinson maintains that we are using a model of education left over from the industrial revolution, where schools are organized along factory lines, complete with ringing bells and separate facilities.  “We educate kids in batches, as if the most important thing about them is their date of manufacture,” he states in another video on the topic.

Influenced by Robinson, best-selling author Seth Godin recently published a manifesto , “Stop Stealing Dreams,” on the need for radical education reform. He lays out the need for a post-industrial educational model that caters to diverse learning styles, passion for ideas and what individual students really care about. In such a school, teachers are coaches who help students in a journey of self-discovery. Students have a great deal of choice to determine what they study and how they study it, in stark contrast to the one-size-fits-all system of today.

Your child is right that he or she will never use trigonometry (unless so inclined). Exposing them to variety is one thing, but forcing the same subject for 13 years is another. In the modern marketplace, depth is just as important, if not more so, than breadth. Schools are all about breadth.

In today’s schools, the “good” students end up conforming, diminishing their own prospects for greatness, and the rest end up in an excruciating battle with themselves, their parents (trust me on this), their teachers and the endless tutors. My job as a parent, I’m reminded over and over again by the school, is to enforce the absurdity of the current system — make them turn everything in on time — which I do faithfully because there seems to be no other choice.

My youngest child, a rising second grader, rambunctious and restless as any you’ll find, has “fallen behind” in reading. He is “not sufficiently available for learning,” we are told. The teachers and guidance counselors, loving and well-meaning though they are, insist on ADHD meds so he can amp up his reading and catch up with his classmates. He’s a creative, bright, independent child, who will, there’s not a doubt in my mind, learn to read well and become highly successful. But he’s just not on their timetable for reading.

We are forced, in the words of Ken Robinson, to “anesthetize” him so he can function in today’s antiquated classroom setting. The Ritalin will do nothing to make him a more successful human being, a better thinker, or a more productive member of society. It will simply help him keep up with the masses and potentially drain him of some of his creative juices. By forcing him and so many other children like him to take thesepowerful drugs , schools deprive the future economy and society of precisely the creative talent they will need the most.

Greg Selkoe, the 36-year-old CEO of Karmaloop, a growing hipster media company with revenue of more than $130 Million a year, stated in a recent interview in Inc.: “I was diagnosed with ADHD in elementary school and actually got kicked out of several schools before landing in one for kids with learning issues. What made me not do well in school has actually been very beneficial in business, because I can focus on something very intensely for a short while and then move on to the next thing.”

Yet today’s schools insist that we prescribe our kids drugs to rid them of their hyper-focus.

I’ve talked with a number of educators, who see the writing on the wall for the current education system. They know that the economic reality of the day demands that schools change. But they also know that college-obsessed parents would balk at such changes, fearful that it might detract from their kids’ chances to go to the best college possible.
It will take monumental leadership to change the current educational mindset and model. In the meantime, my kids will struggle through school, battered along the way, and, like their father, be forced to discover most of their talents and passions on their own, outside of school.

Retrieved from: http://www.washingtonpost.com/blogs/answer-sheet/post/how-schools-even-great-ones-fail-kids-with-adhd/2012/09/23/8e81c83c-f828-11e1-8253-3f495ae70650_blog.html

Information regarding the upcoming DSM V

In Neuropsychology, Psychiatry, School Psychology on Wednesday, 26 September 2012 at 08:00

DSM-5: Finding a Middle Ground

Nassir Ghaemi, MD

DSM-5: Validity vs Reliability

This year’s American Psychiatric Association (APA) annual meeting was probably the last before the publication of theDiagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), scheduled for May of next year. Hence, there was a sense of tense uncertainty in the many sessions addressing potential DSM-5 revisions.

DSM-5 Task Force Vice Chair Darrel Regier headed a symposium reviewing results of field trials on the reliability of proposed DSM-5 criteria. The trials were meant to assess whether clinicians can use the proposed criteria consistently and provided kappa values for the individual proposals.

Kappa values reflect the agreement in a rating by 2 different persons, after correction for chance agreement. From a statistical perspective, kappa values greater than 0.5 are generally considered good. As an example, 70% agreement between raters translates to a kappa value of 0.4.

Results of the field trials showed good agreement for such disorders as major neurocognitive disorder, autism spectrum disorders, and post-traumatic stress disorder, with kappa values of 0.78, 0.69, and 0.67, respectively. However, poor kappa values, in the range of 0.20-0.40, were reported for commonly diagnosed conditions, such as generalized anxiety disorder and major depressive disorder. All of the observed kappa values in the DSM-5 field trials translate to agreement between clinicians of around 50%.

Is this good or bad? A recent editorial[1] by DSM-5 leaders makes comparisons with other medical settings, and the claim is that most medical diagnoses involve diagnostic kappa values similar to those in the DSM-5 field trials. I spoke with prominent psychiatrists at this year’s meeting who were involved in some of these DSM studies and discussions; they expressed unhappiness with the kappa values in DSM-5 field trials, and some pointed out that kappa values in the DSM-III were higher.

So, the reliability of DSM-5 criteria seems to have declined compared to DSM-III. Is this a problem? It might be, but it might not be.

Reliability only means that we agree. It doesn’t mean that we agree on what is right. Validity is a separate issue. It could be that criteria are changed so that they are more valid — that is, actually true — but this could increase unreliability; raters might have to use, for instance, some criteria that are less objective and hence less replicable.

We will see. DSM-5 might be more valid but less reliable than DSM-IV and DSM-III. If so, that’s progress, in a way.

It is also important to think about other medical studies with low reliability. We should be careful about criticizing certain diagnoses, such as bipolar disorder (as some have[2]), without an awareness that this is the case for almost all our diagnoses. The problem of reliability is a general one, not a problem about claimed “overdiagnosis” of some conditions.

In my view, it is definitely time for a new edition of DSM; we can’t pretend that something written almost 2 decades ago is anywhere near up to date, with a generation of new research. Some of the proposed changes in DSM-5 — for example, the inclusion of antidepressant-induced mania as part of bipolar disorder; the inclusion of dimensions for axis II personality conditions; and the removal of nosologically nonspecific axis II diagnoses, such as “histrionic” personality — are consistent with an update based on convincing new research. But other changes, such as the wish to discourage the diagnosis of childhood bipolar disorder by making up a new category based on limited data (temper dysregulation disorder), merely repeat the mistakes of DSM-IV. Making up diagnoses because we don’t like others is not a scientifically sound way to revise a profession’s diagnostic system, and it won’t serve us well for the next 20 years.

But DSM-IV Has Limitations, Too

Also at this year’s APA meeting, Steven Hyman, a psychiatrist and neurobiology researcher who is former head of the National Institute of Mental Health, gave a plenary lecture on DSM-5 that was refreshingly honest in its appreciation of the limitations that the DSM-IV has placed on research. Rewinding to DSM-III, from the 1980s, he made the point that although that edition was a major advance, it is now out of date, and that DSM-IV, which merely continued the basic DSM-III structure, needs major changes. “The DSM-III was a brilliant document that could not have foreseen the science. It’s time to move on scientifically,” said Hyman.

Hyman noted that DSM-III actually hinders science. Researchers have difficulty getting funding from the National Institutes of Health or publishing papers that go outside DSM criteria: “For example, it was very hard to get a grant to test the hypothesis that maybe the apparent comorbidity of multiple anxiety disorder and mood disorders was just that there was a single underlying process or single disorder that got expressed with different symptom complexes in different times in life.”

There was a name for that condition — neurotic depression — and Sir Martin Roth, the great British psychopathologist, warned repeatedly in the 1970s and 1980s that it would be a mistake for DSM-III to remove it. DSM-III made that mistake, and the field has since acted like it would be a sin to study the matter any further.

There are many examples of this ilk in DSM-III and DSM-IV. Some who are upset with proposed changes in DSM-5 are diagnostic conservatives who seem to think that all our questions were answered in 1980 and 1994.

Dr. Hyman has been influential in designing the new Research Domain Criteria (RDOC), an attempt to create a DSM for research that begins with biological, rather than clinical, terms. I agree with the need for a DSM for research, but I don’t think our biological knowledge is advanced enough yet — despite all the advances that have been made — to build a diagnostic system from them, even for research purposes.

I think we should have a new DSM just for research: a system of Research Diagnostic Criteria (RDC), like what was created in the 1970s that led to DSM-III to begin with. I’ve started that process with my colleagues in the world of bipolar disorder research. We will publish a new RDC for bipolar disorder within the coming year — before DSM-5, I hope. If we do so, I hope that colleagues in other specialties in psychiatry will produce similar RDCs.

With these new publications, psychiatry may then be in a position for real advance. We will then have 3 nosologies, all complementary to each other and able to improve the others:

  1. DSM-5: a nosology based on a mix of research, economic concerns, social preferences, and professional consensus that is used for basic practice, insurance reimbursement, and short-term consensus.
  2. RDOC: a nosology based solely on biological research that is used for research.
  3. RDC: a nosology based solely on clinical research that is used for research.

In summary, DSM-5 is on its way, and May 2013 is as good a date as any for its publication. In some places, it will be a much-needed advance over the now-outdated DSM-IV. But in other places, it keeps old categories that are not as well proven as they should be, and it even adds a few new categories that are mainly based on professional, economic, and social concerns rather than on sufficient scientific evidence.


  1. Kraemer HC, Kupfer DJ, Clarke DE, Narrow WE, Regier DA. DSM-5: how reliable is reliable enough? Am J Psychiatry. 2012;169:13-15. http://ajp.psychiatryonline.org/article.aspx?articleid=181221 Accessed May 15, 2012.
  2. Zimmerman M, Ruggero CJ, Chelminski I, Young D. Is bipolar disorder overdiagnosed? J Clin Psychiatry. 2008;69:935-940.

Retrieved from: http://www.medscape.com/viewarticle/764740?src=ptalk

Early detection of ASDs

In Autism Spectrum Disorders, Neuropsychology, School Psychology on Wednesday, 26 September 2012 at 06:54

ASD’s Can Be Diagnosed in Patients as Young as 12 Months

Fran Lowry & Hien T. Nghiem, MD

Clinical Context

Autism-spectrum disorders (ASDs) are neurodevelopmental disorders diagnosed by clinical observation of core behavioral symptoms. The prevalence of ASDs is estimated to be approximately 1% of the general population and is typically diagnosed in the preschool years. However, it has been reported that behavioral risk signs of ASDs may be evident before 12 months of age.

By 9 to 12 months of age, infants who will eventually receive a diagnosis of ASD may demonstrate the absence of social communicative features, such as shared affective engagement, imitation, social orienting, and joint attention, and present with unusual sensory features such as repetitive play, sensory preoccupations, emotional dysregulation, hyporesponsiveness to novel stimuli, and atypical motor behaviors. The First Year Inventory (FYI) is a parent-report measure designed to identify 12-month-old infants at risk for ASD. FYI taps behaviors that indicate risk in the developmental domains of sensory–regulatory and social–communication functioning.

The aim of this study is to determine an effective FYI scoring cutoff for most accurately indentifying infants who are at risk for a later diagnosis of ASD. The aim was met by conducting a follow-up of 699 children at 3 years of age from a community sample whose parents completed the FYI when their children were 12 months old.

Study Synopsis and Perspective

A questionnaire for parents is a promising tool for identifying 12-month-old infants who are at risk for an eventual diagnosis of ASD, new research shows.

A longitudinal follow-up study showed that 31% of children identified by the inventory as being at risk for ASD at 12 months had a confirmed diagnosis by age 3 years.

In addition, 85% of the children identified at 12 months had a developmental disability or concern by age 3 years, coauthor Grace Baranek, PhD, from the University of North Carolina School of Medicine, Chapel Hill, told Medscape Medical News.

“These children have the advantage of being enrolled in an intervention sooner and being tracked sooner than they would normally be, because most of the screenings that are recommended by the American Academy of Pediatrics happen at 18 or 24 months of age,” Dr. Baranek said.

Led by Lauren M. Turner-Brown, PhD, who is also from the University of North Carolina School of Medicine, the study was published online July 10 in Autism: The International Journal of Research & Practice.

Critical Changes

The FYI was developed specifically for 12-month-old infants because this age seems to map onto a period of critical developmental and neurobiological changes that are occurring in many infants who will eventually be diagnosed with ASD, she explained.

The current study was carried out to determine the effectiveness of the inventory in identifying infants at risk for a later diagnosis of ASD. In it, the parents of the 699 children who had completed the FYI when their child was 12 months old completed the additional screening questionnaires when their child reached the age of 3 years.

The parents and children were recruited through a community mailing that was based on North Carolina birth records.

In addition to the FYI, parents received the Social Responsiveness Scale–Preschool Version and the Developmental Concerns Questionnaire, which asked specific questions about parent concerns and child diagnoses. They also received $5.00 to encourage participation in the study.

The inventory identified 6 children with ASD and 3 children with pervasive developmental disorder–not otherwise specified.

Sooner Is Better

A high score in the sensory regulatory domain, which looked at such things as unusual behaviors with play, repetitive behaviors, unusual responses to sensory things such as light and sounds, and day-to-day regulatory patterns such as feeding, sleeping, and eating, was an important predictor of a future diagnosis of ASD, Dr. Baranek said.

Scoring badly in the social communication domain, especially when accompanied by a high score in the sensory regulatory domain, was also predictive, she said. “What we are finding is that although we can identify a lot of children who go on to have autism through their lack of social communicative abilities, the sensory regulatory items help us to more specifically identify the kids with autism so we’re not overidentifying just children with language delay.”

Once the FYI tool is refined, Dr. Baranek said, she and her team would like to see it used in primary care settings at the 12-month baby check, where physicians, nurse practitioners, and early interventionists could screen the child and use the inventory as a basis for progressive surveillance.

“The sooner we can identify any child who has a concern, the sooner they can be referred for more comprehensive evaluation and be connected with support services,” she said.

Significant Impact

Autism Society board chairman Jim Ball agreed. Commenting on this work for Medscape Medical News, Ball said: “Early screening and diagnosis can have a significant impact in an individual’s life, leading to improved educational and social outcomes, as well as employment and independent living in adulthood.”

He added that it is a priority of the Autism Society “to ensure all families know the signs of autism, have access to expert diagnosticians, receive appropriate services, and transition effectively into adulthood.”

The study was funded in part by the National Institutes of Health, Autism Speaks, and the Ireland Family Foundation. Dr. Turner-Brown, Dr. Barane, and Ball have disclosed no relevant financial relationships.

Autism. Published online July 10, 2012.

Study highlights

  • Families who participated in the FYI normative study and who gave consent to be recontacted were invited to participate in this longitudinal follow-up.
  • There were 2 phases: the initial FYI screening mailing at 12 months of age and the subsequent follow-up mailing at age 3 years.
  • At 3 years, parents of 699 children completed the Social Responsiveness Scale–Preschool version and the Developmental Concerns Questionnaire to determine developmental outcomes.
  • In addition, children deemed at risk for ASD on the basis of liberal cut points on the FYI, Social Responsiveness Scale–Preschool, and/or Developmental Concerns Questionnaire were invited for in-person diagnostic evaluations.
  • 38 families participated in the in-person diagnostic assessments. In addition to the FYI, Social Responsiveness Scale–Preschool, and Developmental Concerns Questionnaire, the 38 children who received further in-person diagnostic evaluation also completed the Mullen Scales of Early Learning, the Vineland Adaptive Behavior Scale, and the Autism Diagnostic Observation Schedule.
  • A “best estimate” diagnostic outcome was determined and divided into 1 of 4 categories: diagnosis of ASD; diagnosis of other developmental disability; no professional diagnosis, but developmental concerns noted or observed; and no developmental concerns.
  • 9 children had a confirmed diagnosis of ASD from the sample of 699 children, representing 1.3% of this sample.
  • A total of 43 children (6%) were in the diagnosed or treated group for non-ASD developmental problems.
  • An additional 82 (12%) children were in the developmental concerns group.
  • Finally, 574 (82%) of 699 children were in the no concerns group.
  • According to the receiver operating characteristic (ROC) analyses, “a total risk score…of 19.2, which is at or above the 96th percentile, was chosen as the best cutoff score.”
  • A second ROC analysis was performed to calculate the optimal cutoffs for each of the 2 FYI domains.
  • For the social communication domain, “a domain score of 22.5, which is at the 94th percentile, yielded the optimal classification of children with ASD at age 3.”
  • “For the sensory-regulatory domain, a score of 14.75, which is at the 88th percentile, yielded optimal classification of children with an ASD diagnosis at age 3.”
  • The ROC analyses determined that a 2-domain cutoff score yielded optimal classification of children: 31% of those meeting algorithm cutoffs had ASD and 85% had a developmental disability or concern by age 3 years.
  • Limitations of the study included the following:
    • lack of design as an epidemiological study,
    • lack of generalizability because the families who participated in the study tended to be more educated and less racially diverse,
    • that unidentified children were probably missed by current measures, and
    • the feasibility of such large-scale diagnostic protocols.

Clinical Implications

  • By 9 to 12 months of age, infants who will eventually receive a diagnosis of ASD may demonstrate the absence of social communicative features and the presence of unusual sensory features.
  • These results suggest that the FYI is a promising tool for identifying 12-month-old infants who are at risk for an eventual diagnosis of ASD.

Retrieved from: http://www.medscape.org/viewarticle/769367


First Direct Genetic Evidence for ADHD Discovered-2010

In ADHD, ADHD Adult, ADHD child/adolescent, Genes, Genomic Medicine, Neuropsychology, Psychiatry, School Psychology on Tuesday, 25 September 2012 at 06:20

an older article, but one i thought worthy of posting.

First Direct Genetic Evidence for ADHD Discovered

Caroline Cassels

September 29, 2010 — New research provides the first direct evidence that attention-deficit/hyperactivity disorder (ADHD) is genetic.

In a study published online September 30 in The Lancet, investigators from the University of Cardiff in the United Kingdom say their findings, which show that ADHD has a genetic basis, suggest it should be classified as a neurodevelopmental and not a behavioral disorder.

“We’ve known for many years that ADHD may well be genetic because it tends to run in families in many instances. What is really exciting now is that we’ve found the first direct genetic link to ADHD,” principal investigator Anita Thapar, MD, told reporters attending a press conference to unveil the study results.

In the genomewide analysis, 366 children 5 to 17 years of age who met diagnostic criteria for ADHD but not schizophrenia or autism and 1047 matched controls without the condition were included. Researchers found that compared with the control group without ADHD, children with the disorder were twice as likely — approximately 15% vs 7% — to have copy number variants (CNVs).

CNVs, explained study investigator Nigel M. Williams, PhD, are sections of the genome in which there are variations from the usual 2 copies of each chromosome, such that some individuals will carry just 1 (a deletion) and others will have 3 or more (duplications).

“If a gene is included in one of these copy number variants, it can have deleterious consequences,” said Dr. Williams.

Shared Biological Link

The study authors note that the increased rate of CNVs was particularly high among children with a combination of ADHD and learning disabilities but “there was also a significant excess in cases with no such disability.”

The researchers also found that CNVs overlap with chromosomal regions that have previously been linked to autism and schizophrenia. Although these disorders are thought to be completely separate, there is some overlap between ADHD and autism in terms of symptoms and learning difficulties.

We’ve looked at only 1 class of variation, but it’s an important one because it has been linked to other brain disorders.

This finding suggests there may be a shared biological basis for the 2 conditions and, according to investigators, provides the first direct evidence that ADHD is a neurodevelopmental condition.

“We found that the most significant excess of these types of copy number variants was on a specific region of chromosome 16. This chromosomal region includes a number of genes, including one that affects brain development,” said Dr. Thapar.

The team’s research marks the start of the “unraveling of the genetics” of ADHD, according to Dr. Thapar.

“We’ve looked at only 1 class of variation, but it’s an important one because it has been linked to other brain disorders,” she said.

Implications for DSM-5?

Dr. Thapar added that the study results also have direct implications for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is currently under development by the American Psychiatric Association.

A “huge debate” about whether ADHD should be classified as a behavioral or neurodevelopmental disorder is ongoing. However, she said, these findings should help put this controversy to rest.

“Our results clearly show that ADHD should be considered a neurodevelopmental disorder,” she said.

In fact, Dr. Thapar noted that the study findings have been submitted to one of the DSM-5 work groups for consideration in the development of the new manual.

The investigators note that despite epidemiologic evidence derived from twin studies showing high heritability and the fact that ADHD is often accompanied by learning disabilities, there is still a great deal of public misunderstanding about the disorder.

Some people say this is not a real disorder, that it is the result of bad parenting. Children and parents can encounter much stigma because of this. So this finding of a direct genetic link to ADHD should help clear this misunderstanding and help address the issue of stigma.

“Some people say this is not a real disorder, that it is the result of bad parenting. Children and parents can encounter much stigma because of this. So this finding of a direct genetic link to ADHD should help clear this misunderstanding and help address the issue of stigma,” said Dr. Thapar.

Although there are no immediate treatment implications, Dr. Thapar said she hopes the research will have an immediate impact in terms of shifting public perception about ADHD and fuel further research into the biological basis of the disorder with a view to developing better, more effective therapies for affected individuals.

In an accompanying editorial, Peter H. Burbach, PhD, from the Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, the Netherlands, writes, “The first gains beyond today’s study might be initial insights into the pathogenesis and neurobiology of brain development as influenced by these genetic variants. This knowledge will eventually enter the clinic and might affect the way people think about and treat neurodevelopmental disorders by accounting for the biological consequence of the specific patient’s genotype.”

Lancet. Published online September 30, 2010.

Retrieved from: http://www.medscape.com/viewarticle/729652

coming soon to a bookstore near you!

In ADHD, ADHD Adult, ADHD child/adolescent, Neuropsychology, School Psychology, Uncategorized on Monday, 24 September 2012 at 16:47

Psychometric Analysis of the New ADHD DSM-V Derived Symptoms

Ahmad Ghanizadeh

BMC Psychiatry. 2012;12(21) © 2012 BioMed Central, Ltd.

Abstract and Introduction

AbstractBackground Following the agreements on the reformulating and revising of ADHD diagnostic criteria, recently, the proposed revision for ADHD added 4 new symptoms to the hyperactivity and Impulsivity aspect in DSM-V. This study investigates the psychometric properties of the proposed ADHD diagnostic criteria.
Method ADHD diagnosis was made according to DSM-IV. The parents completed the screening test of ADHD checklist of Child Symptom Inventory-4 and the 4 items describing the new proposed symptoms in DSM-V.
Results The confirmatory factor analysis of the ADHD DSM-V derived items supports the loading of two factors including inattentiveness and hyperactivity/impulsivity. There is a sufficient reliability for the items. However, confirmatory factor analysis showed that the three-factor model is better fitted than the two-factor one. Moreover, the results of the exploratory analysis raised some concerns about the factor loading of the four new items.
Conclusions The current results support the two-factor model of the DSM-V ADHD diagnostic criteria including inattentiveness and hyperactivity/impulsivity. However, the four new items can be considered as a third factor.


Attention-deficit/hyperactivity disorder (ADHD) is one of the most common behavioral disorders in children and adolescents. Its rate in community samples is variably reported. A study reported the rate of 5.29%.[1] Meanwhile, the rate of its screening symptoms is much higher, reaching up to 10.1% in school age children.[2] This high rate of ADHD prevalence emphasizes the need for accurate identification and diagnosis of ADHD.[3]

There has been a recent significant argument or controversy regarding the necessity of reformulating and revising ADHD criteria.[1,4,5] For example, recent criticism of the current ADHD subtypes and the suggestion of including age-specific ADHD criteria in DSM V should be considered.[6] In addition, the current ADHD subtypes are frequently criticized.[3] Some researchers are interested in introducing ADHD-inattentive type as a learning disorder.[7] Furthermore, there is a debate whether oppositional defiant disorder should be considered as a type of ADHD.[8,9] Girls with ADHD are underdiagnosed in the community.[6] Moreover, the impact of the change in the age of the onset has been investigated.[10]

Given that the proposed DSM-V criteria for ADHD are available and would be implemented in the near future,[11] it is advised that their psychometric properties and modifications be studied before their clinical application. To the best of the author’s knowledge, there are no published studies investigating the psychometric properties of the proposed ADHD diagnostic criteria for DSM-V.

DSM-IV defines ADHD as a cluster of symptoms; the patient must have at least six or more out of the 9 symptoms of inattention and/or six or more out of the 9 symptoms of hyperactivity/impulsivity.[12] The proposed revision of ADHD by American Psychiatric Association added 4 new symptoms to the Hyperactivity and Impulsivity aspect in DSM- V. These four symptoms are: “Tends to act without thinking, such as starting tasks without adequate preparation or avoiding reading or listening to instructions, may speak out without considering consequences or make important decisions on the spur of the moment, such as impulsively buying items, suddenly quitting a job, or breaking up with a friend”, “Is often impatient, as shown by feeling restless when waiting for others and wanting to move faster than others, wanting people to get to the point, speeding while driving, and cutting into traffic to go faster than others”, “Is uncomfortable doing things slowly and systematically and often rushes through activities or tasks”, and “Finds it difficult to resist temptations or opportunities, even if it means taking risks (A child may grab toys off a store shelf or play with dangerous objects; adults may commit to a relationship after only a brief acquaintance or take a job or enter into a business arrangement without doing due diligence)”.[11]

The aim of this study was to investigate the psychometric properties of the proposed ADHD symptoms in DSM-V. In the first step, factor analyses were conducted to assess the loadings for the symptoms. Then, the convergent and discriminative validity of the categories of inattentiveness and hyperactivity-impulsivity of DSM-V ADHD symptoms were assessed. Finally, the internal reliability of the inattentiveness and hyperactivity- impulsivity was calculated.


106 children, who were consecutive referrals to a university affiliated Child and Adolescent Psychiatry Clinic in Shiraz, Iran, participated in this study. All of the children and adolescents were interviewed face to face by a board certified Child and Adolescent psychiatrist. In addition, at least one of their parents or caregivers was interviewed face to face as a collateral information resource.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, DSM-IV diagnostic criteria was used to make psychiatric diagnoses.[12] Interviews were conducted according to the Farsi version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children.[13]

Parents reported ADHD symptoms by completing the ADHD checklist of child symptom inventory-4.[14–16] The ADHD checklist of child symptom inventory-4 includes 18 symptoms. The symptoms are categorized into two groups of inattentiveness and hyperactive/impulsivity symptoms. The inattentiveness symptoms category consists of 9 symptoms according to DSM-IV. The category of hyperactive/impulsivity symptoms consists of 9 symptoms according to DSM-IV as well. In fact, the symptoms are the DSM-IV diagnostic criteria. There is a 5-point Likert response scale for the symptoms. The responses ranged from “never,” “sometimes,” “often,” to “almost always”. Scores 0 and 1 were assigned to the categories of “never” and “sometimes”, respectively. The categories of “often” and “almost always” were assigned to 2 and 3, respectively. The range of scoring for each of inattentiveness and hyperactivity-impulsivity categories was from 0 to 9. The Farsi version of this checklist has enough reliability, convergent and discrimination validity[15] and has been used in many studies.[17–19] The internal reliability of this checklist for ADHD-inattentive type, ADHD-Hyperactive impulsive type, and combined type of ADHD is 0.81, 0.85, and 0.83, respectively.[14]

The four new items proposed by DSM-V to be added to ADHD diagnostic criteria were translated into Farsi and back translated into English by a bilingual child and adolescent psychiatrist and a psychologist. Every effort was made to preserve the concept of each symptom. After a pilot study on children referred to the clinic, the final version was used in the current study. The responses to these symptoms were in the Likert scale ranging from “never,” “sometimes,” “often,” to “almost always”.

The children and parents or caregivers gave their assent or informed written consent for voluntary participation in this study. This study was approved by the Ethics Committee of Shiraz University of Medical Sciences.


SPSS statistical software was used to analyze the data. A factor analysis with varimax rotation was conducted to examine the factor structure of the ADHD DSM-V symptoms. The Kaiser-Meyer-Olkin Measure and the Bartlett’s test of sphericity were conducted. Internal consistency was examined using Cronbach’s tests.

One-, two-, three-factor models of confirmatory factor analysis were also conducted using LISREL 8.54 software. The convergent and discriminative validity of ADHD symptoms were analyzed using Pearson’s r correlation coefficient.

Another factor analysis was also conducted including the four newly proposed symptoms to examine item loading of the 13 symptoms of DSM-V derived hyperactivity- impulsivity symptoms. Here, the symptoms of inattentiveness were not included in the analysis. This analysis was conducted to examine whether the 13 items could be divided into two categories of hyperactivity and impulsivity.

Another factor analysis was conducted including the DSM-IV derived inattentiveness symptoms and the four new symptoms proposed in DSM-V. The symptoms of hyperactivity-impulsivity of DSM-IV were not included.


The sample included 84 (79.2%) boys and 22 (20.8%) girls. The age range of the children and adolescents was 5.5 to 17years. Their mean age was 9.1(SD = 2.5) years.

The Kaiser-Meyer-Olkin Measure was 0.76. It shows the adequacy of sampling. The Bartlett’s test of sphericity was less than 0.001. These results indicate that the data are suitable for factor analysis. The factor loading of the principal component analysis is indicated in Table 1. The factor of Hyperactivity-Impulsivity explained 30.4% (eigenvalue = 6.7) of the total variance. The factor of Inattentiveness accounted for 12.1% (eigenvalue = 2.6). Nearly all of the symptoms of inattentiveness were loaded in one factor. All of the Hyperactivity-Impulsivity symptoms were loaded on another factor. Three out of the four newly proposed ADHD separate symptoms were loaded on the factor including inattentiveness symptoms.


Table 1. Principal component analysis of the ADHD DSM-V checklist by rotated method of varimax

Component DSM-V symptoms Hyperactivity- Impulsivity
ADHD- item 1- makes careless mistakes −.049 .600
ADHD- item 2- sustaining attention .032 .731
ADHD- item 3- listening when spoken to .323 .319
ADHD- item 4- follows instructions .354 .515
ADHD- Item 5- organizing tasks .164 .775
ADHD-Item 6 – sustained mental effort −.097 .784
ADHD- item 7- loses things .185 .527
ADHD- item 8- distracted by extraneous stimuli .223 .536
ADHD- item 9- forgetful in daily activities .157 .486
ADHD- item10- fidgets with hands .532 .227
ADHD- item11- leaves seat in classroom .657 .206
ADHD- item 12- runs about .638 .178
ADHD- item 13- playing or leisure activities .864 −.013
ADHD- item 14- often “on the go” .800 −.008
ADHD- item 15- talks excessively .726 .152
ADHD- item 16- blurts out answers .663 .134
ADHD- item 17- awaiting turn .625 .335
ADHD- item 18- interrupts or intrudes on others .713 .086
ADHD- item 19- act without thinking .272 .412
ADHD- item 20- impatient .431 .330
ADHD- item 21- uncomfortable doing things slowly and systematically .358 .430
ADHD- item 22- difficult to resist temptations or opportunities .236 .399

Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization.

In order to test which of the various models gives the best fit to the data, three confirmatory factor analyses were conducted. A one-factor model was not a good fit (Chi- square = 384.65, df = 209, P value 0.0001, Root Mean Square Error of Approximation (RMSEA) = 0.098, Non-normed Fit index (NNFI) = 0.96, Comparative Fit index = 0.96.).

A two-factor model fit well. The results of two-factor model confirmatory factor analysis showing the correlation between inattentiveness and hyperactivity/impulsivity factors that was .56 are displayed in Table 2.

Table 2. The two-factor model of Confirmatory Factor Analysis of the ADHD DSM- V Checklist

Component DSM-V symptoms Hyperactivity- Impulsivity
ADHD- item 1- makes careless mistakes .49
ADHD- item 2- sustaining attention .71
ADHD- item 3- listening when spoken to .53
ADHD- item 4- follows instructions .73
ADHD- Item 5- organizing tasks .81
ADHD-Item 6 – sustained mental effort .66
ADHD- item 7- loses things .57
ADHD- item 8- distracted by extraneous stimuli .63
ADHD- item 9- forgetful in daily activities .56
ADHD- item10- fidgets with hands .64
ADHD- item11- leaves seat in classroom .72
ADHD- item 12- runs about .71
ADHD- item 13- playing or leisure activities .84
ADHD- item 14- often “on the go” .81
ADHD- item 15- talks excessively .76
ADHD- item 16- blurts out answers .69
ADHD- item 17- awaiting turn .76
ADHD- item 18- interrupts or intrudes on others .72
ADHD- item 19- act without thinking .49
ADHD- item 20- impatient .62
ADHD- item 21- uncomfortable doing things slowly and systematically .58
ADHD- item 22- difficult to resist temptations or opportunities .51

Chi-square = 384.65, df = 209, P valu < 0.0001, Root Mean Square Error of Approximation (RMSEA) = 0.098, Non-normed Fit index (NNFI) = 0.96, Comparative Fit index = 0.96.

However, a three-factor model of confirmatory factor analysis also fit well and it was better than the two-factor model (Table 3).

Table 3. The three-factor model of Confirmatory Factor Analysis of the ADHD DSM-V Checklist

Component Newly DSM-V symptoms Hyperactivity- Impulsivity
Inattentiveness added items
ADHD- item 1- makes careless mistakes .49
ADHD- item 2- sustaining attention .71
ADHD- item 3- listening when spoken to .52
ADHD- item 4- follows instructions .72
ADHD- Item 5- organizing tasks .82
ADHD-Item 6 – sustained mental effort .67
ADHD- item 7- loses things .57
ADHD- item 8- distracted by extraneous stimuli .63
ADHD- item 9- forgetful in daily activities .56
ADHD- item10- fidgets with hands .65
ADHD- item11- leaves seat in classroom .74
ADHD- item 12- runs about .73
ADHD- item 13- playing or leisure activities .86
ADHD- item 14- often “on the go” .83
ADHD- item 15- talks excessively .78
ADHD- item 16- blurts out answers .71
ADHD- item 17- awaiting turn .78
ADHD- item 18- interrupts or intrudes on others .74
ADHD- item 19- act without thinking .63
ADHD- item 20- impatient .80
ADHD- item 21- uncomfortable doing things slowly and systematically .78
ADHD- item 22- difficult to resist temptations or opportunities .66

Chi-square = 31.84, df = 206, P valu < 0.0001, Root Mean Square Error of Approximation (RMSEA) = 0.077, Non-normed Fit index (NNFI) = 0.99, Comparative Fit index = 0.99.

The factor loading of the second component analysis including only the symptoms of hyperactivity-impulsivity of DSM-V is displayed in Table 4. The Kaiser-Meyer-Olkin Measure was 0.83. Bartlett’s test of sphericity was less than 0.001. It shows that all of the symptoms of the ADHD DSM-IV derived are loaded in one factor. Meanwhile, the four new symptoms proposed in DSM-V are loaded in another factor.

Table 4. Principal components analysis of the hyperactivity-impulsivity symptoms of ADHD DSM-V Checklist

Hyperactivity-impulsivity symptoms
1 2
ADHD- item10- fidgets with hands .566 .123
ADHD- item11- leaves seat in classroom .666 .214
ADHD- item 12- runs about .629 .225
ADHD- item 13- playing or leisure activities .834 .111
ADHD- item 14- often “on the go” .771 .157
ADHD- item 15- talks excessively .753 .154
ADHD- item 16- blurts out answers .682 .112
ADHD- item 17- awaiting turn .574 .396
ADHD- item 18- interrupts or intrudes on others .717 .132
ADHD- item 19- act without thinking .207 .496
ADHD- item 20- impatient .208 .794
ADHD- item 21- uncomfortable doing things slowly and systematically .187 .755
ADHD- item 22- difficult to resist temptations or opportunities .022 .781

Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization.

The principal component analysis including the DSM-IV derived inattentiveness symptoms and the four new symptoms proposed in DSM-V indicated the two factor loading (Table 5). This analysis indicates that all of the inattentiveness symptoms are loaded in one factor and the new symptoms proposed in DSM-V are loaded in another factor.

Table 5. Principal component analysis including the DSM-IV derived inattentiveness symptoms and the four new symptoms proposed in DSM-V

Inattentiveness symptom of DSM-IV and new proposed symptoms in DSM-V
1 2
ADHD- item 1- makes careless mistakes .676 −.045
ADHD- item 2- sustaining attention .780 .079
ADHD- item 3- listening when spoken to .486 .122
ADHD- item 4- follows instructions .551 .322
ADHD- Item 5- organizing tasks .686 .386
ADHD-Item 6 – sustained mental effort .667 .192
ADHD- item 7- loses things .414 .341
ADHD- item 8- distracted by extraneous stimuli .450 .367
ADHD- item 9- forgetful in daily activities .579 .057
ADHD- item 19- act without thinking .275 .565
ADHD- item 20- impatient .069 .785
ADHD- item 21- uncomfortable doing things slowly and systematically .136 .793
ADHD- item 22- difficult to resist temptations or opportunities .058 .750

Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization.

The convergent and discriminative validity for the whole 22 symptoms proposed for ADHD in DSM-V were calculated. The range of convergent validity for the symptoms of inattentiveness was from 0.504 to 0.772 and that of discriminative validity for the symptoms of inattentiveness was from 0.017 to 0.427. Also, the range of convergent validity for the symptoms of hyperactivity-impulsivity was from 0.42 to 0.770 and that of discriminative validity for the symptoms of hyperactivity-impulsivity was from 0.12 to 0.39.

The alpha coefficient for the whole 24 symptoms of ADHD in DSM-V was 0.88. The alpha for the DSM-V hyperactivity-impulsivity was 0.87. It was 0.80 for DSM-IV inattention.


To the best of the author’s knowledge, this is the first study investigating psychometric and factor structure of ADHD DSM-V derived symptoms. So, it is not possible to compare the current results with those of other studies. Confirmatory factor analysis confirmed the proposed two-factor loading of inattentiveness and hyperactivity/impulsivity for the new ADHD DSM-V criteria. However, the three-factor model of confirmatory factor analysis showed that the four new items can be considered as the third factor.

The results indicate that convergent and discriminative validity for ADHD DSM-V derived inattention symptoms are sufficient. Although the symptoms of hyperactivity- impulsivity are discriminated from inattentiveness symptoms, the convergent validity of the four newly proposed symptoms in DSM-V is not as high as that of the 9 symptoms derived from DSM-IV. The three new criteria for hyperactivity/impulsivity were loaded in inattentiveness factor rather than in hyperactivity-impulsivity factor. These may not support the fact that the 4 proposed symptoms for revision of ADHD exactly describe hyperactivity-impulsivity symptoms. However, the internal consistency and reliability of the inattentiveness and hyperactive/impulsivity symptoms are high.\

Considering the factor loading of the four newly proposed symptoms added to DSM-V, there is a concern that inattentiveness symptoms may falsely increase the diagnosis of ADHD-hyperactive/impulsive type or combined type of ADHD. It means that the symptoms which are loaded as inattentive symptoms may lead to subthreshold ADHD- hyperactive/impulsive type using DSM-IV, while fulfilling criteria of ADHD- hyperactive/impulsive type using DSM-V.

With respect to the fact that the better diagnoses and classification of children with ADHD could lead to a better treatment, more discussion and justification about the new items are required. Probably, future studies should investigate the neuropsychological functioning of children with ADHD for the classification of the subtypes of ADHD. The current results indicated that continued research is required to reach accurate diagnostic criteria for making accurate ADHD diagnoses.

There is some overlap between ADHD symptoms and ODD in DSM-IV.[20] ODD symptoms are properly differentiated from ADHD. However, two items of the ADHD including “Often has trouble organizing activities” and “Often runs about or climbs when and where it is not appropriate” are loaded in the oppositional defiant disorder component rather than ADHD component.[20] Another concern is whether the new added symptoms in DSM-V are well differentiated from ODD symptoms. This needs further studies.

There are some limitations in this study which need to be considered. This study was conducted on a clinical sample of children and adolescents with ADHD. Further studies with larger sample size including community sample with a wider age rage are recommended. The children and their parents were the sources of information. Including other informants such as teachers is also recommended. This study is based on one sample in a specific geographical area. In addition, the use of translation instead of the actual questionnaire is another limitation. A multi-site approach with a more limited age range would be required to appropriately assess the psychometric properties of the proposed items of a classification used worldwide.

Despite the above-mentioned limitations, this is the first study that assesses psychometric properties of ADHD DSM-V derived symptoms. In addition, the children, adolescents and parents were interviewed face to face using a well known semi- structured interview. Moreover, all the interviews were conducted by a Board-certified child and adolescent psychiatrist.


The findings of present study support the two-factor model of the DSM-V ADHD diagnostic criteria including inattentiveness and hyperactivity/impulsivity. Nevertheless, the four new items can be considered as a third factor.


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  13. Ghanizadeh A, Mohammadi MR, Yazdanshenas A: Psychometric properties of the Farsi translation of the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version. BMC Psychiatry 2006, 6:10.
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  17. Ghanizadeh A, Mohammadi MR, Moini R: Comorbidity of psychiatric disorders and parental psychiatric disorders in a sample of Iranian children with ADHD. J Atten Disord 2008, 12(2):149–155.
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Retrieved from: http://www.medscape.com/viewarticle/764516

Perinatal Risk Factors for ADHD Confirmed

In ADHD, ADHD Adult, Psychiatry, School Psychology on Monday, 24 September 2012 at 16:06

important info!

Perinatal Risk Factors for ADHD Confirmed

Megan Brooks

September 13, 2012 — The combination of maternal gestational diabetes mellitus (GDM) and low socioeconomic status (SES) is a strong risk factor for childhood attention-deficit/hyperactivity disorder (ADHD), a study from Germany confirms.

Perinatal health problems, maternal smoking during pregnancy, and atopic eczema also raise the risk for ADHD, whereas fully breastfeeding appears to protect against ADHD, regardless of the duration of breastfeeding, the study showed.

“Modification of these environmental risk factors by evidence-based prevention programs may help to decrease the burden of ADHD,” write coinvestigators Jochen Schmitt, MD, MPH, of Technical University Dresden, and Marcel Romanos, MD, from the University Hospital of Würzburg, in Germany.

The study was published online September 10 in Archives of Pediatrics and Adolescent Medicine.

It follows a study published in the same journal earlier this year by Yoko Nomura, PhD, MPH, from the Department of Psychology, Queens College, City University of New York, and colleagues. That study, which included 212 preschool-age children, linked maternal GDM and low SES, especially in combination, to a heightened risk for childhood ADHD.

Nationwide Study

These latest findings from Dr. Schmitt and Dr. Romanos replicate this finding in a large nationwide representative sample of 3- to 17-year-olds who participated in the German Health Interview and Examination Survey for Children and Adolescents (n = 13,488).

The outcome of interest was childhood ADHD, and the primary exposures of interest were self-reported physician-diagnosed GDM (absent or present) and SES, classified as low, medium, or high on the basis of parental education, professional qualification, professional status, and family income.

The authors also considered age, sex, and a broad set of environmental exposures in the prenatal and perinatal period and in infancy as competing risk factors in multivariate analysis.

A total of 660 children (4.9%) had ADHD; the prevalence of GDM and low SES was 2.3% (n = 280) and 25.5% (n = 3420), respectively, the authors report.

Both maternal GDM and low SES were significantly related to ADHD. In multivariate regression modeling (based on 11,222 observations without any missing data), GDM and low SES were independent risk factors for childhood ADHD. The same was true for perinatal health problems, maternal smoking during pregnancy, and atopic eczema, whereas breastfeeding was protective.

Table: Risk for ADHD With Outcomes of Interest

Characteristic/Exposure aOR (95% CI)
Maternal GDM 1.91 (1.21 – 3.01)
Low SES 2.04 (1.56 – 2.68)
Smoking 1.48 (1.19 – 1.84)
Perinatal health problems 1.69 (1.40 – 2.03)
Atopic eczema 1.62 (1.30 – 2.02)
Breastfeeding 0.83 (0.69 – 0.996)

aOR = adjusted odds ratio; CI = confidence interval

The investigators note that their findings confirm those of Dr. Nomura and colleagues by showing an association between low SES, maternal GDM, and ADHD “and their additive interaction as risk factors for ADHD in a large population-based sample.”

The researchers say their study also extends previous research by showing that fully breastfeeding may have protective effects on childhood ADHD.

Fetus a “Captive Audience”

Dr. Nomura told Medscape Medical News that “being able to duplicate our findings in a different sample and a much larger sample is important.”

“I’m not sure if most doctors know that GDM is a risk factor for ADHD; biological and environmental risk factors for ADHD is a fairly new scientific field,” she added.

“ADHD is a highly hereditary illness, but it’s not only hereditary; we are beginning to gather information about environmental or biological causes and beginning to focus on perinatal risk factors for ADHD,” said Dr. Nomura.

“The fetus is a captive audience,” she noted, “and it seems like in utero exposure to a variety of things like excessive insulin, smoking, plastic materials, food dyes, toxic chemicals may cause epigenetic changes in brain development that may show up later in life.”

Arch Pediatr Adolesc Med. Published online September 10, 2012. Abstract


Autism Patients Might Benefit from Drug Therapy

In Medication, Psychiatry, School Psychology on Sunday, 23 September 2012 at 09:01

Autism Patients Might Benefit from Drug Therapy

By SYDNEY LUPKIN | ABC News – Wed, Sep 19, 2012 2:37 PM EDT

Researchers have found a drug that can help patients with Fragile X syndrome, the most common cause of inherited intellectual impairment (formerly known as mental retardation), stay calm in social situations by treating their anxiety.

Dr. Elizabeth Berry-Kravis and her team found that a drug called Arbaclofen reduced social avoidance and repetitive behavior in Fragile X patients, especially those with autism, by treating their anxiety. The drug increases GABA, a chemical in the brain that regulates the excitatory system in Fragile X patients, who have been known to have too little GABA to do the job otherwise, causing their excitatory systems to “signal out of control” and make them anxious.

Such patients have been known to cover their ears or run away at their own birthdays because they are overwhelmed by the attention, but one trial participant said he was able to enjoy his birthday party for the first time in his life while he was on Arbaclofen, she said.

“I feel like it’s kind of the beginning of chemotherapy when people first realized you could use chemotherapy to treat cancer patients instead of just letting them die,” said Berry-Kravis, a professor of neurology and biochemistry at Rush University Medical Center in Chicago who has studied Fragile X for more than 20 years.

She said people used to think Fragile X patients couldn’t be helped either, but she and her team have proven that by using knowledge from existing brain mechanism studies, doctors can select medications to target specific problems in Fragile X patients’ brains.

Fragile X syndrome is a change in the FMRI gene, which makes a protein necessary for brain growth, and studies indicate it causes autism in up to one-third of patients diagnosed with it. Unlike Fragile X syndrome, which is genetic, autism is a behavioral diagnosis characterized by an inability to relate to other people or read social cues. Autism and Fragile X are linked, but not mutually exclusive. A core symptom of both is social withdrawal.

Sixty-three patients with Fragile X participated in Berry-Kravis’s placebo-controlled, double-blind clinical trial from December 2008 through March 2010. Of those, the patients with autism showed the biggest improvements in social behavior, Berry-Kravis said.

To psychologist Lori Warner, who directs the HOPE Center at Beaumont Children’s Hospital, the study is exciting because when her autistic patients are anxious, they often have a harder time learning the social cues they can’t read on their own.

“Reducing anxiety opens up your brain to be able to take in what’s happening in an environment and be able to learn from and understand social cues because you’re no longer frightened of the situation,” Warner said.

She works mostly with autism patients, and although some do have Fragile X as well, most do not.

Fragile X affects one in 4,000 men and one in 6,000 to 8,000 women, according to the Centers for Disease Control and Prevention.

Although Arbaclofen worked best on autistic Fragile X patients, further studies will be needed to prove whether it can help all autism patients, not just those with autism caused by Fragile X.

“There’s a difference between one person’s brain and another in how it’s set up,” Berry-Vargis said. “This is not a magic cure. It’s a step.”

Retrieved from: http://gma.yahoo.com/autism-patients-might-benefit-drug-therapy-183744169–abc-news-health.html

ASD interventions

In Autism Spectrum Disorders, School Psychology on Thursday, 20 September 2012 at 04:29

Interventions for Adolescents and Young Adults

By: Lee Wilkinson, Ph. D

Although it would seem obvious that children with ASD will eventually transition to adolescence and adulthood, there is a paucity of information about effective interventions for these age groups compared to data for younger children. Even though the core symptoms of ASD (impairments in communication and social interaction and restricted/repetitive behaviors and interests) may improve overtime with intervention for many individuals, some degree of impairment typically remains throughout the lifespan. Consequently, the focus of intervention/treatment must shift from remediating core deficits in childhood to promoting adaptive behaviors that can facilitate and enhance ultimate functional independence and quality of life in adulthood. This includes new developmental challenges such as independent living, vocational engagement, post-secondary education, and family support. Unfortunately, there is evidence to suggest that improvements in symptoms and problem behaviors may decrease or end once youth with ASD transition from school-based programs. This is likely due, at least in part, to the termination of services received through the secondary school system upon exiting from high school, as well as the lack of adult services. The lack of services available to help young adults with ASD transition to greater independence has been noted by researchers for a number of years and has become an increasingly important issue as the prevalence of ASD continues to grow and as children identified with ASD reach adolescence and adulthood.

Comparative Effectiveness Review

What are the effects of currently available interventions/treatments on adolescents and young adults with ASD? To answer this question, researchers at the Vanderbilt Evidence-based Practice Center systematically reviewed evidence on therapies for adolescents and young adults (ages 13 to 30) with autism spectrum disorders (ASD). Their review focused on the outcomes, including harms and adverse effects, of interventions addressing the core symptoms of ASD; common medical and mental health comorbidities occurring with ASD; the attainment of goals toward functional/adult independence; educational and occupational/vocational attainment; quality of life; access to health and other services; and the transitioning process (e.g., process of transitioning to greater independent functioning). Researchers also addressed the effects ofinterventions on family outcomes including parent distress and satisfaction with interventions.

Of more than 4,500 studies on autism interventions published between 1980 and 2011, only 32 focused on interventions/therapies for individuals ages 13 to 30. Most of the studies available were of poor quality, which may reflect the relative recency of the field. Five studies, primarily of medical interventions, had fair quality. Behavioral, educational, and adaptive/life skills studies were typically small and short term and suggested some potential improvements in social skills and functional behavior. Small studies suggested that vocational programs may increase employment success for some individuals. Few data are available to support the use of medical or allied health interventions in the adolescent and young adult population. The medical studies that have been conducted focused on the use of medications to address specific challenging behaviors, including irritability and aggression, for which effectiveness in this age group is largely unknown and inferred from studies including mostly younger children. However, antipsychotic medications and serotonin reuptake inhibitors were associated with improvements in specific challenging behaviors. Similarly, little evidence supports the use of allied health interventions including facilitated communication.


Despite an increasing population of adolescents and young adults identified with an ASD and the need for effective intervention across the lifespan, very few studies have been conducted to assess treatment approaches for adolescents and young adults with ASD. Moreover, the available research is lacking in scientific rigor. As a result, there is little evidence available for specific treatment approaches in this population; especially for evidence-based approaches to support the transition of youth with ASD to adulthood. In particular, families have little in the way of evidence-based approaches to support interventions capable of optimizing the transition of teens with autism into adulthood. Research is needed across all intervention types on which outcomes to use in future studies. “Overall, there is very little evidence in all areas of care for adolescents and young adults with autism, and it is urgent that more rigorous studies be developed and conducted,” commented Melissa McPheeters, director of Vanderbilt’s Evidence-Based Practice Center and senior author of the report. “There are growing numbers of adolescents and adults with autism in need of substantial support. Without a stronger evidence base, it is very hard to know which interventions will yield the most meaningful outcomes for individuals with autism and their families,” said Zachary Warren of Vanderbilt who also contributed to the report.

Lounds Taylor J, Dove D, Veenstra-VanderWeele J, Sathe NA, McPheeters ML, Jerome RN, Warren Z. Interventions for Adolescents and Young Adults With Autism Spectrum Disorders. Comparative Effectiveness Review No. 65. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2007-10065-I.) AHRQ Publication No. 12-EHC063-EF. Rockville, MD: Agency for Healthcare Research and Quality. August 2012. http://www.effectivehealthcare.ahrq.gov/reports/final.cfm

The complete report is available at: http://effectivehealthcare.ahrq.gov/ehc/products/271/1196/CER65_Autism-Young-Adults_20120723.pdf

Lee A. Wilkinson, PhD, CCBT, NCSP is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers.

Dr. Wilkinson can be reached at: http://bestpracticeautism.com

Retrieved from: http://www.examiner.com/article/interventions-for-adolescents-and-young-adults-with-asd?goback=.gde_58284_member_165763295


Cyberbullying in the schools

In Education, School Psychology, Special Education on Wednesday, 19 September 2012 at 06:19

in this age of computers, smartphones, twitter, facebook, etc., it has become increasingly easier and easier to ‘broadcast’ anything, even massive negativity.  i have seen an uprising in the amount of cyberbullying by students to other students year after year.  i have many examples, and will share one from my middle school.  we had a child with asperger’s who ‘liked’ a girl.  while in the cafeteria, some girls convinced him that he should “ask her out.”  now, the girl he liked was in on the joke.  so, he walked up to the girl in the cafeteria and did what they told him…asked her out.  she pretended to be flattered and accepted.  well, my student got very excited and started “flapping” and very obviously (and in his very asperger’s way) showed his excitement.  as you can imagine, this boy, who didn’t really get attention from his peers, and especially girls, put on a bit of a ‘show.’  that night, the while episode was on youtube.  all i can be thankful for is that my student did not know of it.  but…when trying to find some disciplinary action to take via the school system and anti-bullying, we could not as the incident happened at home (via their home computers) and not at school.  while we did call the parents and have it removed, that was about all we could do.  and this is a MILD story.  i have so many more in which the student being cyberbullied DID know what was being posted/written and there was little we could do about it.  kids who send sexually explicit photos to others, kids who post death threats to other kids, kids who arrange bullying ‘events’ via social media and get others involved…the list goes on and on. 

on another note, i have also had teacher friends of mine videoed in class, then the videos were carefully edited for maximum effect and posted on youtube. 

as a side note, our district does have some leeway now to deal with cyberbullying, but in my opinion, it is not enough.

so, the following article holds promise for cyberbullying.


Teachers Fight Online Slams

Amid Free-Speech Concerns, Law Targets Comments That ‘Torment’ Faculty


After years spent trying to shield students from online bullying by their peers, schools are beginning to crack down on Internet postings that disparage teachers.

Schools elsewhere in the U.S. have punished the occasional tweeter who hurls an insult at a teacher, but North Carolina has taken it a step further, making it a crime for students to post statements via the Internet that “intimidate or torment” faculty. Students convicted under the law could be guilty of a misdemeanor and punished with fines of as much as $1,000 and/or probation.

The move is one of the most aggressive yet by states to police students’ online activities. While officials have long had the ability to regulate student speech at school, the threat of cyberbullying teachers, which typically occurs off-campus, has prompted efforts to restrain students’ use of the Internet on their own time.

Judy Kidd, a Charlotte, N.C., teacher said teachers needed a law for ‘protection’ from online comments.

School officials in North Carolina and elsewhere say the moves are necessary to protect teachers in an age when comments posted online—sometimes by students pretending to be the teachers they are mocking—can spread quickly and damage reputations.

The North Carolina law makes it a crime for a student to “build a fake profile or web site” with the “intent to intimidate or torment a school employee.”

Critics, however, argue the law risks trampling on mere venting and other less inflammatory forms of expression.

“Our concern is that we don’t throw the First Amendment out the window in our haste to get the kid who is calling the principal bad names on Facebook,” said Frank LoMonte, executive director of the Student Press Law Center in Arlington, Va., a national group that advocates for students’ free-speech rights.

Traditional issues of free speech on public-school grounds are largely settled, thanks to a 1969 Supreme Court ruling in Tinker v. Des Moines. That ruling held that students’ First Amendment rights are generally protected on campus, but that administrators can punish them for speech on school grounds when they can clearly show it caused significant disruption to school activities or violated others’ rights.

But while past off-campus insults about a school employee were largely undetected and unpunished, cyberinsults are digitally preserved and on display for many to see.

The wide use of social media, particular among teens, makes such platforms the go-to place for such incendiary comments.

While nearly every U.S. state has now passed measures to curb student-on-student cyberbullying, North Carolina is apparently the first to pass a law aimed at students bullying teachers online.

Courts have been mixed on the issue. Last year, the Third U.S. Circuit Court of Appeals, in two separate decisions, said two schools, both in Pennsylvania, had encroached on students’ free-speech rights by punishing them for creating social media profiles mocking their school principals. The court held that the students’ parodies, which were created off-campus, didn’t significantly disrupt the schools.

School Rules

Under a new law, North Carolina students face a fine of as much as $1,000 and/or probation if they:

  • Build a fake profile of…
  • Post a real or fake image of…
  • Post information about…
  • Or repeatedly contact…

…school employees, including teachers

In one case, Justin Layshock, a high-school student, mocked his principal in a Myspace profile parody, writing, among other things, that the principal was “too drunk to remember” his own birthday. In the other case, a middle-school student identified in court documents only by initials J.S. created a Myspace page to make fun of her school principal. using his photo and including among his general interests: “hitting on students and their parents.”

Yet in a separate case in Connecticut last year, the Second U.S. Circuit Court of Appeals found administrators were within the law when they disciplined Avery Doninger, a high-school student, for posting a message to her blog encouraging people to call school officials a profanity in order to protest the school’s “jamfest” being canceled.

Even though Ms. Doninger wrote the post off campus, the court held that it created a substantial disturbance at school to warrant a punishment. Mr. Layshock and Ms. Doninger, whose cases garnered national attention, have gone on to graduate from college, attorneys for them said.

In the past year, the U.S. Supreme Court has turned down opportunities to hear those three cases, as well as a fourth about student speech, which might have brought some clarity. In the fourth case, the Fourth U.S. Circuit Court of Appeals found it permissible for administrators in West Virginia to suspend a student who had created a Myspace page ridiculing another student.

The Classroom Teachers Association of North Carolina l based in Charlotte, lobbied for the teacher-bullying provisions to be included in the state’s School Violence Prevention Act of 2012 after fielding complaints about students using social media sites and email to make false accusations about school employees, said Judy Kidd, the group’s president. In one case Ms. Kidd cited, a sixth-grader sent sexually explicit emails about a teacher to other students. In another, a high-school student posted false allegations on Facebook that an instructor for the Reserve Officers’ Training Corps had groped her while fitting her for a uniform.

“It became apparent that we had to get some kind of protection,” said Ms. Kidd, a high-school science teacher in the Charlotte-Mecklenburg Schools.

Some free-speech advocates say the North Carolina law gives administrators wide latitude to go after students and possibly infringe on free speech. They say the law, which was passed in July, could be enforced against students who are making truthful statements or posting undoctored photos of staff.

Thomas Wheeler, an Indiana lawyer who represents school districts, said he hoped a case will be heard by the Supreme Court and result in clear guidance from the justices on how far schools can go to police what students say online and on social media sites. “The times have changed and we are trying to get caught up,” he said.

Write to Steve Eder at steve.eder@wsj.com

A version of this article appeared September 18, 2012, on page A3 in the U.S. edition of The Wall Street Journal, with the headline: Teachers Fight Online Slam.

Retrieved from: http://online.wsj.com/article/SB10000872396390443779404577644032386310506.html?KEYWORDS=student+online+postings&goback=.gde_159675_member_165295745

Managing Adverse Effects to Optimize Treatment for ADHD

In ADHD, ADHD Adult, ADHD child/adolescent, ADHD stimulant treatment, Medication, Psychiatry, School Psychology on Sunday, 16 September 2012 at 10:35

Managing Adverse Effects to Optimize Treatment for ADHD



Attention-deficit/hyperactivity disorder (ADHD) begins in early childhood, and at least 50% of children will go on to have symptoms and impairment in adulthood.[1] Treatment requires a combination of medication and counseling, and adherence to medication therapy is essential for good outcomes. Managing adverse effects is a key component of effective treatment. Diagnosis and treatment of psychiatric comorbidity, which is common, is another essential aspect of care. This review will examine common adverse effects, prescribing medication successfully, deciding when to switch to an alternative medication, and some aspects of using concomitant medication.

Initiating Treatment


According to the text revision of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), the diagnosis of ADHD requires symptom onset before age 7 years. When evaluating children, parent and teacher input is essential and easy to obtain. Although some investigators have suggested that adult-onset ADHD is possible,[2] a full evaluation of an adult involves attempts to document symptoms and impairment in childhood. Interviews with parents and examination of school or medical records are often helpful.

Monitoring treatment success requires documentation of baseline functional impairment. In adults, collateral interviews with partners or even coworkers, with the patient’s permission, may be illuminating. Adults with ADHD experience important consequences from their impaired functioning. In a case-control study of 500 adults, those with ADHD had lower educational attainment, less job stability, lower incomes, and less successful relationships.[3] The evaluating clinician should investigate all of these areas.

The other essential aspect of evaluation is screening for comorbidity. In many cases, ADHD is not the chief complaint but comes to light during evaluation of another symptom. The most prevalent comorbid conditions are depression, bipolar disorder, and anxiety disorders.[4] Substance-use disorders including nicotine dependence are also more common in people with ADHD than in the general population.

Patient Education

Once the diagnosis is established, the physician should explain the implications and the proposed treatment plan. Educating patients and families about both the therapeutic and adverse effects of pharmacotherapy will help them know what to expect. Describing the benefits of treatment, including possible improvements in psychosocial outcomes, will allow a fully informed decision.

After learning about the side-effect profile of psychostimulants, a few patients who are ambivalent about medication may reject that treatment option. Nonstimulants should also be discussed to provide the full range of options, but the clinician should mention the trade-off of lower efficacy of nonstimulants compared with psychostimulants.[5] Once a patient has consented to a specific medication, the physician should explain the minimum trial duration necessary to determine a response and the dose-adjustment schedule. Clearly worded written information about the medication is usually appreciated by patients and their families. The informed-consent process should be documented.

Managing Adverse Effects

The common adverse effects of treatment are inherent in the pharmacodynamics of stimulant medication. Enhanced catecholamine neurotransmission in the central and autonomic nervous systems can cause insomnia, anorexia, and increased heart rate and blood pressure. These effects are most noticeable at the outset of treatment and after increases in dose. Patients often adjust to them during the ensuing weeks but may require encouragement during that interval.


Studies show that adults and children with untreated ADHD experience sleep anomalies compared with control subjects. A review of sleep studies of unmedicated children found evidence of more nocturnal motor activity and daytime somnolence compared with controls.[6] An actigraphic study of 33 adults with ADHD and 39 control subjects found similar differences between the groups at baseline, and sleep latency was prolonged in the ADHD subjects.[7] After treatment with methylphenidate, the adult patients continued to experience prolonged sleep latency and less total sleep duration, but sleep efficiency improved.

In a study that used the most comprehensive method of evaluating sleep, polysomnography in a sleep lab, 34 untreated adults with ADHD had increased nocturnal activity, reduced sleep efficiency, more awakenings, and reduced REM sleep compared with control subjects.[8] For 10 patients who were treated with open-label methylphenidate, repeat polysomnography showed better sleep efficiency, and the patients also reported improved restorative value of sleep.

Clinicians can conclude from these studies that the effect of medication on sleep may be beneficial in at least some patients, but further research with more subjects and with a variety of medications is needed. The fact remains that many patients treated with psychostimulants complain of initial insomnia, so an approach to manage this problem is necessary. Clinicians should document sleep patterns and complaints before treatment to help interpret problems that may arise after medication is prescribed.

Sleep hygiene, consisting of simple behavioral approaches to promote sound sleep (eg, creating a restful environment and avoiding caffeine), is an inexpensive intervention for all patients with insomnia. In a study of initial insomnia in 27 children 6-14 years treated for ADHD with psychostimulants, the researchers provided a sleep hygiene intervention to which 5 of the children responded.[9] They randomly assigned the nonresponders to either 5 mg of melatonin or placebo. Adverse effects of placebo and melatonin were not significantly different. The investigators found the combination of sleep hygiene and melatonin to be safe and effective, with an effect size of 1.7.

Although comparable randomized, controlled trial data do not exist for adults, mirtazapine has been reported as safe and effective for adults taking psychostimulants.[10]

Atomoxetine may have an effect on sleep that is different from that of psychostimulants, including reduced sleep latency but less efficiency. In a randomized, double-blinded, crossover trial, methylphenidate treatment for children with ADHD caused more initial insomnia but fewer awakenings compared with atomoxetine treatment.[11] Switching to atomoxetine may be considered for patients who prefer it or who do not respond to adjunctive interventions for stimulant-associated insomnia.

Appetite and Growth

Appetite reduction is common with psychostimulants and also can occur with nonstimulants, including atomoxetine and bupropion. This may be accompanied by nausea and abdominal pain in some patients. Some adults treated with psychostimulants may regard appetite suppression with resultant weight loss as beneficial. With long-acting stimulants, appetite returns later in the day.

Simple approaches to this problem include eating breakfast before taking medication. Having food in the stomach may also help reduce abdominal symptoms. Children in particular should have a nutritious, high-calorie snack in the evening if their food intake has been low since breakfast. However, parents should be warned to monitor evening intake of empty calories, such as candy and chips.

Weight loss or a downward shift of weight percentile is typical in children treated with psychostimulants. Short-term reduction in height growth rate during the initial 1-3 years of treatment with psychostimulants is well documented. In a literature review article, Poulton[12] concluded that a mean 1 cm/year deficit in height occurs during that interval. Less conclusive findings included a possible negative correlation between dose and growth, greater growth effect from dextroamphetamine than from methylphenidate, and rebound in growth of height and weight after discontinuation of stimulants.

More controversial is the effect on final stature. According to Poulton, “It would appear that most children achieve a satisfactory adult height, but there may be an important subgroup whose growth is permanently attenuated.”[12] Clinicians must discuss this with parents, many of whom will already have some concerns about the issue, and monitor children’s height and weight, ideally at each visit.

Research on atomoxetine is less comprehensive, but available evidence suggests a short-term downward shift in height and weight percentile. The effect on height may be minimal,[13] but longer-term studies are needed.

In a child or adult with worrisome weight loss, or if a child’s parents are anxious about growth deceleration, switching to another medication should be considered. Substituting methylphenidate for amphetamine would be more rational than substituting amphetamine for methylphenidate, but a nonstimulant is more likely to be ameliorative.

Affective Symptoms

Irritability, dysphoria, and (rarely) suicidal ideation can occur during treatment of ADHD.[14] Atomoxetine carries an FDA warning of a 0.4% incidence of suicidal ideation that has occurred in children during the first month of therapy.[15] No completed suicides have been reported, but discontinuation of atomoxetine is indicated if suicidal thoughts emerge. Minor mood changes and irritability occur with both psychostimulants and atomoxetine. Little evidence is available to guide intervention, but if the symptom is severe, the clinician may consider dose reduction, switching to an alternative psychostimulant, or trying an antidepressant nonstimulant such as bupropion or nortriptyline.

Psychosis and Mania

As dopamine transmission agonists, psychostimulants at excessive and prolonged doses would be expected to provoke psychotic symptoms or mania. These are well-reported but uncommon adverse effects during treatment in children, with an incidence estimated at 0.25%.[16] Emergent delusions, hallucinations, mania, or disorganized behavior requires treatment discontinuation. Most such symptoms resolve, but in a few cases, a bipolar disorder may be unmasked, which takes treatment priority.

Cardiovascular Effects

Psychostimulants cause increased heart rate and blood pressure in adults and children. The effect is mild in most cases, but in adults, some patients with borderline baseline blood pressure may develop frank hypertension. In a 24-month study of 223 adults treated with mixed amphetamine salts, 5 subjects developed hypertension and 2 experienced palpitations or tachycardia that required medication discontinuation.[17]

In a manufacturer-sponsored review of clinical-trial data, atomoxetine was found to cause small but clinically insignificant effects on blood pressure and heart rate in children, adolescents, and adults.[18] Treatment discontinuation for these effects was necessary only in a few adults. In managing any patient on psychostimulants or atomoxetine, clinicians should document pulse rate and blood pressure at baseline and every 6 months, with more frequent monitoring of patients with elevated risk for hypertension.

A more controversial aspect of ADHD medications is the effect on cardiac conduction and the rare occurrence of sudden death. In an unpublished review of documented cases of sudden death in children and adults treated with stimulants or atomoxetine through 2005, many of these patients had an underlying cardiac anomaly discovered on autopsy or were taking other medications.[19] Furthermore, psychostimulants have little effect on the QTc interval. Data on atomoxetine are conflicting, with US trials suggesting no QTc effect.[14] A Europe-wide postmarketing surveillance study, however, found a small number of cases of QTc prolongation that resolved with medication discontinuation.[20]

Whether a baseline electrocardiogram (ECG) is necessary for every patient is a matter of debate among specialists. Dr. David Goodman, an ADHD researcher and clinician, recommends specific screening for cardiac risk.[21] The 5 items he inquires about are history of spontaneous syncope, exercise-induced syncope, exercise-induced chest pain, sudden death in family members age 30 years and younger, and a family history of structural or electrical abnormalities. An ECG — and in ambiguous situations, specialist consultation — would be appropriate before initiating medication in older adults or any patient with risk factors.

Complex Psychopharmacology

Because comorbidity is common with ADHD, clinicians may prescribe psychostimulants with other medications, such as antidepressants, mood stabilizers, or antipsychotics. In fact, experienced psychopharmacologists often prescribe psychostimulants adjunctively for adults with treatment-resistant depression. Atomoxetine metabolism and a small portion of amphetamine metabolism involve CYP2D6, so caution is appropriate when combining these medications with fluoxetine, paroxetine, or fluvoxamine, which inhibit the enzyme.

Tricyclic antidepressants have been safely prescribed with psychostimulants, although several case reports exist of increased adverse effects with the combination of imipramine and methylphenidate.[22] Psychostimulants combined with monoamine oxidase inhibitors may cause a hypertensive crisis; coadministration is contraindicated.

The comorbidity of bipolar disorder and ADHD remains an area of active research and controversy. In a recent randomized, controlled trial, 40 children 6-17 years old with bipolar mania or hypomania and ADHD received divalproex for 8 weeks.[23] The 30 whose mood stabilized but who had active ADHD symptoms received mixed amphetamine salts. The researchers reported no significant adverse effects or worsening of mania. Similar controlled trials in adults are lacking, but in a retrospective study of 16 adult patients with bipolar disorder who were receiving methylphenidate, 5 patients had comorbid ADHD.[24] The others received a stimulant for depression. The patients were also taking various mood stabilizers, including divalproex, lithium, carbamazepine, lamotrigine, and second-generation antipsychotics. The investigators concluded that the practice was safe and effective, although “mild to moderate side effects” occurred, the single most common of which was irritability.


Initiating treatment with psychostimulants is no different from initiating other psychiatric medications. The key steps are:

  • Obtaining baseline data and, in exceptional cases, specialist consultation;
  • Educating patients and families about risks and benefits;
  • Documenting informed consent; and
  • Monitoring adverse effects and intervening as needed.

Rare adverse effects, such as jaundice, skin reactions, vasculitis, and thrombocytopenia, are idiosyncratic, and routine testing for them is not cost-effective.[14] Any unusual complaints should prompt further investigation. Regular documentation of pulse and blood pressure (and growth in children) is mandatory. Most adverse effects can be managed by reassurance or dose reduction, but switching to a different agent may at times be necessary. Combining medications for comorbidities is justifiable and often safe if diagnoses and rationale are well documented, but evidence of efficacy is not well established.


ADHD and Sensory Defensiveness

In ADHD, ADHD Adult, ADHD child/adolescent, School Psychology on Sunday, 16 September 2012 at 10:30

ADD and Hypersensitivity:
Is There A Connection?

Follow Up Report by Mary Jane Johnson

from http://www.oneaddplace.com

It has been several months now since I reported on ADHD and hypersensivity. Since that time I have heard from several ADD adults who suffer some of the same symptoms. One person sent me an article entitled “Social and Emotional Issues of Adults with Sensory Defensiveness “from the Sensory Integration Newsletter published by The American Occupational Therapy Assoc.

Many of these same hypersensitivities are mentioned in this article and I will quote from the article as well as what was shared by the readers who wrote to me. Sensory Integration Newsletter states, “Adults with tactile defensiveness commonly report strong clothing preferences and avoidances, and aversions to clothes with tags, jewelry….may also feel uncomfortable with wool or synthetic materials against the skin….and may be bothered by these aversions to an extreme degree….

“Along those same lines K. wrote in that, “I have to keep my shoes tied tight on my feet… If they are not tight I get frustrated… I find that I constantly re-tie my shoes as tight as possible, during the day.” And D. relates, “I agree completely about the elastic… I also do not like sleeves, high collars, knee socks that fall down, tags on the inside of shirts, anything touching my skin that isn’t soft or cottony, slacks too tight in the crotch… I hate panty hose… I don’t wear my coat in the car, I have a nice thin vest with lots of pockets that I wear while shopping.

“In regards to sensitivity to food textures M. shares, “My dad as a child couldn’t stand different foods to touch, so my grandmother bought him a compartmentalized plate… I had to do the same for my son… He stopped picking up wet finger foods or food that made his hands sticky… He wanted a different spoon or fork for each food… He wanted only bland soft foods and to this day there are very few foods he likes… My taste is more sensitive than the others in my family.” D. says, “I am also a picky eater, but I love spicy food. I can’t stand browned scrambled eggs and my fried eggs must be perfect.”

When it comes to heat and cold sensitivity, M. writes, “If it gets around 70 degrees I’m cold… That’s why we live in the desert… my hands and feet seem to always have had poor circulation… My hands get cold inside good leather gloves.” K. states, “…especially cold… I need to dress and keep the house warm as soon as cool weather moves in… If I didn’t love New England so much I would probably live in a warm climate year round.

“The remarks about hearing sensitivity includes: M., “clock in the living room because he could hear it ticking all the way in his room…My son can sleep through noises but certain frequencies hurt or upset him…I travel with a Sears ‘sleepmate’ white noise machine. I can’t sleep without masking the noise. I annoy the heck out of my husband by my ability to hear the TV at the other end of the house… I can’t have a ticking clock in the room where I sleep… My dad also has a noise machine.

” K., “…when trying to focus on things I can’t filter out noises…While typing this letter I can hear water dripping in the next room, the refrigerator turning on and off, and a car engine idling outside. “And D., “I enjoy loud music, but only when I feel like it. I think that’s why people think we are selfish at times.”

Sensory Integration Newsletter reports, “Social events… puts the person with defensiveness in an uncomfortable situation… Almost all subjects described the discomfort experienced when someone’s touch takes them by surprise… Many subjects describe shaking hands as unpleasant… When the touch or hug from comes from behind, it’s effect is multiplied because of the element of surprise… and many need to exert self-control to avoid striking out at the person who touched them.

“M. shares, “I don’t like being touched… even shaking hands is difficult… It’s taken my husband years to learn how to touch me without provoking a negative response… Touching my head or hair is a no no!” A twist on this particular hypersensitivity comes from D. who says, “I am happy to say the hypersensitivity to touch, in the romantic sense, is more often a plus than a minus.” And K. adds, “I don’t mind shaking someone’s hand, but forget hugging… Whenever someone hugs me, I tense up and my stomach gets tied up in knots… Being married my wife loves to be touched… I get all tied up when she hugs me or wants to be hugged or held… It tears me apart because I love my wife and yet for some reason want my space

“……..”Most subjects described feeling uncomfortable in crowded places such as crowded elevators, buses, or subways, restaurants, stores, malls… Shopping is difficult for them”, states Sensory Integration Newsletter. K. agrees by saying, “I have difficulty going into elevators, and detest having to go to malls, food stores, sporting events, etc… I get very over-stimulated, overwhelmed and irritable until I’m free from crowded areas.” D. states, “I notice that claustrophobia is more evident when I am somewhere I don’t like to be, such as in a car on a trip of more than an hour.” In some individuals there seems to be a connection between having ADD and being hypersensitive, as these cases indicate.


(Kinnealey and Oliver, © 2002)

Circle the item as T – true or F – False as it applies to you.






1.  T   F


I am sensitive and get bothered by smells that don’t seem to bother other people.

2.  T   F I am sensitive or bothered by sounds that don’t seem to bother other people.
3.  T   F I am bothered by looking down a long flight of stairs or going down an escalator.
4.  T   F I get car sick.
5.  T   F I am sensitive to movement.  I get dizzy very easily.
6.  T   F I am sensitive to and bothered by lights/contrasts/reflections or objects close to my face (that don’t seem to bother others).
7.  T   F I am bothered by some food textures in my mouth (or I avoid them).
8.  T   F It bothers me to be barefoot on grass or sand.
9.  T   F I am bothered by tags and labels in my clothes (or I remove them).
10. T   F I am bothered by turtleneck shirts, tight fitting clothes, elastic, nylons, or synthetic material in clothes (any of the above).
11. T   F I am bothered by the feeling of jewelry (or I never wear it because of this).
12. T   F I am very aware that certain parts of my body are very sensitive.
13. T   F I avoid putting creams and lotions on my skin because of how it feels.
14. T   F I have a sensitive scalp.
15. T   F I do not like being in crowded areas such as elevators, malls, subways, crowded shops or bars (or I never put myself in these situations).
16. T   F Growing up, I did not like to be hugged (except by my mother).
17. T   F I am often uncomfortable with physical intimacy because touching bothers me.
18. T   F I feel bothered when someone touches me from behind or unexpectedly, or stands too close.
19. T   F I was very active as a child (or I am now).
20. T   F I have mood swings more than other people.
21. T   F I do not go to sleep easily and wake up easily and/or I don’t sleep between 6 and 8 hours each night.
22. T   F I consider myself to be anxious.
23. T   F I feel I must mentally prepare myself for situations in which people are apt to touch me.
24. T   F It is important for me to be in control and know what to expect.
25. T   F I am perfectionistic, or compulsive.
26. T   F I avoid if at all possible, situations in which my senses will be stressed.

____________ Total Score (count up the number of “Trues”)


> 10   = definite sensory defensiveness

6 – 10 = moderate sensory defensiveness

< 6      = not sensory defensive


Healthy Diet and ADHD

In ADHD, ADHD Adult, ADHD child/adolescent, Alternative Health, School Psychology on Sunday, 16 September 2012 at 05:16

Healthy vs Western Diet Linked to Better Outcomes in ADHD

Megan Brooks & Penny Murata, MD


Clinical Context

In children with attention-deficit/hyperactivity disorder (ADHD), the effectiveness of diet and dietary supplements is not clear. Dietary measures that have been proposed include sugar restriction; the additive- and salicylate-free Feingold diet; the oligoantigenic or elimination diet; and ketogenic, megavitamin, and polyunsaturated fatty acid (PUFA) supplements. In the July 2011 issue of the Journal of Attention Disorders, Howard and colleagues reported a link between ADHD and a “Western” diet high in fat, refined sugars, and sodium.

This review of the literature assesses the evidence for dietary treatment in children with ADHD.

Study Synopsis and Perspective

When drug therapy fails to control ADHD or is unacceptable, adopting a “healthy” diet, eliminating items known to predispose to ADHD, and adding omega-3 fatty acid supplementation may be worth trying, new research suggests.

“The recent increase of interest in this form of therapy for ADHD, and especially in the use of omega supplements, significance of iron deficiency, and the avoidance of the ‘Western pattern’ diet, make the discussion timely,” the authors write.

Many parents and physicians continue to be interested in how diet and dietary changes, particularly parents wanting to find an alternative to stimulant medication or a complementary therapy. Nevertheless, it remains a “controversial” topic, the authors note.

For their review, J. Gordon Millichap, MD, and Michelle M. Yee, CPNP, from Children’s Memorial Hospital in Chicago, Illinois, searched PubMed for relevant studies on the role of diet and dietary supplements for the treatment of children with ADHD.

They note that their recommendations on diet and dietary supplements are based on a critical review of the data and their own experience in a neurology clinic for children and adolescents with ADHD.

The study was published online on January 9 in Pediatrics.

Elimination Diets Not Advisable

Perhaps the “most promising and practical” complementary or alternative treatment, write Dr. Millichap and Ms. Yee, is adopting a “healthy” dietary pattern, omitting items shown to predispose to ADHD or to make the condition worse. These items include fast foods, red meat, processed meat, potato chips, high-fat dairy foods, and soft drinks.

They point to a “provocative” study published last year, which found a link between ADHD in adolescents and a “Western-style” dietary pattern that was high in fat, refined sugars, and sodium and low in fiber, folate, and omega-3 fatty acids (Howard et al, J Atten Disord. 2011;15:403-411). ADHD was not associated with a “healthy” dietary pattern rich in fish, vegetables, fruit, legumes, and whole-grain foods.

Adopting a healthy dietary pattern “may offer an alternative method of treatment of ADHD and less reliance on medications,” the authors of the current study write.

They also note that although many parents report worsening of hyperactivity symptoms after consumption of foods and drinks containing sugar or aspartame — and isolated reports support the parents’ observations — most controlled studies have failed to find a significant harmful effect of sugar or aspartame, the authors note.

Additionally, they say that the elimination of sugar and aspartame and adapting additive-free diets are complicated, disruptive, and often impractical; such measures are indicated only in select cases.

Fatty Acid Supplements May Be Helpful

Low levels of long-chain PUFAs have been reported in the plasma and red cells of children with ADHD in comparison with their ADHD-free peers, Dr. Millichap and Ms. Yee note. Some studies have demonstrated a reduction in ADHD symptoms with PUFA supplementation, although no definitive conclusions can be drawn.

However, the authors note that “on the basis of reports of efficacy and safety, we use doses of 300 to 600 mg/day of omega-3, and 30 to 60 mg/day of omega-6 fatty acids, continued for 2 or 3 months, or longer if indicated.”

“As initial or add-on therapy, we have occasional reports of improved school grades and lessening of symptoms of ADHD, without occurrence of adverse effects. Most parents are enthusiastic about trying the diet supplements, despite our explanation of only possible benefit and lack of proof of efficacy,” they note.

They also note that iron and zinc supplementation is advisable when there is a known deficiency in these minerals, and this may “enhance the effectiveness” of stimulant therapy.

Pediatrics. Published online January 9, 2012.

Related Link
The National Institute of Mental Health’s Attention Deficit Hyperactivity Disorder (ADHD) site offers a wide range of information helpful for parent education including a downloadable booklet discussing the condition and its management.

Study Highlights

  • This review study provides an overview of the role diet has in children with ADHD. The following supplements, foods, and diets affect the children’s health outcomes in various ways, according to several studies.
  • Omega-3 and omega-6 fatty acid supplements
    • Low long-chain PUFA levels were reported in children with ADHD vs control patients.
    • Some studies showed that PUFA reduced ADHD symptoms, but other studies did not.
    • Doses of omega-3, 300 to 600 mg/day, and omega-6, 30 to 60 mg/day, for 2 to 3 months or longer have been used.
    • Concurrent ADHD medication is almost always needed.
  • Additive and salicylate-free (Feingold) diet
    • Adherence to the diet is complicated and may be disruptive or impractical.
    • Foods to be avoided are apples, grapes, luncheon meats, sausage, hot dogs, and cold drinks with artificial flavors and coloring agents.
    • Permitted foods are grapefruit, pears, pineapple, bananas, beef, lamb, plain bread, certain cereals, milk, eggs, and color-free vitamins.
    • Controlled trials found a small subgroup of preschool children had an adverse response to challenges of additives and preservatives.
    • Children with ADHD and atopy vs no atopy have a higher response to elimination of foods, artificial colorings, and preservatives.
  • Oligoantigenic (hypoallergenic/elimination) diet
    • Adherence to the diet is complicated and may be disruptive or impractical.
    • The oligoantigenic diet eliminates sensitizing food antigens or allergens, including cow’s milk, cheese, wheat cereals, egg, chocolate, nuts, and citrus fruits.
    • Elimination of some foods appeared to decrease some ADHD symptoms, but plays an uncertain role in ADHD treatment.
    • A 2- to 3-week period of elimination diet is followed by the reintroduction of single items each week until the food sensitivity is identified.
    • Behavior improvements might not occur for up to 2 weeks.
    • Enzyme-potentiated desensitization might enable children to become tolerant of provoking foods.
  • Sugar and aspartame
    • Sugar does not affect behavior or cognitive performance, but might affect a subset.
    • In preschool boys, daily sucrose and total sugar intake correlated with duration of aggression.
    • Reactive hypoglycemia after sugar load might reduce cognitive function.
    • Hypoglycemia is linked with impaired electrical activity of the cerebral cortex and slow rhythms on electroencephalogram.
  • Ketogenic diet
    • A ketogenic diet high in fats and low in carbohydrates for children with intractable seizures helped to control seizures and improve behavior, attention, and social functioning.
  • Iron deficiency
    • Iron deficiency is not consistently linked with ADHD severity or frequency.
    • 1 study showed that low serum ferritin correlated with baseline inattention, hyperactivity, impulsivity, and effective amphetamine dose needed.
  • Zinc deficiency
    • Low zinc levels were found in the serum, red cells, hair, urine, and nails of children with ADHD, but mostly in countries with endemic zinc deficiency.
    • In the United States, low serum zinc was linked with inattention, but not with hyperactivity or impulsivity.
    • Zinc supplements might enhance the effect of d-amphetamine, but are not routinely recommended.
  • Other alternative dietary therapies
    • Orthomolecular medicine and megavitamin therapy refer to combination of minerals and nutrients.
    • A study of megavitamin therapy in children with ADHD showed no improvement in behavior, but 42% had elevated serum transaminase levels.
  • “Healthy” vs “Western” diet pattern
    • A cohort study of children from birth to age 14 years found a “Western” dietary pattern associated with ADHD diagnosis and a “Healthy” diet pattern not associated with ADHD diagnosis.
    • The Western dietary pattern includes fast foods, red and processed meats, potato chips, high-fat dairy products, and soft drinks.
    • The Healthy dietary pattern includes fish, vegetables, tomatoes, fresh fruit, whole grains, and low-fat dairy products.

Clinical Implications

  • Indications for dietary therapy in children with ADHD include medication failure or adverse reactions, patient or parental preference, mineral deficiency, and need for change from an ADHD-linked Western diet to an ADHD-free Healthy diet.
  • In children with ADHD, additive-free and elimination diets are time-consuming and disruptive, but might be indicated in selected patients; iron and zinc are indicated for deficiencies; omega-3 supplements have inconsistent effects; and a Healthy diet rich in fish, vegetables, fruit, legumes, and whole grains might be beneficial vs a Western diet of fast foods, red or processed meats, high-fat dairy products, soft drinks, and potato chips.

A Discussion of Language Acquisition Theories (2002)

In Education, School Psychology on Saturday, 15 September 2012 at 09:19

A Discussion of Language Acquisition Theories

by Vedat Kiymazarslan, 2002


A great many theories regarding language development in human beings have been proposed in the past and still being proposed in the present time. Such theories have generally arisen out of major disciplines such as psychology and linguistics. Psychological and linguistic thinking have profoundly influenced one another and the outcome of language acquisition theories alike. This article aims to discuss language acquisition theories and assess their implications for applied linguistics and for a possible theory of foreign/second language teaching.

Language acquisition theories have basically centered around “nurture” and “nature” distinction or on “empiricism” and “nativism”. The doctrine of empiricism holds that all knowledge comes from experience, ultimately from our interaction with the environment through our reasoning or senses. Empiricism, in this sense, can be contrasted to nativism, which holds that at least some knowledge is not acquired through interaction with the environment, but is genetically transmitted and innate. To put it another way, some theoreticians have based their theories on environmental factors while others believed that it is the innate factors that determine the acquisition of language. It is, however, important to note that neither nurturists (environmentalists) disagree thoroughly with the nativist ideas nor do nativists with the nurturist ideas. Only the weight they lay on the environmental and innate factors is relatively little or more. Before sifting through language acquisition theories here, therefore, making a distinction between these two types of perspectives will be beneficial for a better understanding of various language acquisition theories and their implications for the field of applied linguistics. In the following paragraphs, the two claims posed by the proponents of the two separate doctrines will be explained and the reason why such a distinction has been made in this article will be clarified.

Environmentalist theories of language acquisition hold that an organism’s nurture, or experience, are of more significance to development than its nature or inborn contributions. Yet they do not completely reject the innate factors. Behaviorist and neo-behaviorist stimulus-response learning theories (S-R for simplicity) are the best known examples. Even though such theories have lost their effect partially because of Chomsky’s intelligent review of Skinner’s Verbal Behavior (Chomsky, 1959), their effect has not been so little when we consider the present cognitive approach as an offshoot of behaviorism.

The nativist theories, on the other hand, assert that much of the capacity for language learning in human is ‘innate’. It is part of the genetic makeup of human species and is nearly independent of any particular experience which may occur after birth. Thus, the nativists claim that language acquisition is innately determined and that we are born with a built-in device which predisposes us to acquire language. This mechanism predisposes us to a systematic perception of language around us. Eric Lenneberg (cited in Brown, 1987:19), in his attempt to explain language development in the child, assumed that language is a species – specific behavior and it is ‘biologically determined’. Another important point as regards the innatist account is that nativists do not deny the importance of environmental stimuli, but they say language acquisition cannot be accounted for on the basis of environmental factors only. There must be some innate guide to achieve this end. In Table 1 below, a classification around the nurture/nature distinction has been made.



Some of the Resulting
Foreign/Second Language Teaching Methods



(environmental factors are believed
to be more dominant in language acquisition)


– Bakhtin’s Theory of Polyphony or Dialogics

– Vygotsky’s Zone of Proximal Development

– Skinner’s Verbal Behavior

– Piaget’s View of Language Acquisition

– The Competition Model

– Cognitive Theory: Language Acquisition View

– Discourse Theory

– The Speech Act Theory

– The Acculturation Model

– Accommodation Theory

– The Variable Competence

– The Interactionist View of Language Acquisition

– The Connectionist Model





Community Language Learning


Communicative Approach





(innate factors are believed to be more dominant in language acquisition)


– A Neurofunctional Theory of Language Acquisition


– The Universal Grammar Theory


– Fodor’s Modular Approach


The Monitor Model





The Natural Approach




Table 1. Classification of Language Acquisition Theories Around
“Nurture and Nature Distinction”

The particular reason why such a distinction between environmentalist and nativist theories has been made in this study is to create a clear-cut picture of the current status of language acquisition theories, present and former studies in the field of language acquisition and language teaching methodology. In the following part, the most important ones of language acquisition theories resulting f rom the two opposing views mentioned above will be discussed.


In this part of the article, eight different views of language acquisition will be discussed. Most of the theories may be considered in both L1 (mother tongue) and L2 (second or foreign language) acquisition even though certain theories to be discussed here have been resulted from second language acquisition (SLA) studies. It is important to note once again that language acquisition theories have been influenced especially by linguistic and psychological schools of thought. Thus they have given relatively changing weights on different factors in approaching the acquisition process as can be seen in the following subsections.

2.1 Vygotsky’s Zone of Proximal Development

Vygotsky was a psychologist but his studies on conscious human behavior led him to investigate the role that language plays in human behavior. Vygotsky’s point of view is simply that social interaction plays an important role in the learning process. He places an emphasis on the role of “shared language” in the development of thought and language. The term “shared language” refers to social interaction and can be best elucidated through the notion of “zone of proximal development”.

According to Vygotsky (1962:10), two developmental levels determine the learning process: egocentricity and interaction. We can look at what children do on their own and what they can do while working with others. They mostly choose to remain silent or speak less on their own (less egocentric speech) when they are alone. However, they prefer to speak to other children when they play games with them (more egocentric speech). The difference between these two types of development forms has been called “Zone of Proximal Development”. This zone refers to the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance or in cooperation with more capable friends of the child. The first thing that children do is to develop concepts by talking to adults and then solve the problems they face on their own. In other words, children first need to be exposed to social interaction that will eventually enable them build their inner resources.

As for the drawbacks of the views proposed by Vygotsky, it is not clear what Vygotsky meant by inner resources. Also, his emphasis on the significance of egocentric speech in the development of thought and language is worth discussing. He suggests that egocentric speech is social and helps children interact with others. When a child is alone he uses less egocentric language than he uses it when playing games with other children. This implies that speech is influenced by the presence of other people. It seems that Vygotsky overemphasizes the function of egocentric speech in the development of language. It is true that society and other people are important factors helping children to acquire language. However, Vygotsky fails to account for the role of the self itself in this process, even though he stresses the importance of egocentric speech, which is not the self actually, and see the relative role of inner linguistic and psycholinguistic mechanisms that promote language acquisition.

In conclusion, Vygotsky contends that language is the key to all development and words play a central part not only in the development of thought but in the growth of cognition as a whole. Within this framework, child language development, thus acquisition, can be viewed as the result of social interaction.

2.2. Skinner’s Verbal Behavior

Behavioristic view of language acquisition simply claims that language development is the result of a set of habits. This view has normally been influenced by the general theory of learning described by the psychologist John B. Watson in 1923, and termed behaviorism. Behaviorism denies nativist accounts of innate knowledge as they are viewed as inherently irrational and thus unscientific. Knowledge is the product of interaction with the environment through stimulus-response conditioning.

Broadly speaking, stimulus (ST) – response (RE) learning works as follows. An event in the environment (the unconditioned stimulus, or UST) brings out an unconditioned response (URE) from an organism capable of learning. That response is then followed by another event appealing to the organism. That is, the organism’s response is positively reinforced (PRE). If the sequence UST –> URE –> PRE recurs a sufficient number of times, the organism will learn how to associate its response to the stimulus with the reinforcement (CST). This will consequently cause the organism to give the same response when it confronts with the same stimulus. In this way, the response becomes a conditioned response (CRE).

The most risky part of the behavioristic view is perhaps the idea that all leaning, whether verbal (language) or non-verbal (general learning) takes place by means of the same underlying process, that is via forming habits. In 1957, the psychologist B.F. Skinner produced a behaviorist account of language acquisition in which linguistic utterances served as CST and CRE.

When language acquisition is taken into consideration, the theory claims that both L1 and L2 acquirers receive linguistic input from speakers in their environment, and positive reinforcement for their correct repetitions and imitations. As mentioned above, when language learners’ responses are reinforced positively, they acquire the language relatively easily.

These claims are strictly criticized in Chomsky’s “A Review of B.F. Skinner’s Verbal Behavior”. Chomsky (1959) asserts that there is “neither empirical evidence nor any known argument to support any specific claim about the relative importance of feedback from the environment”. Therefore, it would be unwise to claim that the sequence UST –> URE –> PRE and imitation can account for the process of language acquisition. What is more, the theory overlooks the speaker (internal) factors in this process.

The behaviorists see errors as first language habits interfering with the acquisition of second language habits. If there are similarities between the two languages, the language learners will acquire the target structures easily. If there are differences, acquisition will be more difficult. This approach is known as the contrastive analysis hypothesis (CAH). According to the hypothesis, the differences between languages can be used to reveal and predict all errors and the data obtained can be used in foreign/second language teaching for promoting a better acquisition environment. Lightbown and Spada (1993: 25) note that:

“… there is little doubt that a learner’s first language influences the acquisition of second language. [But] … the influence is not simply a matter of habits, but rather a systematic attempt by the learner to use knowledge already acquired in learning a new language.”

This is another way of saying that mother tongue interference cannot entirely explain the difficulties that an L2 learner may face. It is true that there might be some influences resulting from L1, but research (Ellis, 1985:29) has shown that not all errors predicted by CAH are actually made. For example, Turkish learners of English simply use utterances just as “No understand” even though the corresponding structure of Turkish (“Anlamiyorum” literally, “UNDERSTAND-NO-ME”) is thoroughly different.

In brief, Skinner’s view of language acquisition is a popular example of the nurturist ideas. Behaviorism, as known by most of us, was passively accepted by the influential Bloomfieldian structuralist school of linguistics and produced some well-know applications in the field of foreign/second language teaching – for instance, the Audiolingual Method or the Army Method. The theory sees the language learner as a tabula rasa with no built-in knowledge. The theory and the resulting teaching methods failed due to the fact that imitation and simple S-R connections only cannot explain acquisition and provide a sound basis for language teaching methodology.

2.3. Piaget’s View of Language Acquisition

Even though Piaget was a biologist and a psychologist, his ideas have been influential in the field of first and second language acquisition studies. In fact he studied the overall behavioral development in the human infant. But his theory of development in children has striking implications as regards language acquisition.

Ellidokuzoglu (1999:16) notes that “many scientists, especially the psychologists are hesitant to attribute a domain-specific built-in linguistic knowledge to the human infant.” Accordingly, they view the human brain as a homogeneous computational system that examines different types of data via general information processing principles. Piaget was one of those psychologists who view language acquisition as a case of general human learning. He has not suggested, however, that the development is not innate, but only that there is no specific language module. Piaget’s view was then that the development (i.e., language acquisition) results mainly from external factors or social interactions. Piaget (cited in Brown, 1987:47, Eyseneck, 1990:51) outlined the course of intellectual development as follows:

– The sensorimotor stage from ages 0 to 2 (understanding the environment)
– The preoperational stage from ages 2 to 7 (understanding the symbols)
– The concrete operational stage from ages 7 to 11 (mental tasks and language use)
– The formal operational stage from the age 11 onwards (dealing with abstraction)

Piaget observes, for instance, that the pre-linguistic stage (birth to one year) is a determining period in the development of sensory-motor intelligence, when children are forming a sense of their physical identity in relation to the environment. Piaget, unlike Vygotsky, believes that egocentric speech on its own serves no function in language development.
2.4. The Universal Grammar Theory

Among theories of language acquisition, Universal Grammar (UG) has recently gained wider acceptance and popularity. Though noted among L2 acquisition theories, the defenders of UG are not originally motivated to account for L2 acquisition, nor for first language (L1) acquisition. However, UG is more of an L1 acquisition theory rather than L2. It attempts to clarify the relatively quick acquisition of L1s on the basis of ‘minimum exposure’ to external input. The ‘logical problem’ of language acquisition, according to UG proponents, is that language learning would be impossible without ‘universal language-specific knowledge’ (Cook, 1991:153; Bloor & Bloor: 244). The main reason behind this argument is the input data:

“…[L]anguage input is the evidence out of which the learner constructs knowledge of language – what goes into the [brain]. Such evidence can be either positive or negative. … The positive evidence of the position of words in a few sentences [the learner] hear[s] is sufficient to show [him] the rules of [a language].” (Cook, 1991: 154)

The views supports the idea that the external input per se may not account for language acquisition (Ellidokuzoglu, 1999:20). Similarly, the Chomskyan view holds that the input is poor and deficient in two ways. First, the input is claimed to be ‘degenerate’ because it is damaged by performance features such as slips, hesitations or false starts. Accordingly, it is suggested that the input is not an adequate base for language learning. Second, the input is devoid of grammar corrections. This means that the input does not normally contain ‘negative evidence’, the knowledge from which the learner could exercise what is ‘not’possible in a given language.

As for L2 acquisition, however, the above question is not usually asked largely because of the frequent failure of L2 learners, who happen to be generally cognitively mature adults, in attaining native-like proficiency. But why can’t adults who have already acquired an L1, acquire an L2 thoroughly? Don’t they have any help from UG? Or if they do, then how much of UG is accessible in SLA? These and similar questions have divided researchers into three basic camps with respect to their approach to the problem:

Direct access -L2 acquisition is just like L1 acquisition. Language acquisition device (LAD) is involved.

No access – L2 learners use their general learning capacity.

Indirect access – Only that part of UG which has been used in L1 acquisition is used in L2 acquisition.

Proponents of UG, for example, believe that both children and adults utilize similar universal principles when acquiring a language; and LAD is still involved in the acquisition process. This view can be better understood in the following quote.

[A]dvocates of [UG] approach working on second-language learning… argue that there is no reason to assume that language faculty atrophies with age. Most second-language researchers who adopt the [UG] perspective assume that the principles and parameters of [UG] are still accessible to the adult learner. (McLaughlin, 1987:96)

To support the view above, the acquisition of the third person “-s” can be given as an example. According to research (1996, Cook: 21) both child L1 and adult L2 learners (e.g. Turkish learners of English) acquire the third person “-s” morpheme at a later stage of their overall acquisition process and have a great difficulty in acquiring it when compared to other morphemes such as the plural morpheme “-s” or the progressive morpheme “-ing”. This shows that such learners are somewhat affected by UG-based knowledge. However, in the case of foreign/second language teaching it is very well known that the third person “-s” is taught at the very beginning of a second language learning program and presented in a great majority of textbooks as the first grammatical item.

Accordingly, Fodor’s views have some parallels with the UG Theory. Jerry Fodor studied the relationship between language and mind and his view that language is a modular process has important implications for a theory of language acquisition. The term modular is used to indicate that the brain is seen, unlike older views such as behavioristic view of learning and language learning, to be organized with many modules of cells for a particular ability (for instance, the visual module). These modules, according to Fodor (1983:47), operate in isolation from other modules that they are not directly connected. The language module, if we are to follow Fodor’s ideas, is one of such modules. This modular separateness has been termed as “informational encapsulation” by Fodor. To put it simply, each module is open to specific type of data. In other words, modules are domain specific. This is another way of saying that conscious knowledge cannot penetrate your visual module or language module or any other subconscious module.

Basically, Fodor’s arguments are somewhat similar to that of Chomsky or the proponents of UG Theory in that the external input per se may not account for language acquisition and that language acquisition is genetically predetermined. Add to this, such a modular approach to language acquisition is totally different from the views of Piaget and Vygotsky who have laid the primary emphasis on the role of social or environmental factors in language development.

In the case of foreign/second language teaching, the common view is that inductive learning (teaching a language through hidden grammar or) leads to acquisition. However, dwelling on Fodor’s views as discussed above, it is obvious that inductive learning is confused with acquisition and that by learning something via discovery learning, students just improve their problem-solving skills, but not acquire a language.

As for the problems with Universal Grammar, it can be said that UG’s particular aim is to account for how language works. Yet UG proponents had to deal with acquisition to account for the language itself. “Acquisition part” is thus of secondary importance. A second drawback is that Chomsky studied only the core grammar of the English language (syntax) and investigated a number of linguistic universals seems to be the major problem. And he neglected the peripheral grammar, that is, language specific rules (i.e., rules of specific languages which cannot be generalized). Thirdly, the primary function of language is communication, but it is discarded. The final and the most significant problem is a methodological one. Due to the fact that Chomsky is concerned only with describing and explaining ‘competence’, there can be little likelihood of SLA researchers carrying out empirical research.

In summary, UG has generated valuable predictions about the course of interlanguage and the influence of the first language. Also, it has provided invaluable information regarding L2 teaching as to how L2 teachers (or educational linguists) should present vocabulary items and how they should view grammar. As Cook (1991:158) puts it, UG shows us that language teaching should deal with how vocabulary should be taught, not as tokens with isolated meanings but as items that play a part in the sentence saying what structures and words they may go with in the sentence. The evidence in support of UG, on the other hand, is not conclusive. If the language module that determines the success in L1 acquisition is proved to be accessible in L2 acquisition, L2 teaching methodologists and methods should study and account for how to trigger this language module and redesign their methodologies. The UG theory should, therefore, be studied in detail so as to endow us with a more educational and pedagogical basis for mother tongue and foreign language teaching.

2.5. A Neurofunctional Theory (based on the environmentalist view):

Ellis (1985:273) notes that this theory is based on two systems: the communication hierarchy and the cognitive hierarchy. “The communication hierarchy” means language and other forms of interpersonal communication. “The cognitive hierarchy, on the other hand, refers to a number of cognitive information processing activities possibly related with “conscious” processes. The theory also makes a sharp distinction between Primary Language Acquisition (PLA) and Secondary Language Acquisition (SELA). PLA is seen in the child’s acquisition of one or more languages from the age of two to five. SELA is found in both adults and children. It is, in addition, divided into two parts (a) foreign language learning, that is formal classroom language learning, and (b) second language acquisition, that is, the natural acquisition of a second language after the age of five. This theory claims that PLA and (b) is marked through use of the communication hierarchy while (a) is marked by the use of the cognitive hierarchy only. If we are to accept the existence of some innate and subconscious linguistic properties, which is what the nativists have claimed, we then have the right to ask the question of why (a) is treated only as a cognitive process.

(1) The Acquisition-Learning Hypothesis

Krashen (1985), in his theory of second language acquisition (SLA) suggested that adults have two different ways of developing competence in second languages: Acquisition and learning. “There are two independent ways of developing ability in second languages. ‘Acquisition’ is a subconscious process identical in all important ways to the process children utilize in acquiring their first language, … [and] ‘learning’…, [which is] a conscious process that results in ‘knowing about’ [the rules of] language” (Krashen 1985:1).

Krashen (1983) believes that the result of learning, learned competence (LC) functions as a monitor or editor. That is, while AC is responsible for our fluent production of sentences, LC makes correction on these sentences either before or after their production. This kind of conscious grammar correction, ‘monitoring’, occurs most typically in a grammar exam where the learner has enough time to focus on form and to make use of his conscious knowledge of grammar rules (LC) as an aid to ‘acquired competence’. The way to develop learned competence is fairly easy: analyzing the grammar rules consciously and practising them through exercises. But what Acquisition / Learning Distinction Hypothesis predicts is that learning the grammar rules of a foreign/second language does not result in subconscious acquisition.

The implication of the acquisition-learning hypothesis is that we should balance class time between acquisition activities and learning exercises.

(2) The Natural Order Hypothesis

According to the hypothesis, the acquisition of grammatical structures proceeds in a predicted progression. Certain grammatical structures or morphemes are acquired before others in first language acquisition and there is a similar natural order in SLA. The implication of natural order is not that second or foreign language teaching materials should be arranged in accordance with this sequence but that acquisition is subconscious and free from conscious intervention.

(3) The Input Hypothesis

This hypothesis relates to acquisition, not to learning. Krashen (1985:3) claims that people acquire language best by understanding input that is a little beyond their present level of competence. Consequently, Krashen believes that ‘comprehensible input’ (that is, i + 1) should be provided. The ‘input’ should be relevant and ‘not grammatically sequenced’. The foreign/second language teacher should always send meaningful messages, which are roughly tuned, and ‘must’ create opportunities for students to access i+1 structures to understand and express meaning. For instance, the teacher can lay more emphasis on listening and reading comprehension activities.

(4) The Monitor Hypothesis

As mentioned before, adult second language learners have two means for internalizing the target language. The first is ‘acquisition’ which is a subconscious and intuitive process of constructing the system of a language. The second means is a conscious learning process in which learners attend to form, figure out rules and are generally aware of their own process. The ‘monitor’ is an aspect of this second process. It edits and makes alterations or corrections as they are consciously perceived. Krashen (1985:5) believes that ‘fluency’ in second language performance is due to ‘what we have acquired’, not ‘what we have learned’: Adults should do as much acquiring as possible for the purpose of achieving communicative fluency. Therefore, the monitor should have only a minor role in the process of gaining communicative competence. Similarly, Krashen suggests three conditions for its use: (1) there must be enough time; (2) the focus must be on form and not on meaning; (3) the learner must know the rule. Students may monitor during written tasks (e.g., homework assignments) and preplanned speech, or to some extent during speech. Learned knowledge enables students to read and listen more so they acquire more.

(5) The Affective Filter Hypothesis

The learner’s emotional state, according to Krashen (1985:7), is just like an adjustable filter which freely passes or hinders input necessary to acquisition. In other words, input must be achieved in low-anxiety contexts since acquirers with a low affective filter receive more input and interact with confidence. The filter is ‘affective’ because there are some factors which regulate its strength. These factors are self-confidence, motivation and anxiety state. The pedagogical goal in a foreign/second language class should thus not only include comprehensible input but also create an atmosphere that fosters a low affective filter.

The Monitor Model has been criticized by some linguists and methodologists McLaughlin (1987: 56), notes that the model fails at every juncture by claiming that none of the hypotheses is clear in their predictions. For example, he notes that the acquisition-learning distinction is not properly defined and that the distinction between these two processes cannot be tested empirically. Although it is true that some parts of the theory need more clarification, it would be harsh to suggest that the Model is a pseudo-scientific. Hasanbey (personal communication) define acquisition as follows:

“Any systematic linguistic behavior, the rules of which cannot be verbalized by its performer is the outcome of acquisition. So if one uses a specific language rule in proper contexts and if the same person cannot articulate the underlying language rule which determines its proper context, then that person is said to have acquired the rule in question. On the other hand, if a person can verbalize a language rule, with or without its proper implementation during performance then that person is said to have conscious knowledge of that rule. So one might have acquired and learned the same rule in theory.”

While writing these very sentences, I have displayed a curious example of committing an error which proves the acquisition-learning distinction. In the statement “Hasanbey (personal communication) define acquisition as follows” the verb define should have an “-s” attached to it. I, as an EFL learner/teacher of English for about 20 years, “consciously” know when to attach that suffix to the verbs. But when it comes to fluent writing and speaking during which only subconsciously acquired rules have a say, I frequently miss that third person singular –s. So I and many other L2 learners who commit this error in spite of knowing the underlying rule at a conscious level, are the irrefutable evidence proving the distinction between acquisition and learning. The on-going interest in Krashen’s theory and the emergence of articles supporting his theory in recent journals also proves that his theory is far from being pseudo-scientific. Here is a typical example:

“Krashen’s ‘acquisition-learning’ distinction has met harsh criticism but the theory he put forward deserves a more sympathetic reappraisal. First of all, the theory is not insulated against falsification. The results of the studies examining the effects of explicit positive and/or negative evidence in formal learning are not inconsistent with it. Recent studies on the acquisition of functional categories lends support to the existence of the natural order in English L2. It is also possible to single out major dimensions on which processes and products of the ‘acquired’ and ‘learned’ systems differ using the principles of markedness and differences in computational complexity.”(Zobl, 1995:35)

So far eight theories of language acquisition have been discussed (see Appendix for a brief account of other theories and a classification of theories based on the distinction made here). It can be seen that none of the theories is complete and most of them need developing. Each theory, however, is important for their implications and provides invaluable information as to how a language is acquired. and how language teaching should take place.


The most important implication of language acquisition theories is obviously the fact that applied linguists, methodologist and language teachers should view the acquisition of a language not only as a matter of nurture but also an instance of nature. In addition, only when we distinguish between a general theory of learning and language learning can we ameliorate the conditions L2 education. To do so, applied linguists must be aware of the nature of both L1 and L2 acquisition and must consider the distinction proposed in this study.

Ridgway (2000, 13) notes that the educational linguist (not the applied linguist) is a practitioner who applies and adapts the policies of others in the classroom creatively. If the educational linguist is to adapt language models proposed by others (applied linguists) for classroom practice, it becomes more important “how” he or she will adopt them. How, for instance, should s/he utilize the findings of SLA studies conducted on syntax or natural order and use them for his or her particular classroom settings? How should grammar points be handled? Should they be taught inductively or deductively? Or should there be a balance between grammar lessons and acquisition lessons just as proposed by the proponents of the Monitor Model? How should vocabulary teaching be like and how should a syllabus be designed? How will the results of language planning proposed by the government be implemented? Most of these “how” questions can be answered properly only through a detailed analysis and a thorough understanding of language acquisition theories.

Here, on the shoulders of the methodologists lays quite a heavy responsibility. As we often see, linguistics and TEFL/TESL are largely based on the nurturist facet of language acquisition, emphasizing discourse and ethnolinguistic studies. It would, of course, be unwise to deemphasize such studies and their role in accounting for language acquisition and reaching a possible theory of educational linguistics. However, in this article it has been shown that language acquisition is also a considerable matter of innate factors. What is then the role of that “nature” part of theories in the overall sketch of language acquisition and methodology?

In addition, the author wishes to emphasize the necessity of the subfield “educational psycholinguistics”. In Stubbs’ point of view (1986:283), a thorough description of language in use, language variation, levels of language such as phonology, morphology and syntax, semantics and discourse will form the bases of a complete educational theory of language. If such a theory is expected to be beneficial to foreign and second language teaching, then it should not only include these environmentalist components but also include the subfield “educational psycholinguistics” which would mainly focus on “naturist” accounts as discussed in previous parts of this article. The inclusion of educational psycholingustics in this sense will make the current position of applied linguistics and language teaching far stronger. No longer should mind and innateness be treated as dirty words (Pinker, 1994:22). This will most probably lead to innovative proposals for syllabus development and the design of instructional systems, practices, techniques, procedures in the language classroom, and finally a sound theory of L2 teaching and learning.

Retrieved from:


Seclusion and Restraint in the Public Schools

In Education, School Psychology, Special Education on Saturday, 15 September 2012 at 08:20
September 8, 2012
A Terrifying Way to Discipline Children
By: Bill Lichenstein
Editors’ note appended
IN my public school 40 years ago, teachers didn’t lay their hands on students for bad behavior. They sent them to the principal’s office. But in today’s often overcrowded and underfunded schools, where one in eight students receive help for special learning needs, the use of physical restraints and seclusion rooms has become a common way to maintain order.It’s a dangerous development, as I know from my daughter’s experience. At the age of 5, she was kept in a seclusion room for up to an hour at a time over the course of three months, until we discovered what was happening. The trauma was severe.According to national Department of Education data, most of the nearly 40,000 students who were restrained or isolated in seclusion rooms during the 2009-10 school year had learning, behavioral, physical or developmental needs, even though students with those issues represented just 12 percent of the student population. African-American and Hispanic students were also disproportionately isolated or restrained.Joseph Ryan, an expert on the use of restraints who teaches at Clemson University, told me that the practice of isolating and restraining problematic children originated in schools for children with special needs. It migrated to public schools in the 1970s as federal laws mainstreamed special education students, but without the necessary oversight or staff training. “It’s a quick way to respond but it’s not effective in changing behaviors,” he said.State laws on disciplining students vary widely, and there are no federal laws restricting these practices, although earlier this year Education Secretary Arne Duncan wrote, in a federal guide for schools, that there was “no evidence that using restraint or seclusion is effective.” He recommended evidence-based behavioral interventions and de-escalation techniques instead.

The use of restraints and seclusion has become far more routine than it should be. “They’re the last resort too often being used as the first resort,” said Jessica Butler, a lawyer in Washington who has written about seclusion in public schools.

Among the recent instances that have attracted attention: Children in Middletown, Conn., told their parents that there was a “scream room” in their school where they could hear other children who had been locked away; last December, Sandra Baker of Harrodsburg, Ky., found her fourth-grade son, Christopher, who had misbehaved, stuffed inside a duffel bag, its drawstrings pulled tight, and left outside his classroom. He was “thrown in the hall like trash,” she told me. And in April, Corey Foster, a 16-year-old with learning disabilities, died on a school basketball court in Yonkers, N.Y., as four staff members restrained him following a confrontation during a game. The medical examiner ruled early last month that the death was from cardiac arrest resulting from the student’s having an enlarged heart, and no charges were filed.

I saw firsthand the impact of these practices six years ago when my daughter, Rose, started kindergarten in Lexington, Mass. Rose had speech and language delays. Although she sometimes became overwhelmed more quickly than other children, she was called “a model of age-appropriate behavior” by her preschool. One evaluation said Rose was “happy, loves school, is social.” She could, however, “get fidgety and restless when she is unsure as to what is expected of her. When comfortable, Rose is a very participatory and appropriate class member with a great deal to contribute to her world.”

Once in kindergarten, Rose began throwing violent tantrums at home. She repeatedly watched a scene from the film “Finding Nemo” in which a shark batters its way into a tiny room, attempting to eat the main characters. The school provided no explanation or solution. Finally, on Jan. 6, 2006, a school aide called saying that Rose had taken off her clothes. We needed to come get her.

At school, her mother and I found Rose standing alone on the cement floor of a basement mop closet, illuminated by a single light bulb. There was nothing in the closet for a child — no chair, no books, no crayons, nothing but our daughter standing naked in a pool of urine, looking frightened as she tried to cover herself with her hands. On the floor lay her favorite purple-striped Hanna Andersson outfit and panties.

Rose got dressed and we removed her from the school. We later learned that Rose had been locked in the closet five times that morning. She said that during the last confinement, she needed to use the restroom but didn’t want to wet her outfit. So she disrobed. Rather than help her, the school called us and then covered the narrow door’s small window with a file folder, on which someone had written “Don’t touch!”

We were told that Rose had been in the closet almost daily for three months, for up to an hour at a time. At first, it was for behavior issues, but later for not following directions. Once in the closet, Rose would pound on the door, or scream for help, staff members said, and once her hand was slammed in the doorjamb while being locked inside.

At the time, I notified the Lexington Public Schools, the Massachusetts Department of Children and Families and the Department of Mental Health about Rose and other children in her class whom school staff members indicated had been secluded. If any of these agencies conducted a formal investigation, I was not made aware of it.

Rose still has nightmares and other symptoms of severe stress. We brought an action against the Lexington Public Schools, which we settled when the school system agreed to pay for the treatment Rose needed to recover from this trauma.

The physical and psychological injuries to children as a consequence of this disciplinary system is an issue that has found its way to Congress. Legislation to ban these practices has been introduced in the House and the Senate, but no vote is expected this year.

Meanwhile, Rose is back in public school and has found it within her to forgive those involved in her case. “They weren’t bad people,” she told me. “They just didn’t know about working with children.”

Bill Lichtenstein is an investigative journalist and filmmaker.

Editors’ Note: September 16, 2012
An opinion essay on Sept. 9 criticizing the use of seclusion and restraint to discipline students described an episode on Jan. 6, 2006, in which the writer’s daughter, then a kindergartner, was kept in an isolation room at her school in Lexington, Mass. Several details of that episode have since been disputed.The girl wet herself while being confined in a closet for misbehaving. But school officials, and a 2008 deposition by the girl’s mother, state that she was then cleaned up and dressed while her parents were notified — and that it was not the case that the parents found her standing alone, unclothed, in her urine.

The article incorrectly described the closet where the girl was confined. It was on a mezzanine between two classroom levels, not in the basement.

While the girl’s parents sued the Lexington school district in 2007, and obtained a settlement in 2008, the writer did not notify two Massachusetts state agencies — the Department of Children and Families and the Department of Mental Health — “at the time” of the episode, according to state records.

The girl’s parents divorced in 2007. If The Times had known before the article was published that the writer’s ex-wife was now the girl’s custodial parent, it would have contacted her.

ADHD into Adolescence

In ADHD, ADHD child/adolescent, ADHD stimulant treatment, Medication, Neuropsychology, School Psychology on Friday, 14 September 2012 at 05:26

Adolescent ADHD: Diagnosis and Initial Treatment

Scott H. Kollins, PhD


ADHD Into Adolescence

Longitudinal studies demonstrate that ADHD is a disorder that children do not simply outgrow as they reach adolescence.[1-5] Follow-up studies of children with ADHD estimate that the diagnosis persists in 50% to 80% of cases.[1,6-10] Studies of clinically referred adolescents with ADHD also indicate that the disorder continues into adolescence and is associated with various functional impairments, particularly when compared with nondiagnosed peers, including social competence, behavioral and emotional adjustment, school performance, and general quality of life.[11,12]

Although ADHD as a disorder is continuous from childhood into adolescence,[13] the persistence of ADHD into adolescence needs to be considered in the context of adolescence as a period of development in which there are many changes at multiple levels, including physical, psychological, and social changes. During this developmental period, adolescents typically experience a growing influence of peers and independence from family members.[14] For adolescents with a disorder like ADHD in which social and emotional impairment is common,[15] this transitional period may be particularly difficult. Cognitive demands increase along with greater independence from adult supervision (eg, multiple teachers with different teaching styles, amount and scope of homework) as children enter into middle and high school,[11] which requires greater self-regulation, a quality that is often impaired in those with ADHD.

Neuronal and hormonal developmental changes during adolescence can further influence how symptoms are expressed.[14] Related to these biologically based changes, adolescence also is a critical period neurobiologically, with more risk-taking behavior and drug and alcohol use, which correspond with notable changes in motivational and reward-related brain regions. Such behaviors can be problematic because adolescents are naturally more sensitive to the positive rewarding properties of various drugs and natural stimuli and less sensitive to the aversive properties of these stimuli.[16] These behavioral and neurobiological developmental changes in concert with social, hormonal, and physiological changes place adolescents at high risk for substance use.[17,18] ADHD is an additional risk factor for such substance use behavior (reviewed in greater detail below) and thus places adolescents with ADHD at greater risk during this critical developmental period.

Given such developmental changes, the presentation of ADHD changes in adolescence as well, including symptom presentation; although inattentive symptoms continue to be involved in the clinical characteristics of most patients, hyperactive symptoms decline in severity for many.[7,19-21] This symptom presentation continues to cause functional impairment in domains typically impaired in childhood, including academics.[22]

Adolescents with ADHD smoke at significantly higher rates than peers without ADHD and start smoking earlier, demonstrate a higher level of nicotine dependence, and have greater difficulty quitting than youth without ADHD. Some studies have estimated that 25% to 75% of adolescents with ADHD meet diagnostic criteria for ODD or CD. Although mood disorders are often seen in adolescents with ADHD, with an incidence of roughly 10% to 20%, they are less common than DBD. ADHD may be evidence of more severe bipolar disease. For example, ADHD is more common in those with childhood-onset bipolar disorder, which suggests that in some cases ADHD may signal an earlier onset, more chronic bipolar disorder.

ADHD and Comorbid Conditions in Adolescence

Comorbidity within populations of adolescents with ADHD is typically the norm rather than the exception. For example, in one clinical sample of patients 6 to 18 years old, more than half met the criteria for at least one comorbid disorder.[23] Disruptive behavior disorders, including ODD and CD, are particularly common.[24] In general population studies, ADHD increases the odds of ODD or CD by 10.7-fold.[25] Some studies have estimated that 25% to 75% of adolescents with ADHD meet the diagnostic criteria for ODD or CD.[14] In another study, ODD was comorbid among 54% to 67% of clinically referred 7- to 15-year-old children with ADHD.[23] In this study, differences in subtypes also emerged. ODD was significantly more common among those with combined and hyperactive-impulsive ADHD subtypes (50.7% and 41.9%, respectively) than with inattentive subtype (20.8%). Such rates are concerning not only because of the characteristics of these comorbid disruptive behavior disorders (eg, delinquency) that are dealt with in adolescence, but also because CD is a precursor to antisocial personality disorder in adulthood. Given that CD is commonly seen in children with ADHD and is a precursor to antisocial personality disorder, it is not surprising that rates of antisocial personality disorder (among additional forms of Axis II psychopathology) are elevated in adults with ADHD.[4,5,10,26,27]

SUDs are also common in adolescents with ADHD. In longitudinal studies of hyperactive children, the risk for SUDs ranges from 12% to 24% into adulthood.[8,10,26] Because adolescence is a time when initial exposure to substances occurs and because adolescence is also a developmental period during which susceptibility to the reinforcing effects of substances is heightened,[16-18] substance use in adolescence is a concern both as an outcome of current use and of continued risk for future use. This risk is further elevated among adolescents with ADHD. Individuals with ADHD engage in experimentation earlier than children without ADHD.[28,29] Although such findings indicate that the relationship between ADHD and SUDs is independent of comorbidity, CD is a strong predictor of risk for SUDs among children with ADHD when they reach adolescence and adulthood.[30-32] In addition, prospective studies indicate that children with ADHD and co-occurring CD or bipolar disorder are at a higher risk for SUDs during adolescence.[33-35]

Adolescents with ADHD smoke at significantly higher rates than peers without ADHD. Prevalence rates range from 10% to 46% for adolescents with ADHD vs 10% to 24% for adolescents without ADHD.[34,36,37] Even among nonclinical patient samples, there is a linear relationship between number of ADHD symptoms, lifetime risk of smoking, and age of onset of regular smoking.[38] Additional studies have demonstrated that youth with ADHD initiate smoking earlier, exhibit a higher level of nicotine dependence, have greater difficulty quitting than youth without ADHD, and are at an increased risk for becoming a regular cigarette smoker.[37,39] In addition, the relationship between ADHD and tobacco use has remained significant as an independent risk factor after accounting for comorbidity, including CD.[40,41]

Mood disorders are also common among adolescents with ADHD.[42] For example, in one study, 21.6% of children 6 to 18 years old who had ADHD also had a depressive disorder.[23] The combination of a major depressive disorder and a comorbid disruptive behavior disorder is a risk factor for suicidal behavior,[43] and both major depressive disorder and disruptive behavior disorder are common comorbidities in those with ADHD. One longitudinal study assessing childhood ADHD reported that the diagnosis of ADHD in children predicted adolescent depression and/or suicide attempts. In addition, female sex, maternal depression, and concurrent symptoms in childhood predicted which children with ADHD were at greatest risk for these outcomes.[44]

Bipolar disorder is another disorder commonly seen in children with ADHD. Studies have estimated that bipolar disorder co-occurs among 10% to 20% of children and adolescents with ADHD.[45-47] Longitudinal studies of hyperactive children indicate a similar prevalence in adulthood,[5,10,26] although another longitudinal study of children with ADHD reported higher rates into adolescence (12%).[48] In some cases, ADHD may be evidence of more severe bipolar disorder. For example, ADHD is more common in cases of childhood-onset bipolar disorder, which suggests that in some cases ADHD may signal an earlier onset, more chronic bipolar disorder.[48] Regarding anxiety disorders, longitudinal studies of hyperactive children do not report significant elevations in comorbid anxiety disorders.[5,10,26] However, anxiety disorders have been reported in 10% to 40% of clinic-referred children and adolescents with ADHD.[23,49-51] Overall, these studies demonstrate that comorbidity is typical among adolescents with ADHD and further complicates its clinical presentation in adolescence. In addition to concerns about prognosis, such comorbidities can easily complicate issues related to assessment.

Assessment of Adolescents With ADHD

An empirically-based assessment of ADHD typically includes structured clinical interviews, standardized questionnaires, and a review of records, all in the context of diagnostic criteria.[14,52] Cognitive test performance may provide additional value when differentiating ADHD subtypes.[53] Although there is diagnostic continuity of ADHD from childhood into adolescence,[13] assessing ADHD during adolescence needs to be considered in the context of complicating factors. One such factor involves comorbidity. Comorbidity is common in adolescents with ADHD, and conditions can co-occur with ADHD or can mimic ADHD symptoms. Regarding the latter, a diminished ability to concentrate can also be a symptom of a major depressive episode, distractibility and being overly talkative can also be symptoms of a manic or hypomanic episode, and restlessness and difficulty concentrating can be symptoms of generalized anxiety disorder or post-traumatic stress disorder.[54] Further, substance use can confound the assessment for ADHD, as alcohol and illicit drug use can create cognitive impairments that are also common in youth with ADHD.[55-57]

An additional factor that emerges in assessments of adolescent ADHD involves reporting source. In childhood ADHD assessments, parents and teachers are the typical reporters.[14] However, adolescents spend more time with peers and less time with parents. Further, in contrast to elementary school, adolescents have multiple teachers who spend less time with them during the school day and thus have fewer opportunities to observe their students’ behavior. Self-report methods can be incorporated into adolescent ADHD assessments as well; however, adolescents with ADHD have a tendency to underreport the severity of their symptoms,[7,58] which should be considered in any assessment. In adolescents with ADHD, concerns about the accuracy of self-report involve not only their account of ADHD symptoms, but of past delinquent behaviors as well. In one study, adolescents and young adults with ADHD were less likely than those without ADHD to report accurately on delinquent behaviors they engaged in 1 year earlier.[59] Such inaccurate reporting of behavior in ADHD is consistent with findings that persons with ADHD have a tendency toward a positive illusory bias view of their behavior[60] and with theories of ADHD that argue that problems with self-awareness emerge from working memory impairments.[61]

Developmental changes in the presentation of ADHD symptoms also have implications for self-report in the assessment of adolescents with ADHD. In particular, the decline in overt hyperactive symptoms into adolescence[7,19,21,22] makes inattentive symptoms more prominent. As a clinical observation, inattentive features common in ADHD may be experienced more subjectively (eg, daydreaming) than more overt hyperactive behaviors (eg, getting out of one’s seat at inappropriate times), thus making self-report more relevant in this age group.

Finally, the appropriateness of diagnostic criteria for ADHD complicates adolescent assessment. Specifically, the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition, Text Revision [54] states that symptom onset must have occurred by age 7 to qualify for an ADHD diagnosis. However, studies addressing the empiric basis for this criterion have called it into question and recommend a revision to include childhood onset at or before age 12.[39,62-64] One study assessing the implications of this diagnostic revision in a large longitudinal sample found that the prevalence estimate, correlates, and risk factors of ADHD would not be affected if this new diagnostic criterion were adopted.[65] Thus, although following diagnostic criteria in adolescent ADHD assessments is recommended, incorporating these more recent findings may be crucial in making a diagnosis.

Treatment of ADHD in Adolescence

Relatively less research has been devoted to efficacious treatments for adolescents with ADHD compared with treatments for children with ADHD.[66] Despite diagnostic continuity, given the physical, social, and psychological changes that occur in adolescents with ADHD, it is somewhat difficult to simply extend childhood treatments to this group. ADHD treatments in this age group are likely to require more extensive and costly interventions. Further, treating adolescents is particularly challenging because they are less likely than children to receive mental health services in the first place.[67]

ADHD treatment is focused on symptom management and the reduction of downstream effects of unmanaged ADHD, such as school failure, automobile accidents, and peer rejection.[68] The more complex academic and social demands during adolescence require a management plan that addresses academic needs throughout the school day and into the evening, as well as weekday and weekend activities including driving, athletic and artistic endeavors, and family and peer relationships. Symptom management should be analogous to symptom management for any lifelong condition, such as nearsightedness, diabetes, or asthma. Such comparisons emphasize that ADHD is not the fault of the person with the disorder but rather a neurobiological condition, and making such comparisons may help the teen deal with any stigma associated with a psychiatric disorder.[69]

For children with ADHD, psychoeducation about ADHD, psychopharmacology (primarily stimulants), parent training in behavior management methods, classroom behavioral modification and academic interventions, and special educational placement are the most effective or promising interventions.[68] The empiric literature regarding extending these treatments into adolescence is much less prevalent, however. Thus, although treatment options for adolescent ADHD may be available, not all are equally effective and in many cases well-controlled studies are lacking. However, some treatments for adolescents with ADHD and their families do have empiric support, particularly pharmacotherapy and specific psychosocial treatment approaches.[68,70]

Although the stimulants and nonstimulants used for the treatment of ADHD can cause minor changes in blood pressure and heart rate, most analyses of studies of cardiac events and sudden death in children, youth, and adults with ADHD treated with stimulants have not found a higher incidence of these events in patients without preexisting structural cardiovascular conditions or a family history of sudden death.[71,72] Therefore, only routine assessment of cardiovascular function, similar to screening for participation in school sports, is recommended.

Current guidelines and consensus statements[71,72] do not recommend specialty cardiovascular screening (including routine electrocardiogram) before initiating treatment for ADHD, either with stimulants or nonstimulants. However, because these medications are known to cause small elevations in blood pressure and pulse (in the case of stimulants and atomoxetine) or hypotensive changes (in the case of the alpha-2 agonists), blood pressure and heart rate should be checked before treatment is started and should be monitored regularly at follow-up visits.


Stimulant medications. Stimulants and noradrenergic agonists are psychotropic treatments approved by the US Food and Drug Administration (FDA) for use in adolescents. Stimulants include methylphenidates and amphetamine compounds; these medications have a long-standing history in the treatment of ADHD and are considered the first-line therapies for ADHD.[73] The 2 classes of stimulants have slightly differing mechanisms of action. Whereas both block the reuptake of dopamine and norepinephrine into the presynaptic neuron and thereby increase neurotransmitter concentrations, amphetamine compounds also increase the release of dopamine from presynaptic cytoplasmic storage vesicles.[74]

Stimulants are effective in approximately 70% of adolescents with ADHD.[75-77] At least 7 randomized controlled trials have been conducted among adolescents with ADHD and all but one support the efficacy of stimulants for ADHD in adolescence.[74] Consistent with findings of diagnostic continuity of ADHD from childhood into adolescence, the efficacy of stimulants (specifically, methylphenidate) is largely equal from childhood into adolescence.[78] In a meta-analysis of children and adolescents comparing the efficacy of the methylphenidates and amphetamine compounds, amphetamine compounds had a small yet statistically significant advantage over a standard-release form of methylphenidate for parent and clinicians ratings of ADHD symptoms and global ratings (but not for teacher ratings).[79] Although stimulants are effective in acutely reducing ADHD symptoms, common medication side effects (eg, decreased appetite) have prompted consideration of other pharmacologic interventions.[80]

Nonstimulant medications. Noradrenergic agonists approved by the FDA for use in children and adolescents with ADHD include guanfacine extended release (XR), clonidine modified release (MR),[81] and atomoxetine. Although the precise mechanism of action for treating ADHD is unclear, these medications likely facilitate dopamine and noradrenaline neurotransmission thought to play a role in the pathophysiology of ADHD.[81,82]

In 2009, guanfacine XR was the first alpha-2 agent to be approved by the FDA for use in the treatment of ADHD in children and adolescents. According to one randomized controlled trial in children and adolescents with ADHD, guanfacine XR performed better than placebo in reducing teacher-rated ADHD symptoms but not parent-rated ADHD symptoms.[83] In several double-blind, placebo-controlled trials involving child and adolescent participants, guanfacine XR performed significantly better than placebo in reducing ADHD symptoms.[84,85] A 2-year, open-label, follow-up study of guanfacine XR in children and adolescents, with or without co-administration of stimulants, demonstrated continued efficacy as that seen in short-term randomized controlled trials.[86] Such findings emerged in a similar study,[87] although the attrition rate in both studies was greater than 75%, limiting generalizability.

Two randomized, double-blind, placebo-controlled studies evaluating the efficacy of clonidine MR in children and adolescents with ADHD have been conducted. One assessed clonidine MR as a monotherapy, and another studied it as an add-on agent in patients on a non-optimal stimulant drug regimen. In both trials, clonidine MR significantly reduced ADHD symptoms from baseline and was well tolerated.[88,89]

Atomoxetine is another noradrenergic agonist approved for use in adolescents with ADHD,[90-92] and it has comparable efficacy with methylphenidate in reducing core ADHD symptoms in children and adolescents.[93] In one randomized, placebo-controlled, dose-response study of atomoxetine in children and adolescents with ADHD, atomoxetine was consistently associated with a significant reduction of ADHD symptoms.[94] Social and family functioning also improved among those taking atomoxetine with statistically significant improvements in measures of ability to meet psychosocial role expectations and parental impact. In a randomized, placebo-controlled study of atomoxetine among children and adolescents with ADHD, atomoxetine-treated participant reductions in ADHD symptoms were superior to those of the placebo treatment group as assessed by investigator, parent, and teacher ratings.[95] Additional trials have demonstrated the efficacy and tolerability of this medication in children and adolescents with ADHD.[96-101] In addition, acute atomoxetine treatment appears to be equally effective and equally tolerated in children and adolescents.[102] Such findings suggest that pharmacologic differences in tolerability or ADHD symptom response are negligible between children and adolescents.

Treatment Discontinuation in Adolescence

When considering pharmacotherapy, one issue relevant to adolescents with ADHD involves treatment discontinuation. The prevalence of prescribing by general practitioners to adolescent patients with ADHD drops significantly.[103] Further, this decline is greater than the reported age-related decline in symptoms, indicating that treatment is prematurely discontinued in many cases when symptoms persist.[104] In one longitudinal study,[105] 48% of children between the ages of 9 and 15 had discontinued ADHD medication. Age was a significant moderator of medication adherence such that adolescents were less likely to continue their medication.[105] Thus, in addition to a need for continued research devoted to effective treatments for adolescents with ADHD,[66] unique barriers to treatment such as premature discontinuation need to be addressed.

Psychosocial Treatments

In terms of psychosocial treatments for adolescents with ADHD, the empiric literature is sparse compared with the literature on pharmacotherapy options. In addition, because of the many developmental and environmental changes that occur during the transition into adolescence, childhood treatments are not easily translated for this age group. Developmental changes with implications for treatment include that adolescents have a greater cognitive capacity for abstraction, they have more behavioral self-awareness, adolescents are undergoing identity formation and have a need for independence, there is peer influence, there is variability in daily school routines, and adolescents are undergoing physiologic changes (eg, development of secondary sex characteristics).[66] Thus, treatment approaches are recommended that include increased involvement of the teenager, behavioral contingencies that involve more opportunities to socialize with peers and exert independence, collaboration with multiple teachers, homework issues (particularly time management and organizational skills), and self-monitoring strategies.[44] Among studies that have considered psychosocial treatments for adolescents with ADHD, family-based and school-based approaches are the most promising.[44,106]

Family-Based Interventions

Three studies have examined family-based interventions. Barkley and colleagues[107] randomly assigned 12- to 18-year-olds to 8 to 10 sessions of behavior management training, problem-solving and communication training, or structural family therapy. All strategies resulted in significant improvement in negative communication, conflict, anger during conflicts, school adjustment, internalizing and externalizing symptoms, and maternal depressive symptoms at post-treatment, and improvements were largely maintained at a 3-month follow-up visit. However, only 5% to 20% in each treatment group demonstrated clinically significant reliable change following treatment.

Another study compared parent behavior management training with parent behavior management training/problem solving and communication therapy.[108] Both treatments resulted in significant improvement in parent-teen conflicts but were not statistically different from each other. Although such group-level analysis and normalization rates supported the efficacy of these treatments, reliable change indices were similar to those reported by Barkley and colleagues.[107]

Another study evaluated behavior management, problem solving, and education groups for parents of adolescents with ADHD.[109] Pretreatment and posttreatment comparisons indicated statistically significant reductions in the frequency and intensity of self-reported parent-adolescent conflict and in parent-reported problem behavior and positive effects on parent skills and confidence.

Although all these studies are promising, they did not produce much clinically significant reliable change or they were limited by methodologic design (ie, lack of a control or alternative treatment group). In terms of clinical implications, multimodal long-term treatment may be useful to assist parents in their interactions with their teens to manage parental and family distress,[110] as opposed to simply reducing ADHD symptom severity.

School-Based Interventions

Academic functioning is one of the most common concerns of parents of adolescents with ADHD.[110] Interventions targeting academic impairment in adolescents with ADHD are promising.[111] One school-based intervention involving directed note taking through group-based didactic and modeling yielded statistically significant improvements in on-task behavior, material comprehension, and daily assignment scores in a sample of adolescents with ADHD.[112] A more comprehensive treatment, called the Challenging Horizons Program,[113] involves after-school academic training incorporating behavioral strategies in a group and individual setting and monthly group parent training. This program has yielded moderate to large effect sizes on parent- and teacher-rated academic functioning and classroom disturbance compared with a community care group among middle school students with ADHD.[114] Although effect sizes were less promising for social functioning, and methodologic design limited the generalizability of these findings (eg, quasi-experimental design, small sample size), a 3-year treatment outcome study of this program indicated cumulative long-term benefits for the treatment group compared with a community care control group for parent ratings of ADHD symptoms and social functioning.[115] However, this latter study did not indicate any academic benefits of the treatment. Single-subject design studies also support the beneficial impact of behavioral techniques (eg, self-monitoring and functional analysis) in improving goal-oriented behavior in the classroom while reducing disruptive behavior among adolescents with ADHD.[116,117] This deserves additional consideration in future research.

A variant of the interventions aimed at academic behavior in adolescents with ADHD is also emerging. The Homework Intervention Program is a behavioral-based parent training program targeting homework in middle school students. In a pilot study of a small sample of middle school students diagnosed with ADHD (n = 11), multiple-baseline design analyses indicated an improvement in parent-reported homework problems and ADHD symptoms, overall grade point average, and teacher-reported productivity.[118]

Overall, comprehensive school-based interventions are promising and, similar to family-based interventions, warrant future research. Psychosocial treatment for adolescents with ADHD is a small, yet developing field of research. Current treatments need to be more thoroughly assessed. For example, social impairment continues into adolescence.[119] Further, social impairment in youth with ADHD increases the risk for substance use and related problems,[120] which demonstrates the need to also target social functioning in adolescent ADHD interventions. Providers also need to consider how to individualize treatment for adolescents with ADHD and the various potential comorbidities that can be present. In addition, treatments that complement existing psychosocial treatment approaches should be considered to target the multidimensional challenges that adolescents with ADHD face.[66] Some potentially complimentary treatments have yielded promising results. For example, attention training in cognitive training programs, mindfulness meditation, and physical exercise to reduce disruptive behaviors have shown potential, although more methodologically rigorous trials are required.[121-123]

Driving and ADHD

In North America, motor vehicle accidents are the leading cause of death among adolescents.[124] Drivers with ADHD are at significantly higher risk for poor driving outcomes, including increased traffic citations (particularly speeding), accidents that are their fault, repeated and more severe accidents, driving-related morbidity, and license suspensions and revocations.[125] Such findings were not better accounted for by comorbidity or intelligence. Given that substance use is not uncommon in persons with ADHD, the risks associated with drug and alcohol use should also be considered.[126] In terms of clinical implications of such findings, stimulant medications have been shown to improve driving performance in drivers with ADHD.[127-129] The method of stimulant delivery is also an important factor. In one study, adolescent drivers with ADHD drove better throughout the day on a driving simulator after taking an extended controlled-release stimulant compared with an immediate-release formulation.[126]

ADHD Pharmacotherapy and Growth

The effects of ADHD medication (especially stimulants) have been an area of considerable debate and controversy. Reviews indicate that treatment with stimulant medication does lead to subsequent delays in height (approximately 1 cm per year during the first 3 years of treatment) and weight.[130,131] These reviews also indicate that the effect of stimulants on growth decline over time, that growth deficits may be dose dependent, that growth suppression effects may not differ between methylphenidate and amphetamine, that stimulant discontinuation may lead to growth normalization, and that ADHD may itself be associated with dysregulated growth.[130,131]

In one longitudinal study, methylphenidate treatment was associated with small yet significant delays in height, weight, and body mass index.[132] Within the ADHD sample, those who had not received prior stimulant therapy and those who entered the study with an above average height, weight, and body mass index were most likely to experience growth deficits while taking stimulants. Further, the impact on all growth indices was most apparent during the first year of treatment and attenuated over time. In another longitudinal study that evaluated the effect of stimulant medication on physical growth, a newly medicated group exhibited reductions in size after 3 years of treatment relative to a nonmedicated group; the newly medicated group was 2.0 cm shorter and weighed 2.7 kg less.[133]

These findings indicate that in clinical settings, the potential benefits in symptom reduction and daily functioning need to be contrasted with the small but significant effects of pharmacotherapy (particularly stimulants) on growth. In most cases, growth suppression effects do not appear to be a clinical concern for most children treated with stimulants.[130] Although future studies are required to clarify the effects of continuous pharmacotherapy into adulthood to attain a better perspective of the long-term impact on growth, these findings suggest that growth rate should be monitored during treatment for ADHD.


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Predicting the diagnosis of autism spectrum disorder using gene pathway analysis

In Neuroscience, Psychiatry, School Psychology on Thursday, 13 September 2012 at 13:03

Molecular Psychiatry advance online publication 11 September 2012; doi: 10.1038/mp.2012.126


Predicting the diagnosis of autism spectrum disorder using gene pathway analysis
E Skafidas1, R Testa2,3, D Zantomio4, G Chana5, I P Everall5 and C Pantelis2,5

  1. 1Centre for Neural Engineering, The University of Melbourne, Parkville, VIC, Australia
  2. 2Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne & Melbourne Health, Parkville, VIC, Australia
  3. 3Department of Psychology, Monash University, Clayton, VIC, Australia
  4. 4Department of Haematology, Austin Health, Heidelberg, VIC, Australia
  5. 5Department of Psychiatry, The University of Melbourne, Parkville, Victoria, Australia

Correspondence: Professor C Pantelis, National Neuroscience Facility (NNF), Level 3, 161 Barry Street, Carlton South, VIC 3053, Australia. E-mail: cpant@unimelb.edu.au

Received 6 July 2012; Accepted 9 July 2012
Advance online publication 11 September 2012


Autism spectrum disorder (ASD) depends on a clinical interview with no biomarkers to aid diagnosis. The current investigation interrogated single-nucleotide polymorphisms (SNPs) of individuals with ASD from the Autism Genetic Resource Exchange (AGRE) database. SNPs were mapped to Kyoto Encyclopedia of Genes and Genomes (KEGG)-derived pathways to identify affected cellular processes and develop a diagnostic test. This test was then applied to two independent samples from the Simons Foundation Autism Research Initiative (SFARI) and Wellcome Trust 1958 normal birth cohort (WTBC) for validation. Using AGRE SNP data from a Central European (CEU) cohort, we created a genetic diagnostic classifier consisting of 237 SNPs in 146 genes that correctly predicted ASD diagnosis in 85.6% of CEU cases. This classifier also predicted 84.3% of cases in an ethnically related Tuscan cohort; however, prediction was less accurate (56.4%) in a genetically dissimilar Han Chinese cohort (HAN). Eight SNPs in three genes (KCNMB4, GNAO1, GRM5) had the largest effect in the classifier with some acting as vulnerability SNPs, whereas others were protective. Prediction accuracy diminished as the number of SNPs analyzed in the model was decreased. Our diagnostic classifier correctly predicted ASD diagnosis with an accuracy of 71.7% in CEU individuals from the SFARI (ASD) and WTBC (controls) validation data sets. In conclusion, we have developed an accurate diagnostic test for a genetically homogeneous group to aid in early detection of ASD. While SNPs differ across ethnic groups, our pathway approach identified cellular processes common to ASD across ethnicities. Our results have wide implications for detection, intervention and prevention of ASD.


Autism spectrum disorders (ASDs) are a complex group of sporadic and familial developmental disorders affecting 1 in 150 births1 and characterized by: abnormal social interaction, impaired communication and stereotypic behaviors.2 The etiology of ASD is poorly understood, however, a genetic basis is evidenced by the greater than 70% concordance in monozygotic twins and elevated risk in siblings compared with the population.3, 4, 5 The search for genetic loci in ASD, including linkage and genome-wide association screens (GWAS), has identified a number of candidate genes and loci on almost every chromosome,6, 7, 8, 9, 10, 11 with multiple hotspots on several chromosomes (for example, CNTNAP2, NGLNX4, NRXN1, IMMP2L, DOCK4, SEMA5A, SYNGAP1, DLGAP2, SHANK2 and SHANK3),7, 12, 13, 14, 15 and copy number variations.9, 13, 16, 17, 18, 19, 20, 21 However, none of these have provided adequate specificity or accuracy to be used in ASD diagnosis. Novel approaches are required22 to examine multiple genetic variants and their additive contribution19, 23, 24 taking into account genetic differences between ethnicities and consideration of protective versus vulnerability single-nucleotide polymorphisms (SNPs).

The present study interrogated the Autism Genetics Resource Exchange (AGRE)25 SNP data with two aims: (1) to identify groups of SNPs that populate known cellular pathways that may be pathogenic or protective for ASD, and (2) to apply machine learning to identified SNPs to generate a predictive classifier for ASD diagnosis.26 The results were validated in two independent samples: the US Simons Foundation Autism Research Initiative (SFARI) and UK Wellcome Trust 1958 normal birth cohort (WTBC). This novel and strategic approach assessed the contribution of various SNPs within an additive SNP-based predictive test for ASD.

Materials and methods

The University of Melbourne Human Research Ethics Committee approved the study (Approval Numbers 0932503.1, 0932503.2).


(i) Index sample: subject data from 2609 probands with ASD (including Autism, Asperger’s or Pervasive Developmental Disorder-not otherwise specified, but excluding RETT syndrome and Fragile X), and 4165 relatives of probands, was available from AGRE (http://www.agre.org); 1862 probands and 2587 first-degree relatives had SNP data from the Illumina 550 platform relevant to analyses (Figure 1a). Diagnosis of ASD was made by a specialist clinician and confirmed using the Autism Diagnostic Interview Revised (ADI-R27). Control training data was obtained from HapMap28 instead of relatives, as the latter may possess SNPs that predispose to ASD and skew analysis (Figures 1a and b).

Figure 1.

(a and b) Flow charts show the subjects used in the analyses. Key: AGRE, Autism Genetic Research Exchange; SFARI, Simons Foundation Autism Research Initiative; WTBC, Wellcome Trust 1958 normal birth cohort; CEU, of Central (Western and Northern) European origin; HAN, of Han Chinese origin; TSI, of Tuscan Italian origin; For panels 1a and b: ‘red boxes’—samples used in developing the predictive algorithm; ‘blue boxes’—samples used to investigate different ethnic groups; ‘green boxes’—validation sets; ‘light green boxes’—relatives assessed, including parents and unaffected siblings. Numbers in brackets represent numbers of males/females.

Full figure and legend (140K)Download Power Point slide (259 KB)

(ii) Independent validation samples: 737 probands with ASD (ADI-R diagnosed) derived from SFARI; 2930 control subjects from WTBC (Figure 1b).

As SNP incidence rates vary according to ancestral heritage, HapMap data (Phase 3 NCBI build 36) was utilized to allocate individuals to their closest ethnicity. Individuals of mixed ethnicity were excluded; HapMap data has 1 403 896 SNPs available from 11 ethnicities. Any SNPs not included in the AGRE data measured on the Illumina 550 platform were discarded, resulting in 407 420 SNPs. Mitochondrial SNPs reported in AGRE, but not available in HapMap were excluded. The 30 most prevalent (>95%) SNPs within each ethnicity were identified and each ASD individual assigned to the group for which they shared the highest number of ethnically specific SNPs. HapMap groups were determined to be appropriate for analysis, as prevalence rates of the 30 SNPs relevant to each ethnicity were similar for each AGRE group assigned to that ethnicity, P<0.05.

Gene set enrichment analysis (GSEA)

Pathway analysis was selected because it depicts how groups of genes may contribute to ASD etiology (Supplementary S1) and mitigates the statistical problem of conducting a large number of multiple comparisons required in GWAS studies. The current pathway analysis differs from previous ASD analyses in three unique ways: (1) we divided the cohort into ethnically homogeneous samples with similar SNP rates; (2) both protective and contributory SNPs were accounted for in the analysis and (3) the pathway test statistic was calculated using permutation analysis. Although this is computationally expensive, benefits include taking account of rare alleles, small sample sizes and familial effects. It also relaxes the Hardy–Weinberg equilibrium assumption, that allele and genotype frequencies remain constant within a population over generations. Pathways were obtained from the Kyoto Encyclopedia of Genes and Genomes (KEGG) and SNP-to-gene data obtained from the National Center for Biotechnology Information (NCBI). Intronic and exonic SNPs were included. AGRE individuals most closely matching the genetics of Utah residents of Western and Northern European (CEU), Tuscan Italian (TSI) and Han Chinese origin were used in the analysis. CEU individuals (975 affected individuals and 165 controls) were chosen as the index sample, representing the largest group affected in AGRE (Figure 1a). The CEU and Han Chinese had 116 753 SNPs that differed, whereas the CEU and TSI had 627 SNPs, differing in allelic prevalence at P<1 × 10−5. The pathway test statistic was calculated for CEU and Han individuals using a ‘set-based test’ in the PLINK29 software package, with P=0.05, r2=0.5 and permutations set to at least 2 000 000. Significance threshold was set conservatively at P<1 × 10−5, calculated from the number of pathways being examined (200). Therefore, significance was <0.05/200, set at <1 × 10−5 (see Supplementary S1).

Predicting ASD phenotype based upon candidate SNPs

For each individual, a 775-dimensional vector was constructed, corresponding to 775 unique SNPs identified as part of the GSEA. To examine whether SNPs could predict an individual’s clinical status (ASD versus non-ASD), two-tail unpaired t-tests were used to identify which of the 775 SNPs had statistically significant differences in mean SNP value (P<0.005). This significance level provided low classification error while maintaining acceptable variance in estimation of regression coefficients for each SNP’s contribution status, and provided the set of SNPs that maximized the classifier output between the populations (Figure 2 and Supplementary S2). This resulted in 237 SNPs selected for regression analysis. Each dimension of the vector was assigned a value of 0, 1 or 3, dependent on a SNP having two copies of the dominant allele, heterozygous or two copies of the minor allele. The ‘0, 1, 3’ weighting provided greater classification accuracy over ‘0, 1, 2’. Such approaches using superadditive models have been used previously to understand genetic interactions.30 The formula for the classifier and classifier performance are presented in Supplementary S3.

Figure 2.

Cumulative coefficient estimation error and percentage classification error as a function of P-value; P=0.005 provides good trade-off between classification performance and cumulative regression coefficient error.

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The CEU sample was divided into a training set (732 ASD individuals and 123 controls) and the remainder comprised the validation set. An affected individual was given a value of 10 and an unaffected individual a value of −10, providing a sufficiently large separation to maximize the distance between means (see Supplementary S3). Least squares regression analysis of the training set determined coefficients whose sum over product by SNP value mapped SNPs to clinical status. Kolmogorov–Smirnov goodness of fit test assessed the nature of distribution of SNPs by classification. At P=0.05, the distributions were accepted as being normally distributed, allowing determination of positive and negative predictive values (see ROC, Supplementary S4). The Durbin–Watson test was used to investigate the residual errors of the training set to determine if further correlations existed. At P=0.05, the residuals were uncorrelated. Regression coefficients were used to assess individual SNP contribution to clinical status.

AGRE validation

After analyzing the CEU training cohort, three cohorts were used for validation: 285 (243 probands, 42 controls) CEUs; a genetically similar TSI sample (65 patients, 88 controls); and a genetically dissimilar Han Chinese population (33 patients, 169 controls). To illustrate overlap in SNPs in first-degree relatives of individuals with ASD (n=1512), we mapped the SNPs of parents (n=1219; 581 male) and unaffected siblings (n=293; 98 male) of CEU origin who did not meet criteria for ASD. Finally, the accuracy of the predictive model was modified to test predictive ability using 10, 30 and 60 SNPs having the greatest weightings.

Independent validation

Samples included 507 CEU and 18 TSI subjects with ASD from SFARI, and 2557 CEU and 63 TSI from WTBC (Figure 1b).


Identification of affected pathways

Analyses focused on 975 CEU ASD individuals, in which 13 KEGG pathways were significantly affected (P<1 × 10−5). The pathway analysis identified 775 significant SNPs perturbed in ASD. A number of the pathways were populated by the same genes and had inter-related functions (Table 1).

Table 1 – Statistically significant pathways for the CEU and Han Chinese.

Full table

The most significant pathways were: calcium signaling, gap junction, long-term depression (LTD), long-term potentiation (LTP), olfactory transduction and mitogen-activated kinase-like protein signaling. GSEA on the genetically distinct Han Chinese identified six pathways that overlapped with 13 pathways in the CEU cohort (estimate of this occurring by chance, P=0.05), including: purine metabolism, calcium signaling, phosphatidylinositol signaling, gap junction, long-term potentiation and long-term depression. Related to these pathways, the statistically significant SNPs in both populations were rs3790095 within GNAO1, rs1869901 within PLCB2, rs6806529 within ADCY5 and rs9313203 in ADCY2.

Diagnostic prediction of ASD

From the 775 SNPs identified within the CEU cohort, accurate genetic classification of ASD versus non-ASD was possible using 237 SNPs determined to be highly significant (P<0.005). Figure 3a shows the distribution of ASD and non-ASD individuals based on genetic classification. An individual’s clinical status was set to ASD if their score exceeded the threshold of 3.93. This threshold corresponds to the intersection points of the two normal curves. The theoretical classification error was 8.55%, and positive (ASD) and negative predictive values (controls) were 96.72% and 94.74%, respectively. Classification accuracy for the 285 CEU AGRE validation individuals was 85.6% and 84.3% for the TSI, while accuracy for the Han Chinese population was only 56.4%. Using the same classifier with the identical set of SNPs, accuracy of prediction of ASD in the independent data sets was 71.6%; positive and negative predictive accuracies were 70.8% and 71.8%, respectively.

Figure 3.

(a) Genetic-based classification of CEU population (AGRE and Controls) for ASD and non-ASD individuals, showing Gaussian approximation of distribution of individuals. As both the mapped ASD and control populations were well approximated by normal distributions, the asymptotic Test Positive Predictive Value (PPV) and Negative Predictive Value (NPV) was determined. For individuals with CEU ancestry, the PPV and NPV were 96.72% and 94.74%, respectively. (Note the test was substantially less predictive on individuals with different ancestry, that is, Han Chinese). (b) Genetic-based classification of CEU population, including first-degree relatives (parents and siblings of ASD children). Note that the distribution of relatives of ASD children maps between the ASD and the control groups, with no difference found between mothers and fathers (see Supplementary material S5). Key: ASD, autism spectrum disorder; relatives, first-degree relatives (parents and siblings); Siblings, siblings of ASD cases not meeting criteria for ASD; Autism Classifier Score, scores for each individual derived from the predictive algorithm, with greater values representing greater risk for autism.

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SNPs were compared with the affected and unaffected individuals. Figure 3b shows that relatives (parents and unaffected siblings combined) fall between the two distributions, with a mean score of 2.68 (s.d.=2.27). The percentage overlap of the relatives and affected individuals was 30.4%. The mean scores of the mothers and fathers did not differ (at P=0.05) with scores of 2.83 (s.d.=2.17) and 2.93 (s.d.=2.34), respectively (see Supplementary S5), whereas unaffected siblings (not meeting diagnostic criteria for ASD) fell between parents and cases (mean=4.74, s.d.=3.80). In testing the robustness of the predictive model, using fewer SNPs monotonically decreased accuracy in the AGRE-CEU analyses to 72% for 60 SNPs, 58% for 30 SNPs and 53.5% for 10 SNPs, with the distribution of parents being indistinguishable from controls.

Of the 237 SNPs within our classifier, presence of some contributed to vulnerability to ASD (Table 2a), whereas others were protective (Table 2b). Eight SNPs in three genes, GRM5, GNAO1 and KCNMB4, were highly discriminatory in determining an individual’s classification as ASD or non-ASD. For KCNMB4, rs968122 highly contributed to a clinical diagnosis of ASD, whereas rs12317962 was protective; for GNAO1, SNP rs876619 contributed, whereas rs8053370 was protective; for GRM5, SNPs rs11020772 was contributory, whereas rs905646 and rs6483362 were protective.

Table 2 – List of 15 most contributory (Table 2a) and 15 most protective (Table 2b) SNPs for ASD diagnosis in the CEU Cohort.

Full table


Using pathway analysis, we have generated a genetic diagnostic classifier based on a linear function of 237 SNPs that accurately distinguished ASD from controls within a CEU cohort. This same diagnostic classifier was able to correctly predict and identify ASD individuals with accuracy exceeding 85.6% and 84.3% in the unseen CEU and TSI cohorts, respectively. Our classifier was then able to predict ASD group membership in subjects derived from two independent data sets with an accuracy of 71.6%, thus greatly adding strength to our original finding. However, the classifier was sub-optimal at predicting ASD in the genetically distinct Han Chinese cohort, which may be explained by differences in allelic prevalence. Although only 627 SNPs significantly differed between the TSI and CEU cohorts, this figure increased to 116 753 SNPs between the CEU and Han Chinese. It is likely that an additional set of SNPs may be predictive of ASD diagnosis in Han Chinese and that methods used for our classifier could be applicable to other ethnicities. Interestingly, parents and siblings of ASD-CEU individuals fell as distinct groups between the ASD and controls, reinforcing a genetic basis for ASD with neurobehavioral abnormalities reported in parents of ASD individuals also supporting our findings.31 When we altered the classifier by reducing the number of SNPs, not only did the predictive accuracy suffer but also the relatives merged into the control group. This suggests that use of relatives as controls in SNP GWAS studies is only valid when examining small numbers of SNPs and may not be appropriate when assessing genetic interactions.

There was considerable overlap in the pathways implicated in both the CEU and Han Chinese populations. The analysis demonstrated that SNPs in the Wnt signaling pathway contributed to a diagnosis of ASD in the CEU cohort, but not in the Han Chinese population. Although of interest, a firm conclusion regarding these differences and similarities will require replication in a larger Han Chinese population. Completion of diagnostic classification studies for other ethnic groups will invariably aid in identification of common pathological mechanisms for ASD.

The SNPs contributing most to diagnosis in our classifier corresponded to genes for KCNMB4, GNAO1, GRM5, INPP5D and ADCY8. The three SNPs that markedly skewed an individual towards ASD were related to the genes coding for KCNMB4, GNAO1 and GRM5. Homozygosity for KCNMB4 SNP carries a higher risk of ASD than SNPs related to GNAO1 and GRM5. By contrast, a number of SNPs protected against ASD, including rs8053370 (GNAO1), rs12317962 (KCNMB4), rs6483362 and rs905646 (GRM5). KCNMB4 is a potassium channel that is important in neuronal excitability and has been implicated in epilepsy and dyskinesia.32, 33 It is highly expressed within the fusiform gyrus, as well as in superior temporal, cingulate and orbitofrontal regions (Allen Human Brain Atlas, http://human.brain-map.org/), which are areas implicated in face identification and emotion face processing deficits seen in ASD.34 GNAO1 protein is a subgroup of Ga(o), a G-protein that couples with many neurotransmitter receptors. Ga(o) knockout mice exhibit ‘autism-like’ features, including impaired social interaction, poor motor skills, anxiety and stereotypic turning behavior.35 GNAO1 has also been shown to have a role in nervous development co-localizing with GRIN1 at neuronal dendrites and synapses,36 and interacting with GAP-43 at neuronal growth cones,37 with increased levels of GAP-43 demonstrated in the white matter adjacent to the anterior cingulate cortex in brains from ASD patients.38

In our findings, GRM5 SNPs have both a contributory (rs11020772) and protective (rs905646, rs6483362) effect on ASD. GRM5 is highly expressed in hippocampus, inferior temporal gyrus, inferior frontal gyrus and putamen (Allen Human Brain Atlas), regions implicated in ASD brain MRI studies.39 GRM5 has a role in synaptic plasticity, modulation of synaptic excitation, innate immune function and microglial activation.40, 41, 42, 43 GRM5-positive allosteric modulators can reverse the negative behavioral effects of NMDA receptor antagonists, including stereotypies, sensory motor gating deficits and deficits in working, spatial and recognition memory,44 features described in ASD.45, 46 With regard to GRM5’s involvement with neuroimmune function, this receptor is expressed on microglia,40, 47 with microglial activation demonstrated by us and others in frontal cortex in ASD.48, 49

Further, as GRM5 signaling is mediated via signaling through Gene Protein Couple Receptors, a possible interaction between GNAO1 and GRM5 is plausible. Genes such as PLCB2, ADCY2, ADCY5 and ADCY8 encode for proteins involved in G-protein signaling. Given this association, GRM5 may represent a pivotal etiological target for ASD; however, further work is needed in demonstrating these potential interactions and contribution to glutamatergic dysregulation in ASD.

In conclusion, within genetically homogeneous populations, our predictive genetic classifier obtained a high level of diagnostic accuracy. This demonstrates that genetic biomarkers can correctly classify ASD from non-ASD individuals. Further, our approach of identifying groups of SNPs that populate known KEGG pathways has identified potential cellular processes that are perturbed in ASD, which are common across ethnic groups. Finally, we identified a small number of genes with various SNPs of influential weighting that strongly determined whether a subject fell within the control or ASD group. Overall these findings indicate that a SNP-based test may allow for early identification of ASD. Further studies to validate the specificity and sensitivity of this model within other ethnic groups are required. A predictive classifier as described here may provide a tool for screening at birth or during infancy to provide an index of ‘at-risk status’, including probability estimates of ASD-likelihood. Identifying clinical and brain-based developmental trajectories within such a group would provide the opportunity to investigate potential psychological, social and/or pharmacological interventions to prevent or ameliorate the disorder. A similar approach has been adopted in psychosis research, which has improved our understanding of the disorder and prognosis for affected individuals.50

Conflict of interest

The authors declare no conflict of interest.


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Professor Christos Pantelis was supported by a NHMRC Senior Principal Research Fellowship (ID 628386). AGRE: We gratefully acknowledge the resources provided by the Autism Genetic Resource Exchange (AGRE) Consortium and the participating AGRE families. The Autism Genetic Resource Exchange is a program of Autism Speaks and is supported, in part, by grant 1U24MH081810 from the National Institute of Mental Health to Clara M Lajonchere (PI). SFARI: We are grateful to all of the families at the participating Simons Simplex Collection (SSC) sites, as well as the principal investigators (A Beaudet, R Bernier, J Constantino, E Cook, E Fombonne, D Geschwind, R Goin-Kochel, E Hanson, D Grice, A Klin, D Ledbetter, C Lord, C Martin, D Martin, R Maxim, J Miles, O Ousley, K Pelphrey, B Peterson, J Piggot, C Saulnier, M State, W Stone, J Sutcliffe, C Walsh, Z Warren, E Wijsman). WTBC: We acknowledge use of the British 1958 Birth Cohort DNA collection, funded by the Medical Research Council grant G1234567 and the Wellcome Trust grant 012345.

ADHD Medications in Adults Yield Mixed Cardiovascular Risk Results

In ADHD, ADHD stimulant treatment, Medication, School Psychology on Thursday, 13 September 2012 at 06:22

ADHD Medications in Adults Yield Mixed Cardiovascular Risk Results

Deborah Brauser & Hien T. Nghiem, MD


In the United States, roughly 1.5 million adults use medications for attention-deficit/hyperactivity disorder (ADHD). These medications include amphetamines, atomoxetine, and methylphenidate. ADHD medications are known to increase both blood pressure (< 5 mm Hg) and heart rate (< 7 bpm). Given these effects, there are concerns regarding serious cardiovascular events related to taking ADHD medications.

The aim of this study by Hennessy and colleagues was to determine whether use of methylphenidate in adults is associated with elevated rates of serious cardiovascular events compared with rates in nonusers.

Study Synopsis and Perspective

Although adults prescribed the ADHD medication methylphenidate may be at increased risk for adverse cardiovascular events, this association may not be causal, new research suggests.

In a cohort study of almost 220,000 individuals, new users of methylphenidate had almost twice the risk for sudden death or ventricular arrhythmia than age-matched control participants had. They also had a significantly higher risk for all-cause death.

However, the medication dosage “was inversely associated with risk,” meaning it lacked a dose-response relationship, report the investigators.

“We were surprised by the risk findings. But the inverse associations leads us to be somewhat skeptical,” coinvestigator Sean Hennessy, PharmD, PhD, associate professor of epidemiology and pharmacology at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, told Medscape Medical News.

“Ordinarily, if a drug increases the risk of adverse outcomes, that increase is going to be dose-dependent. We didn’t see that, and in fact, found an inverse relationship for death and other outcomes,” he explained.

Dr. Hennessy said that this could be due to “frail, elderly patients who have other things going on” and who are prescribed low-dose methylphenidate.

“Maybe baseline differences in those patients that aren’t captured in the medical claims data are responsible for the elevated risk of adverse outcomes we were seeing rather than it being a causal effect of the methylphenidate itself,” he opined.

“So I would say to wait for these findings to be replicated and clarified in other research before they are acted on clinically.”

The study is published in the February issue of the American Journal of Psychiatry

Am J Psychiatry. 2012;169:112-114;178-185.

Mixed Findings

According to the investigators, methylphenidate and other ADHD medications are used by almost 1.5 million adults in the United States — even though these medications have been shown to raise blood pressure and heart rate.

“Given these effects, case reports of sudden death, stroke, and myocardial infarction have led to regulatory and public concern about the cardiovascular safety of these drugs,” write the researchers.

However, in May 2011, and reported by Medscape Medical News at that time, the same group of researchers published a study in Pediatrics that showed no increased risk for cardiovascular events in children treated with ADHD medications.

In addition, researchers from Kaiser Permanente Northern California published a study in December 2011 in the Journal of the American Medical Association that examined risks in adults younger than age 65 years who were taking methylphenidate, amphetamine, atomoxetine, or pemoline.

The combined group of ADHD medication users showed no increased risk for serious cardiovascular events, including myocardial infarction, sudden cardiac death, or stroke, compared with the group of nonusers.

For this analysis, investigators examined records from Medicaid and commercial databases, representing 19 states, for adults in a broader age range. Included were 43,999 new users of methylphenidate and 175,955 individuals who did not use methylphenidate, amphetamines, or atomoxetine (for both groups, 55.4% were women).

In each group, 67.3% of the participants were between the ages of 18 and 47 years, 23.2% were between the ages of 48 and 64 years, and 9.5% were aged 65 years or older.

Primary cardiac events assessed included sudden death or ventricular arrhythmia, myocardial infarction, stroke, and a combination of stroke/myocardial infarction. All-cause death was a secondary measure.

Unexpected Results

Results showed that the adjusted hazard ratio (HR) for sudden death/ventricular arrhythmia for the methylphenidate users compared with the nonusers was 1.84 (95% confidence interval [CI], 1.33 – 2.55). For all-cause death, the HR was 1.74 (95% CI, 1.60 – 1.89).

Adjusted HRs for myocardial infarction and stroke (alone or in combination) were not statistically different between the 2 treatment groups.

For the participants who experienced a cardiovascular event, the median treatment dosage was 20 mg/day. No significant association was found for sudden death/ventricular arrhythmia between the patients who took more or less than 20 mg/day of methylphenidate.

“However, there were unexpected inverse associations” between high methylphenidate dosage and stroke, myocardial infarction, stroke/myocardial infarction, and all-cause death compared with low dosage, report the researchers. They add that this lack of a dose-response association discredits a causal relationship.

“Furthermore, the inverse relationships…may suggest that lower dosages were prescribed to the frailest patients, who might have had a greater risk of all-cause death and sudden death — that is, the results may have been affected by unmeasured confounding,” write the investigators.

Other limitations cited included the fact that the study was not randomized and that administrative databases do not include potential confounders such as smoking, blood pressure, substance use, and exercise use/nonuse.

Dr. Hennessy reported that the investigators also assessed cardiovascular risks in their study participants who were also taking amphetamines or atomoxetine. They will be publishing those results soon.

Findings “Generally Reassuring”

Christopher J. Kratochvil, MD, from the University of Nebraska Medical Center in Omaha, writes in an accompanying editorial that this and other studies are “generally reassuring and demonstrate movement in the right direction, with systematic retrospective analyses better informing us of issues related to cardiovascular safety with ADHD pharmacotherapy.”

“While gaps persist in the methodical and comprehensive assessments of the safety of ADHD medications, these studies add valuable information to our already large repository of safety and efficacy data…and better inform the risk-benefit analysis of their use,” writes Dr. Kratochvil, who was not involved with this research.

He adds that establishing a “robust” national electronic health records system containing detailed data elements will also offer considerable help to clinicians.

These large and more accessible databases “will allow us to improve our identification and understanding of rare but serious adverse effects and better address these questions of public health significance,” he concludes.

The study was funded through a sponsored research agreement with Shire Development, Inc., and by a Clinical and Translational Science Award from the National Institutes of Health. The study authors all receive salary support from Shire through their employers. All financial disclosures for the study authors and Dr. Kratochvil are listed in the original article.

Study Highlights

■This study was a nonrandomized cohort study of new users of methylphenidate based on administrative data from a 5-state Medicaid database (1999-2003) and a 14-state commercial insurance database (2001-2006).

■All new methylphenidate users with at least 180 days of prior enrollment were identified.

■Users were matched on data source, state, sex, and age to as many as 4 comparison participants who did not use methylphenidate, amphetamines, or atomoxetine.

■A total of 43,999 new methylphenidate users were identified and were matched to 175,955 nonusers.

■The main outcome measures were (1) sudden death or ventricular arrhythmia; (2) stroke; (3) myocardial infarction; and (4) a composite endpoint of stroke or myocardial infarction.

■Secondary outcomes included all-cause death and nonsuicide death.

■Results demonstrated that the age-standardized incidence rate per 1000 person-years of sudden death or ventricular arrhythmia was 2.17 (95% CI, 1.63 – 2.83) in methylphenidate users and 0.98 (95% CI, 0.89 – 1.08) in nonusers, for an adjusted HR of 1.84 (95% CI, 1.33 – 2.55).

■Dosage was inversely associated with the risks for stroke, myocardial infarction, stroke/myocardial infarction, and all-cause death.

■Adjusted HRs for stroke, myocardial infarction, and the composite endpoint of stroke or myocardial infarction did not differ statistically from one another.

■For the secondary outcome of all-cause death, methylphenidate demonstrated a positive association (adjusted HR, 1.74; 95% CI, 1.60 – 1.89). Nonsuicide deaths were nearly identical.

■Limitations of this study include the potential for unmeasured confounders (ie, smoking, blood pressure, nonprescribed aspirin use, substance misuse, and level of physical activity) because the study was not randomized.

Clinical Implications

■ADHD medications raise blood pressure by less than 5 mm Hg and heart rate by less than 7 bpm.

■Although initiation of methylphenidate was associated with a 1.8-fold increase in the risk for sudden death or ventricular arrhythmia, the lack of a dose-response relationship suggests that this association may not be a causal one.


ADHD in Adults

In ADHD, Anxiety, Brain studies, School Psychology on Thursday, 13 September 2012 at 05:58

Unmasking ADHD in Adults

David W. Goodman, MD


Adult ADHD

During the past decade, awareness has grown that ADHD is not limited to children and adolescents. Rather, ADHD is now recognized as a chronic neuropsychiatric disorder that persists into adulthood in up to 65% of children with ADHD.[1-3] Data from the National Comorbidity Survey Replication (NCSR) estimate that 4.4% of adults in the United States have ADHD, although as many as 75% have never been diagnosed and 90% remain untreated.[4,5] The many similarities in symptoms and impairments seen in ADHD and mood and anxiety disorders likely account for many of the misdiagnoses.[6] In addition, the rate of comorbidity in ADHD with mood and anxiety disorders, sleep disorders, and substance use disorders is high and further complicates accurate diagnosis.[5]

Current criteria for ADHD in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) were originally developed and validated for children.[7] Diagnostic criteria require an onset of symptoms before age 7 years; the presence of at least 6 of 9 possible symptoms in 1 or both of the 2 diagnostic clusters of inattentiveness and hyperactivity; and impairment in 2 or more settings (such as home, school, and work).[7] Many similarities exist in the presentations of childhood and adult ADHD; however, adults are more likely to present with symptoms of inattention than hyperactivity.[8] But the presence of childhood symptoms is necessary for a diagnosis of ADHD in an adult.

Clinicians can use several screening tools to help in the ADHD diagnostic process; however, high scores on these tools must be interpreted within a clinical context following a clinical interview. For example, a high score on the ASRS may suggest ADHD[9,10] but may also be the result of acute anxiety, acute depression, or active substance abuse. Patients who take online screeners and self-diagnose ADHD present their symptoms and “diagnosis” to their clinicians in a descriptive rather than a diagnostic context, not understanding how other possible psychiatric disorders may lead to high screening scores. As a result, their self-diagnoses are typically inaccurate.

The clinical interview includes a comprehensive patient history that covers all major psychiatric disorders. The clinician reviews the presenting symptoms in a diagnostic evaluation, inquiring about other possible psychiatric disorders that the patient may not include in the description of symptoms. Through this process, the clinician can rule out primary mood or anxiety disorders (among others), and also ascertain a longitudinal course of symptoms originating during childhood to confirm a diagnosis of ADHD. An accurate account of childhood symptoms of ADHD improves if corroborative historical information can be obtained from an outside informant (for example, a parent). This historical information can be obtained by having a parent complete a childhood ADHD symptom rating scale that can be returned to the PCP. The use of an outside informant also conveys to the patient that third-party information will be used to establish an accurate diagnosis, a disincentive to those who simply seek a prescription for stimulants.


The cognitive and affective symptoms of ADHD can be similar to those of other psychiatric disorders, most notably mood and anxiety disorders. However, specific distinguishing characteristics can assist with the differential diagnosis. In this case, despite reporting current symptoms that might be consistent with ADHD, the notable absence of ADHD symptoms during Ms Jones’s childhood and adolescence precludes a diagnosis of ADHD. A more accurate diagnosis is generalized anxiety disorder (GAD), which is characterized by excessive anxiety and worry that is difficult to control and is associated with at least 3 of the following symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance, which cause clinically significant distress or functional impairments.[7] Significant chronic anxiety exacerbated by an acute, stressful event can produce cognitive symptoms that appear similar to ADHD. Remember: patients use psychological terms descriptively, not diagnostically.

A survey of 400 primary care physicians highlighted the challenges clinicians face when diagnosing ADHD in adults.[11] Approximately two-thirds of the participating respondents referred adults with possible ADHD to specialists for diagnosis and treatment, whereas they felt more competent and confident when diagnosing depression or GAD. Surveys find that only 2% of PCPs refer patients to specialists for the diagnosis and management of depression; for GAD, only 3% refer out.[11,12]

ADHD and Comorbidity

ADHD affects approximately 9 to 10 million adults in the United States (4.4% of the adult population). This makes ADHD in adults the second most prevalent psychiatric disorder after major depressive disorder (MDD), which reportedly affects 6.6% of the US population, and more prevalent than GAD (3%), bipolar disorder (2%), and schizophrenia (1%).[5] Adults with ADHD have a higher percentage of comorbidities than their peers without ADHD.[5] Among the most prevalent psychiatric comorbidities in patients with ADHD are anxiety disorders, mood disorders, and substance use disorders (SUD).[13] Many adults with ADHD present with symptoms of anxiety, MDD, or both. Further, high levels of stress may mimic the symptoms of ADHD.[13] Consequently, the high prevalence rate of ADHD in the adult population makes it essential for clinicians to include ADHD as part of the differential diagnosis in any mental health evaluation or whenever patients present with depression or anxiety.

Data from the NCSR suggest that up to 75% of adults with ADHD were not diagnosed during childhood.[5] Many adults play down a possible diagnosis of ADHD because they do not recall being hyperactive in childhood or because they have not been previously diagnosed with the disorder. Other adults will dismiss the diagnosis because they appear to be functioning well and are successful in their chosen fields, even though they have symptoms such as restlessness, low self-esteem, or poor time-management skills.[14] Exceptionally intelligent individuals or adults who had predominantly inattentive ADHD as children may not have had observable impairments during childhood because disruptive behavior was absent; however, symptoms may surface as demands increase with greater school and work responsibilities.[15] Similarly, clinicians may overlook ADHD among high-functioning patients, not realizing the need to look past a patient’s success to explore whether the patient might have developed strategies to compensate for ADHD-related deficiencies and is working hard to compensate.

PCPs who rely on the accuracy of a psychiatric diagnosis of adult ADHD from mental health clinicians may not serve their patients well. Data from the NCSR indicate that 37% of women and 53% of men later diagnosed with ADHD were currently taking or had been in treatment for other mental disorders or SUDs in the previous year, in contrast to 25% who had been treated for ADHD.[5] From these data, Kessler and colleagues concluded that adult ADHD is often misdiagnosed by mental health providers.[5] Before prescribing medication, the PCP should review the psychiatric presentation and history with the patient to ensure agreement on the diagnosis. Premature prescription of stimulants for ADHD will only cloud the diagnosis, as adults with ADHD, as well as people in general, may report improvements in mood, cognition, and energy when taking stimulants, which does not confirm a diagnosis of ADHD. In addition, undetected psychiatric disorders may worsen in the presence of stimulants prescribed for ADHD.

Strict adherence to the DSM-IV-TR diagnostic criteria might lead to substantial underdiagnosis of ADHD, as these criteria were originally developed for young boys and may not reflect ADHD symptoms in adults.[16] Clinicians may need to examine whether the patient is advancing appropriately in his or her career or has become a workaholic to compensate for disorganization, procrastination, and sloppy errors.[17] Recent research highlights that adults with ADHD often underestimate the degree of ADHD-related impairments.[18] ADHD that persists into adulthood has been associated with many adverse life experiences or outcomes, including divorce, substance abuse, motor vehicle infractions, academic and occupational underachievement, and brushes with the law.[5,16,19-24] Research suggests that although the number of symptoms may decline along the lifespan, the severity of the impairments does not.[25]

Among the numerous medical conditions that may be associated with cognitive symptoms similar to those of ADHD are thyroid disorders, sleep apnea, hypoglycemia, and lead poisoning.[13] The prevalence of psychiatric comorbidity associated with ADHD is high, with 1 large study reporting that 87% of adults with ADHD had at least 1 comorbid psychiatric diagnosis and 56% had at least 2 comorbid psychiatric disorders.[25] Common comorbidities in ADHD include GAD (which occurs in 25% to 43% of the adult population with ADHD), MDD (16% to 31%), bipolar disorder (up to 47%), and SUD (21% to 53%).[26-28]

Differentiating ADHD and Other Psychiatric Disorders

Clinicians often mistake adult ADHD symptoms as manifestations of other psychiatric disorders, especially anxiety, MDD, or bipolar disorder.[29] It is especially important that clinicians attend to the context of the symptoms: when they originated, how long they have persisted, and whether aggravating or alleviating factors exist. Clinicians also need to determine whether the symptoms might be a function of stress or another condition, such as a sleep disorder. Patient misinterpretation of the symptoms may be more prevalent among adults who were not diagnosed with ADHD during childhood, and some adults may be surprised that they did not “outgrow” their childhood ADHD. Other adults may not recall being diagnosed with ADHD during childhood, suggesting that the absence of a self-report of an ADHD diagnosis may not accurately reflect the absence of childhood ADHD.[30] Misdiagnosis and subsequent inappropriate treatment may help to resolve some secondary symptoms (anxiety and minor depression) but will not resolve the core symptoms of inattentiveness, impulsivity, and hyperactivity.

ADHD is historically a disorder of childhood; as such, diagnosis requires evidence of symptoms occurring during childhood. Adults typically present with fewer overt symptoms and different manifestations of hyperactivity, inattention, and impulsivity than children (Table 1).[31] Whereas hyperactive children cannot sit still and are fidgety, adults may feel restless, have difficulty relaxing, and show impatience. Childhood manifestations of inattention include daydreaming, poor reading comprehension, and working slowly; adult manifestations include procrastination, disorganization, forgetfulness, and missing or showing up late for appointments. Making careless mistakes is common among patients of all ages with ADHD. Impulsive symptoms during childhood include blurting out answers, interrupting others, and having temper outbursts; adults will also manifest with temper outbursts and verbal impulsivity, as well as impulsive spending, starting but not necessarily finishing multiple projects, and moving from job to job.[31]

Table 1.

ADHD Symptom Evolution from Childhood to Adulthood

Childhood Adulthood
  Difficulty sustaining attention (meetings, reading, paperwork)
Failure to pay attention to details Makes careless errors
Appears not to listen Easily distracted/forgetful
Lacks follow-through Poor concentration
Cannot organize Difficulty finishing tasks
Loses important items Disorganized/misplaces items
Squirming/fidgeting Inefficiencies at work
Cannot stay seated Internal restlessness
Cannot wait his/her turn Difficulty sitting through meetings
Runs/climbs excessively Works more than one job
Cannot play/work quietly Works long hours
“On the go”/seems “driven by a motor” Self-selects very active jobs
Talks excessively Overwhelmed
Talks excessively
Blurts out answers Impulsive job changes
Cannot wait in line Drives too fast
Intrudes/interrupts others Interrupts others
Easily frustrated

The Question of Early Symptoms

A particularly challenging component in diagnosing adult ADHD is obtaining sufficient retrospective information to confirm the presence of ADHD symptoms during childhood. Patients may not remember having ADHD-related symptoms before age 7 (a diagnostic criterion for pediatric ADHD in the DSM-IV-TR), although they may identify problems in late grade school or early middle school that continued throughout high school. A recent study compared 4 groups of adults: those who met all criteria for childhood-onset ADHD; those who met all criteria except the age-at-onset criterion (late-onset ADHD); those with subthreshold ADHD who did not meet full symptom criteria; and those without ADHD.[32] Substantial similarities existed between the adults who met the age-at-onset criterion and those with late-onset ADHD, leading these and other investigators to conclude that the current age-at-onset criterion of 7 years is too stringent and to suggest extending the criterion to age 12 in the next iteration of the DSM.[32,33]

Many adults who were not diagnosed during childhood have developed compensatory mechanisms enabling them to function, albeit less than optimally. Clinicians could ask to speak with the patient’s parents or other family members who may be able to provide insights into the patient’s childhood symptomatology. Similarly, current family members, a spouse, and friends might report clinically relevant ADHD symptoms that have been observed for a long time. While an adult might recognize restlessness as a possible ADHD symptom and admit to receiving numerous driving citations, others might note that the patient overreacts, has difficulty staying with tasks, is easily frustrated, or has held numerous jobs.

No standard for the screening of adults for ADHD currently exists. Among the tools that clinicians can use to help in the diagnostic process are the 18-item World Health Organization’s (WHO) ASRS, which can be freely downloaded from the Internet[34]; the Conners’ Adult ADHD Rating Scale (CAARS); the Brown Attention Deficit Disorder Scale (BADDS); the Wender Utah Rating Scale; and the Wender-Reimherr Adult Attention Deficit Disorder Scale. A recent factor analysis determined that many of these scales are in strong agreement with one another, suggesting that clinicians can choose whichever scale is the most pragmatic, cost efficient, and least time-consuming to use.[35] Patients who screen positive on these assessments should then undergo a full diagnostic evaluation, including a clinical interview that assesses current and lifetime symptoms, a thorough developmental history, and behavioral assessments to identify any functional impairments and symptoms.[31]

Treatment of ADHD in Adults

As yet, no formal guidelines have been developed for the treatment of adult ADHD in the United States. However, guidelines for the treatment of ADHD in children and adolescents, as well as international guidelines for the treatment of adult ADHD, offer recommendations that can be extrapolated to US adults. Considerable concordance exists among the guidelines established by the Canadian ADHD Resource Alliance (CADDRA),[17] the American Academy of Child and Adolescent Psychiatry (AACAP), the National Institutes of Health (NIH), and the British Association for Psychopharmacology on Childhood ADHD.[36] The National Institute for Health and Clinical Excellence (NICE) guidelines address both childhood and adult ADHD.[37] The European Network Adult ADHD consensus statement on the diagnosis and treatment of adult ADHD notes the substantial negative and far-reaching consequences of non-treatment of ADHD.[38] These guidelines recommend a multimodal approach to the treatment of ADHD in adults, beginning with psychoeducation about ADHD and pharmacotherapy for ADHD and any comorbid disorders. Recognizing that pharmacotherapy is often insufficient to address all the problems associated with adult ADHD, the guidelines recommend various symptom-specific coaching programs and cognitive behavior therapy to teach problem solving, coping, and time management skills.[38] Similar multimodal treatment recommendations have been proposed by CADDRA.[17]

Available pharmacologic treatments include short-acting and long-acting stimulant and nonstimulant medications. Psychostimulants, including amphetamines and methylphenidates, are recommended as first-line therapy for both children and adults across all sets of US and international guidelines. Currently, only long-acting agents have been approved for the treatment of ADHD in adults in the United States. Despite this, research suggests that 46% of adults diagnosed with ADHD are prescribed off-label, short-acting stimulants.[39]

Approximately 95% of children who were diagnosed with ADHD during childhood and treated with stimulants do not persist with their medication into adulthood,[40] perhaps because clinicians and patients continue to believe that ADHD is a disorder of childhood. Stimulant medications have been shown to effectively address many of the symptoms of ADHD, including poor attention span, restlessness, short-term memory, and hyperactivity. Some patients may respond preferentially to either amphetamine or methylphenidate compounds, and a small percentage of patients do not respond to stimulants at all.[41,42] Side effects are dose-dependent and can include insomnia, nausea, loss of appetite and weight loss, irritability, mood changes, and clinically nonsignificant increases in heart rate and blood pressure in the majority of patients.[43,44,45] However, clinical practice dictates monitoring vital signs to detect any clinically significant changes that may need to be addressed. A baseline check of vital signs also allows for the detection of undiagnosed hypertension that would require treatment before consideration of stimulant medication. Treatment should be initiated at a low dose and titrated based on symptom reduction and side effects. The dose response in adults is variable; clinicians should not expect that higher doses are needed because the patient is an adult or overweight.

US Food and Drug Administration (FDA)-approved nonstimulants in the ADHD armamentarium include atomoxetine, extended-release (XR) guanfacine, and extended-release (ER) clonidine. Only atomoxetine is currently approved for use in adults, while guanfacine XR and clonidine ER have been approved for use in children and adolescents up to age 18. Other agents that are used off-label include bupropion, tricyclic antidepressants (especially desipramine), and modafinil. The onset of action for atomoxetine is slower than for stimulants, taking to a few weeks to attain the maximum treatment effect. The lack of an abuse potential with nonstimulants may be particularly attractive for use in patients who have SUDs, are at risk for substance abuse, or are potential diverters or sellers of illicit substances.

Atomoxetine is a selective inhibitor of the presynaptic norepinephrine transporter. It has been associated with slightly increased diastolic blood pressure and heart rate, and patients with milder forms of autonomic impairment should be monitored if given this agent.[46] In addition, atomoxetine is predominantly metabolized by the cytochrome P450 2D6 (CYP2D6) isoenzyme, necessitating caution for patients who take medication that inhibits CYP2D6, including fluoxetine, paroxetine, and bupropion.[13] Guanfacine is a direct agonist of the α-2a subtype of norepinephrine receptors. Guanfacine XR can be used as monotherapy or adjunctive therapy with a long-acting psychostimulant.[47,48] Clonidine ER is an α-2a-adrenergic receptor agonist that is considered a second-line agent in the treatment of ADHD, but it may be particularly useful for patients with ADHD and comorbid Tourette syndrome or other tic disorders. As yet, the α-2a agonists have not been studied sufficiently in adults either as monotherapy or as adjunctive treatment in combination with stimulants. Because of the effects of these agents on blood pressure and pulse, monitoring vital signs is recommended, and caution is needed in adults who are being treated for hypertension with other medications.

Monitoring Effects and Side Effects After Initial Treatment

Routine clinical monitoring is necessary throughout the duration of treatment.[13] It is important to meet with the patient on a more frequent basis after medication has been initiated to review tolerability and efficacy and to adjust the dosage (or the medication) as necessary; this typically requires follow-up every 2 to 3 weeks and availability by phone if the patient encounters problems with the medication or dosage. Patients engaged in psychotherapy or skills training will likely be seen on a more frequent, often weekly or biweekly, basis. Once stabilized on an effective and well-tolerated dosage of medication, patients can be seen every 2 to 3 months to monitor the need for dosage adjustments based on tolerability and residual symptoms. Clinicians should assess ADHD symptoms, medication side effects, medication adherence, and comorbid medical/psychiatric conditions at each visit. Similarly, clinicians should monitor caffeine and nicotine intake, as these will further elevate blood pressure and heart rate for all patients on ADHD pharmacotherapies. Although not a common problem, patients with a low body mass index (BMI) should be monitored for suppressed appetite leading to weight loss. Regular assessment of medication utility as measured by daily functional performance should be part of routine monitoring. In the process, you can discuss the continued benefit of medication with the patient. On occasion, a patient may wish to stop the medication to reassess its benefit, and the physician should provide support and oversight in this process. A follow-up reassessment when the patient is off the medication can clarify the re-emergence of ADHD symptoms and impact on daily productivity.

One means for monitoring symptom reduction is through the periodic use of symptom checklists, such as the patient-rated 18-item ASRS. The ASRS is an easy and preferred tool to use because it is standardized, validated, nonproprietary, and readily available on the Internet. It can be administered at baseline and then intermittently, especially with changes to medication dosage, to complement the clinical interview. Patients and their clinicians can get a sense of ADHD symptom improvement with treatment or an increase in symptoms if treatment is suspended or stopped. Patients may forget their ratings of baseline symptoms and find the change in symptom ratings helpful to verify treatment benefit. Although symptom reduction is desirable, the true measure of treatment benefit is the improvement in daily function, such as the ability to initiate and complete more tasks, sustain attention, be less distractible in conversations and meetings, finish tasks on time, reduce careless oversights and errors, and have better, more patient social interactions.

Stimulants, Nonstimulants, and Cardiovascular Risk in Adults

Stimulants are associated with mild elevations in both blood pressure and pulse. It is recommended that patients receiving stimulants have blood pressure and heart rate checked at baseline and regularly throughout treatment.[49] A retrospective database analysis in the United Kingdom found no additional risk of sudden death associated with either stimulants or atomoxetine in children and adolescents 2 to 21 years of age with ADHD.[50] Another retrospective study of adults with new ADHD treatments found that preexisting cardiovascular conditions appeared more likely to reduce prescribing of stimulant treatment in younger vs older patients but did not appear to influence initiation of atomoxetine therapy.[51] In this cohort of 8752 patients, 41% with 1 or more preexisting cardiovascular conditions were prescribed stimulants.[51] Small studies have demonstrated that adults being treated for primary essential hypertension can be safely treated with mixed amphetamine salts[52,53] and methylphenidate.[54] However, stimulant medications for ADHD should not be initiated until the patient is normotensive with a stable antihypertensive medication dose.

In 2008, in response to evidence supporting concerns that the use of stimulants for ADHD could augment the risk of serious cardiovascular events by increasing heart rate and blood pressure, the American Heart Association (AHA) recommended an electrocardiogram (ECG) before initiating treatment in children.[55] This recommendation contradicted recommendations by the AACAP and the American Academy of Pediatrics (AAP), which found that sudden cardiac death in persons taking stimulants was a rare event that could not be prevented or predicted by routine screening with ECG.[56] The AAP recommends an ECG only in those patients with the following risk factors: previously detected cardiac disease, palpitations, syncope, or seizures; a family history of sudden death in children or young adults; hypertrophic cardiomyopathy; or long QT syndrome.[56] Two recent large studies found no significant additional risk of sudden death, myocardial infarction, or stroke in children, young adults, or middle-age adults who were receiving stimulants or atomoxetine.[45,57]

Clinical trials of ADHD medications demonstrate short-term efficacy and safety; however, the majority of patients require chronic long-term treatment.[58-60] Recent studies have demonstrated the safety and efficacy of stimulants, atomoxetine, and guanfacine XR over 24-month treatment periods in children and adolescents.[61] Significant differences between stimulants regarding efficacy or risk of cardiac or cerebrovascular events are not apparent.[62] If clinicians observe any cardiovascular changes, they should determine whether these changes are directly related to the ADHD medication or might instead be related to cardiovascular risks and changes associated with normal aging — for example, weight gain as a cause of hypertension. Nevertheless, long-term studies addressing adverse events are warranted.[59]

Approaches to Improve Executive Function in Adults With ADHD

ADHD can be associated with executive function impairments that can compromise occupational functioning.[63] Executive function is broadly defined as the ability to organize, sequence, prioritize, and hold information in your memory as you consider multiple factors (working memory). Executive function can be defined behaviorally (symptoms observed by patient or others) or by specific neuropsychological measures. Most ADHD symptom checklists enumerate executive function symptoms because they are part of the ADHD symptom criteria. By this definition, all patients with ADHD have executive dysfunction. Executive function may improve with ADHD medication such that inattention, distractibility, and sustained attention improve. In this case, executive dysfunction may be an epiphenomenon of inattention, distractibility, and restlessness. Adults with ADHD may notice improvements in many of their symptoms of impulsivity, inattention, and restlessness but may still struggle with difficulties in organization, developing timelines, planning, and making and initiating decisions.

If the definition of executive function is based on abnormalities that appear on specific neuropsychological tests, then approximately one-third of ADHD patients have executive dysfunction, not 100% as the behavioral definition demands.[64] The clinical relevance of these distinctions is that patients with ADHD may have improved attention and less distractibility and restlessness but still be disorganized. If the clinician believes the disorganization is a residual ADHD symptom, the clinician may respond by increasing the dose of ADHD medication, only to find no further benefit but more side effects. These residual executive dysfunction symptoms tend not to improve with escalating medication dosing.

Results from 2 large trials indicate that adults with ADHD who experienced improvements in executive function with stimulant treatment also experienced improvements in health-related quality of life, particularly in the domains of performance and function.[65] However, a clinical trial of adults with ADHD found that the presence of executive function deficits, as assessed by standardized neuropsychological testing, did not affect clinical response to treatment with osmotic controlled-release oral delivery system (OROS) methylphenidate, and that measures of executive function were not affected by treatment response.[66] The need to better define executive function deficits so that an accurate assessment can be determined is critical; the means to minimize such impairments can be challenging.

Some patients might benefit from adjunctive therapy to address executive function deficits. Research in children and adolescents suggests that the concurrent use of stimulant and nonstimulant therapies can afford significantly greater improvements in ADHD symptoms than stimulant monotherapy, although some combinations have been associated with an additive adverse effect burden and higher cost.[67;48]

Many clinicians recommend cognitive behavior therapy (CBT) or other forms of psychotherapy once the patient has been stabilized on pharmacotherapy. CBT and other interventions can help the patient address organization skills and self-efficacy that have evolved over many years of insufficient treatment for ADHD; it can help patients develop effective compensatory strategies and improve other functional impairments typically associated with ADHD.[68,69] CBT may also help the subset of patients who choose not to use medications (or for whom medications are not appropriate or intolerable), as well as the large proportion of patients who have comorbid conditions.[70] Research suggests that adding CBT may enhance the response to and benefits of pharmacologic treatments.[68]

Metacognitive therapy uses principles and methods of CBT to teach time management, organization, and planning skills, and to address depressive and anxious thoughts that undermine effective self-management. Solanto and colleagues[71] compared a 12-week course of group metacognitive therapy (N = 41) with supportive therapy (including nonspecific group support and validation, psychoeducation, and therapist attention; N = 38) in adults with ADHD. They found that metacognitive therapy provided significantly more benefit in adults with ADHD “with respect to inattention symptoms that reflect the specific functions of time management, organization, and planning.” These benefits were seen in patients who were receiving medication treatment as well as those who were not.

When appropriate, patients may also benefit from couples or family counseling or both, and life skills training or coaching. A review of studies of group and individual psychosocial treatments for adult ADHD found that various psychosocial therapies, including skills-training and psychoeducation, improved motivation and reduced residual symptoms in adults with ADHD.[72]

ADHD and Substance Use Disorders

Up to 75% of adults with ADHD have had at least one comorbid condition,[13] and 40% of adults with ADHD present with a concurrent comorbidity.[73] The high rate of comorbid psychiatric conditions — particularly anxiety disorders, mood disorders, and SUDs — can influence both diagnosis and treatment of ADHD as well as the other condition(s). A significant number of adults with ADHD have a comorbid mood disorder, and a significant proportion of adults with mood disorders have comorbid ADHD.[74] As many as 50% of adult patients with ADHD have had comorbid SUDs.[23] Consequently, clinicians should maintain a high index of suspicion for ADHD among patients with any mental health concern because of its high prevalence in these subpopulations.[75,13]

Evidence suggests that ADHD is a significant risk factor for the development of both SUDs and cigarette smoking.[76] A recent meta-analysis and meta-regression analysis suggests that nearly 1 in 4 patients with SUD met DSM criteria for comorbid ADHD,[77] and 10% to 30% of adults with ADHD have SUD.[78] Alcohol dependence is associated with higher ADHD prevalence than cocaine dependence.[77] Substance use, including cigarette smoking, begins at an earlier age among adults with ADHD,[79] and SUDs are generally more severe in patients with comorbid ADHD.[16] Moreover, SUD may manifest with self-control, attention, and behavioral symptoms similar to those seen in ADHD. The prognosis for patients with ADHD and SUD worsens with additional comorbidities. Adolescents with ADHD and comorbid major depression generally have more severe substance use at baseline and throughout treatment compared with nondepressed adolescents with ADHD and SUD.[80]

Concerns that children treated for ADHD with stimulants are at elevated risk for developing SUD have not been supported by the research. A naturalistic, controlled, 10-year follow-up study of 112 boys and men over 10 years and found no statistically significant associations between stimulant treatment and alcohol, drug, or nicotine use disorders.[81] The investigators concluded that the risk for subsequent SUD is neither increased nor decreased in individuals treated with stimulants for ADHD during childhood and adolescence.

ADHD Comorbidity

It is estimated that only 25% of adult ADHD cases are uncomplicated.[26] In addition to SUD, ADHD has a high comorbidity with mood and anxiety disorders. Data from the NCSR indicate that 9.4% of adults with MDD have ADHD, as do 22.6% of adults with dysthymia.[5] The lifetime prevalence of anxiety disorders among adult patients with ADHD is 40% to 60%.[23] ADHD has been identified in 21.2% of adults with bipolar disorder,[5] and the presence of ADHD may increase the risk of developing bipolar disorder.[17] Many patients do not have just 1 comorbid diagnosis; diagnosing patients with SUD and comorbid psychiatric disorders can be particularly challenging because of the high rate of symptom overlap.

The numerous similarities in clinical presentation among these psychiatric disorders can interfere with accurate diagnosis. For example, symptoms of both ADHD and depression may include trouble sleeping, eating, and concentrating; patients with MDD, ADHD, or GAD may be restless and fidgety. It is important to obtain a comprehensive evaluation for child and adult symptoms, including the temporal relationship between the various comorbid disorders.[82] A primary complaint of a consistent negative mood for 3 months is more suggestive of MDD than ADHD, whereas a report of persistent poor concentration and lack of motivation dating from childhood is more consistent with ADHD. Poor concentration and anhedonia following a depressive episode suggests MDD; poor concentration, depression, organizational problems, and impulsivity that are long-standing suggest ADHD.[17] The clinical presentation of MDD is not affected by comorbid ADHD.[23] Clinicians need to distinguish between a lack of motivation suggestive of ADHD, dysregulated mood and irritability that might indicate ADHD with comorbid mood disorder, and significantly low affect symptomatic of depression.[17] The psychotic symptoms present in bipolar disorder are not likely to be misdiagnosed as ADHD; patients with ADHD do not report a cyclic pattern to their symptoms.[28] Primary care physicians who suspect bipolar disorder, or a manic or hypomanic episode, may want to refer the patient to a specialist, particularly if the patient is diagnosed with comorbid ADHD.

What to Manage First?

Identifying the primary disorder can be particularly challenging in adults with ADHD, as many comorbidities have an onset in mid-to-late-adolescence and these individuals have had many years of dealing with their disorders. In patients with active substance abuse, experts recommend that SUD be considered the primary diagnosis and treated first, regardless of age; once the SUD is under control, clinicians can then reassess the patient to determine whether the presenting symptoms were caused by the SUD, comorbid ADHD, or a mood disorder.[17,38] This strategy is based on controlled studies suggesting that treatment for ADHD in patients with comorbid active SUDs has little effect on either ADHD symptoms or substance use.[83] Adults with SUD who require treatment for ADHD cannot be treated with stimulants until they are in recovery treatment, as stimulants are contraindicated for patients who are actively using addictive substances. However, in adults with comorbid SUD, ADHD can be treated with FDA-approved nonstimulants such as atomoxetine or off-label bupropion, tricyclic antidepressants, or modafinil.[84] Stimulants, preferably long-acting formulations, can be used once patients are in stable substance use remission.

In adults, severe psychiatric mood or anxiety disorders are treated before treating ADHD, whereas ADHD is typically treated prior to initiating treatment for other psychiatric disorders of mild to moderate severity. In some cases, treating ADHD will help resolve the mild or moderate symptoms of the other psychiatric disorders. Clinicians must perform an adequate screen in adult patients with ADHD suspected of comorbid depression to rule out bipolarity. It is recommended that patients with comorbid bipolar disorder and ADHD be treated with mood stabilizers or atypical antipsychotics before initiating treatment with stimulants, which can destabilize bipolar symptoms.[85] Patients with comorbid ADHD and MDD can be treated with a stimulant and an antidepressant, particularly selective serotonin reuptake inhibitors (SSRIs).[74] Stimulants can be administered with serotonin-norepinephrine reuptake inhibitors (SNRIs), but this combination needs to be closely monitored for sympathomimetic side effects.[13] However, when atomoxetine is co-administered with SSRIs, one should be mindful of potential kinetic interactions through the cytochrome P450 enzyme system.

ADHD Treatment for Patients in Stable Recovery

Guidelines support and encourage treatment of ADHD in patients with SUD.[2,17,37,38] Indeed, optimal treatment for ADHD may improve adherence to treatment for SUD. Pharmacotherapy choices for adult patients in stable recovery can follow usual adult recommendations. Stimulants are more effective than nonstimulants for adult ADHD[86]; however, stimulants may be diverted or abused. These risks are lower for long-acting stimulants approved for adult ADHD (OROS methylphenidate, dexmethylphenidate XR, mixed amphetamine salts, and lisdexamfetamine) than for the short-acting agents.[83] At this time, atomoxetine is the only nonstimulant treatment approved for adult ADHD. The nonstimulant α-2 receptor agonists guanfacine XR and clonidine ER have not been studied in adults; their use is currently off-label in this population.


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