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CHILDHOOD DISORDERS

There is no clear distinction between “childhood” and “adult”

disorders. Adults can also be diagnosed with a childhood disorder

in which case it is a late diagnosis. Similarly, children may

also be suffering from some other disorder/s which are not

usually first diagnosed in infancy, childhood or adolescence.

Childhood disorders include the following groups/categories:

o Mental Retardation

It includes mild, moderate and severe MR alongwith MR

non-specified type.

o Learning Disorders

It includes Reading disorder, Mathematical disorder and

Wrtinig disorder (Dysgraphia, Dyscalculia and Dyslexia)

alongwith non-specified type.

o Motor Skills Disorder

It includes Developmental Co-ordination Disorder

o Communication Disorders

It includes Expresssive Language Disorder, Mixed

Receptive-Expressive Language Disorder, Phonological

Disorder, Stuttering and Commmunication Disorder

otherwise non-specified

o Pervasive Developmental Disorders

It inclues Autistic disorder, Rett’s disorder,

Childhood Disintegrative Disorder, Asperger’s disorder

and non-specified type of PDD.

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o Attention Deficit and Disruptive Behavior Disorders

It includes ADHD, ADHD non-specified, Conduct Disorder,

Oppositional Defiant Disorder and Disruptive disorder

non-specified.

o Feeding and Eating Disorders of Infancy or Early

Childhood

It includes Pica, Rumination Disorder and Feeding

Disorders of Infancy and Early Childhood.

o Tic Disorders

It includes Tourette’s Disorder, Chronic Motor or Vocal

Tic disorder, Transient Tic Disorder and non-specified

Tic Disorder.

o Elimination Disorders

It includes Encopresis and Eneuresis.

o Other Disorders of Infancy, Childhood or Adolescence

It includes Seperation Anxiety Disorder, Selective

Mutism, Reactive Attachment Disorder of Infancy and

Early Childhood, Stereotypic Movement Disorder and non-

specified type of disorders of infancy, childhood and

adulthood.

Here we are going to discuss six disorders of childhood as

mentioned below.

1. Mental reatrdation

2. Autism

3. Dyslexia

4. Conduct Disorder in relation to ODD

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5. Attention Deficit Hyper Activity Disorder (ADHD)

6. Seperation Anxiety.

MENTAL RETARDATION

This is a commonly used term but one that actually has a very

specific meaning. Technically a person with mental retardation

scores below 70 on an intelligence test and, as such has limited

mental abilities.

Psychologists define MR in terms of limited mental development as

measured by an individual's performance on a psychometric test.

Those in biological sciences define MR as the presence of

observable or inferred brain pathology. In old times and medieval

ages, the mentally retarded were put to death. During the first

half of the 20th century the mental testing movement pioneered by

the work of Alfred Binet, Lewis Terman, And David Wechsler

introduced intelligence as a concept to explain cognitive

development. Operationally a person's level of cognitive

development is determined by the scores obtained on a

standardized intelligence test. On the basis of a statistical

model (normal curve) a person whose IQ score deviates

significantly from an arbitrarily defined norm is judged to be

MR. Degree of MR is determined by the magnitude of deviation from

the norm.

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DSM-IV-TR CRITERIA OF MENTAL RETADATION

Significantly subaverage intellectual functioning: an IQ of

approximately 70 or below on an individually administered IQ

test (for infants, a clinical judgment of significantly

subaverage intellectual functioning).

Concurrent deficits or impairments in present adaptive

functioning (i.e., the person's effectiveness in meeting the

standards expected for his or her age by his or her cultural

group) in at least two of the following areas:

communication, self-care, home living, social/interpersonal

skills, use of community resources, self-direction,

functional academic skills, work, leisure, health, and

safety.

The onset is before age 18 years.

Code based on degree of severity reflecting level of

intellectual impairment:

o 317 Mild Mental Retardation: IQ level 50-55 to

approximately 70 

o 318.0 Moderate Mental Retardation: IQ level 35-40 to

50-55 

o 318.1 Severe Mental Retardation: IQ level 20-25 to 35-

40 

o 318.2 Profound Mental Retardation: IQ level below 20 or

25

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o 319 Mental Retardation, Severity Unspecified: when

there is strong presumption of Mental Retardation but

the person's intelligence is untestable by standard

tests

The second component of diagnosis, adaptive skills, is usually

measured with a self-reported or parent/caregiver-reported

inventory, such as the Vineland Adaptive Behavior Scales, Second

Edition (VABS-II). The DSM-V diagnosis is expected to require

adaptive measurements of less than 2 SDs as compared to the

population mean, with standard scores of 70 or less, in at least

2 of the following domains.

Conceptual skills (communication, language, time, money,

academic)

Social skills (interpersonal skills, social responsibility,

recreation, friendships)

Practical skills (daily living skills, work, travel)

MR/ID also can be categorized as syndromic, if associated

with dysmorphic features, of nonsyndromic, if not associated

with dysmorphisms or malformations.

LEVELS OF MENTAL RETARDATION

MR/ID is divided into four levels based on IQ and degree of social adjustment.

MILD MENTAL RETARDATION At this level, a person:

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o takes longer to learn to talk, but can communicate wellonce he or she knows how

o fully independent in self-careo has problems with reading and writingo is socially immatureo is unable to deal with responsibilities of marriage or

parentingo may benefit from specialized education planso has an IQ range of 50 to 69o May have associated conditions,

including autism, epilepsy, or physical disability.Approximately 85 percent of the mentally retarded population is in the mildly retarded category. They can often acquire academic skills up to the sixth grade level. They can become fairly self-sufficient and in some cases live independently, with community and social support.

MODERATE MENTAL RETARDATION At this level, a person:

o is slow in understanding and using languageo has only a limited ability to communicateo can learn basic reading, writing, counting skillso is a slow learnero is unable to live aloneo can get around on owno can take part in simple social activitieso has an IQ range of 35 to 49

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About 10 percent of the mentally retarded population is considered moderately retarded. They can carry out work and self-care tasks with moderate supervision. They typicallyacquire communication skills in childhood and are able to live and function successfully within the community in a supervised environment such as a group home.

SEVERE MENTAL RETARDATION At this level, a person:

o has noticeable motor impairmento has severe damage to and/or abnormal development of

central nervous systemo has an IQ range of 20 to 34

About 3 to 4 percent of the mentally retarded population is severely retarded. They may master very basic self-care skills and some communication skills. Many severely retarded individualsare able to live in a group home.

PROFOUND MENTAL RETARDATION At this level, a person:

o is unable to understand or comply with requests or instructions

o is immobileo must wear adult diaperso uses very basic nonverbal communicationo cannot care for own needso requires constant help and supervisiono has an IQ of less than 20.

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Only 1 to 2 percent of the mentally retarded population is classified as profoundly retarded. They may be able to develop basic self-care and communication skills with appropriate supportand training. Their retardation is often caused by an accompanying neurological disorder. The profoundly retarded need a high level of structure and supervision.

OTHER MENTAL RETARDATIONChildren in this category are often blind, deaf, mute, and physically disabled. These factors prevent physicians from conducting screening tests.

UNSPECIFIED MENTAL RETARDATIONSigns of MR/ID exist, but there is not enough information to assign the child to a level.

SIGNS OF MENTAL RETARDATION

There are many different signs of intellectual disability in

children. Signs may appear during infancy, or they may not be

noticeable until a child reaches school age. It often depends on

the severity of the disability. Some of the most common signs of

intellectual disability are:

Rolling over, sitting up, crawling, or walking late

Talking late or having trouble with talking

Slow to master things like potty training, dressing, and

feeding himself or herself

Difficulty remembering things

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Inability to connect actions with consequences

Behavior problems such as explosive tantrums

Difficulty with problem-solving or logical thinking

In children with severe or profound intellectual disability,

there may be other health problems as well. These problems may

include seizures, mental disorders, motor

handicaps, vision problems, or hearing problems.

In general, mentally retarded children reach developmental

milestones such as walking and talking much later than the

general population. Symptoms of mental retardation may appear at

birth or later in childhood. Time of onset depends on the

suspected cause of the disability. Some cases of mild mental

retardation are not diagnosed before the child enters preschool.

These children typically have difficulties with social,

communication, and functional academic skills. Children who have

a neurological disorder or illness such

as encephalitis or meningitis may suddenly show signs of

cognitive impairment and adaptive difficulties.

RISK FACTORS OF MENTAL RETARDATION

GENETICS

About 5 percent of mental retardation is caused by hereditary

factors. Mental retardation may be caused by an inherited

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abnormality of the genes, such as fragile X syndrome . Fragile X,

a defect in the chromosome that determines sex, is the most

common inherited cause of mental retardation. Single gene defects

such as phenylketonuria (PKU) and other inborn errors of

metabolism may also cause mental retardation if they are not

found and treated early. An accident or mutation in genetic

development may also cause retardation. Examples of such

accidents are development of an extra chromosome 18 (trisomy 18)

and Down syndrome . Down syndrome is caused by an abnormality in

the development of chromosome 21. It is the most common genetic

cause of mental retardation.

PRENATAL ILLNESSES AND ISSUES

Fetal alcohol syndrome affects one in 600 children in the United

States. It is caused by excessive alcohol intake in the first

twelve weeks (trimester) of pregnancy. Some studies have shown

that even moderate alcohol use during pregnancy may cause

learning disabilities in children. Drug abuse and

cigarette smoking during pregnancy have also been linked to

mental retardation.

Maternal infections and illnesses such as

glandulardisorders, rubella, toxoplasmosis, and cytomegalovirus

infection may cause mental retardation. When the mother has high

blood pressure ( hypertension ) or blood poisoning (toxemia), the

flow of oxygen to the fetus may be reduced, causing brain damage

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and mental retardation. Birth defects that cause physical deformities of the head, brain, and central nervous system

frequently cause mental retardation. Neural tube defect, for

example, is a birth defect in which the neural tube that forms

the spinal cord does not close completely. This defect may cause

children to develop an accumulation of cerebrospinal fluid on the

brain (hydrocephalus). By putting pressure on the brain

hydrocephalus can cause learning impairment.Cretnism is a

condition produced in infants and children due to lack of thyroid

hormone. It usually results from a congenital defect (e.g.,

absence of the thyroid, presence of only a rudimentary gland,

inability of the gland to produce thyroxine). However, it can

develop later if there is a lack of iodine in the diet, or if the

thyroid is diseased or surgically removed. Cretinism causes very

serious retardation of physical and mental development; if the

condition is left untreated, growth is stunted and the physical

stature attained is that of a dwarf. In addition, the skin is

thick, flabby, and waxy in color, the nose is flattened, the

abdomen protrudes, and there is a general slowness of movement

and speech. If discovered early enough and treated with thyroid

extract and sufficient iodine intake throughout life, growth may

become normal and mental facility greatly improved. If the

condition commences after adulthood is reached it is called

myxedema. Congenital hypothyroidism (CH) is a condition of

thyroid hormone deficiency present at birth. Approximately 1 in

4000 newborn infants has a severe deficiency of thyroid function,

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while even more have mild or partial degrees. If untreated for

several months after birth, severe congenital hypothyroidism can

lead to growth failure and permanent intellectual disability.

Treatment consists of a daily dose of thyroid hormone (thyroxine)

by mouth. Because the treatment is simple, effective, and

inexpensive, nearly all of the developed world practices newborn

screening to detect and treat congenital hypothyroidism in the

first weeks of life.

CHILDHOOD ILLNESS AND INJURIES

Hyperthyroidism, whooping cough, chickenpox, measles, and Hib

disease (a bacterial infection) may cause mental retardation if

they are not treated adequately. An infection of the membrane

covering the brain (meningitis) or an inflammation of the brain

itself (encephalitis) cause swelling that in turn may cause brain

damage and mental retardation. Traumatic brain injury caused by a

blow or a violent shake to the head may also cause brain damage and mental retardation in children. Severe head injury, near-

drowning, extreme malnutrition, exposure to toxic substances such

as lead, and severe neglect or abuse can also cause it.

ENVIRONMENTAL FACTORS

Ignored or neglected infants who are not provided the mental and

physical stimulation required for normal development may suffer

irreversible learning impairments. Children who live in poverty

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and suffer from malnutrition , unhealthy living conditions, and

improper or inadequate medical care are at a higher risk.

Exposure to lead can also cause mental retardation. Many children

develop lead poisoning by eating the flaking lead-based paint

often found in older buildings.

DIAGNOSIS OF MENTAL RETARDATION

A complete medical, family, social, and educational history is

compiled from existing medical and school records (if applicable)

and from interviews with parents. Children are given intelligence

tests to measure their learning abilities and intellectual

functioning. Such tests include the Stanford-Binet Intelligence

Scale, the Wechsler Intelligence Scales, the Wechsler Preschool

and Primary Scale of Intelligence, and the Kaufmann Assessment

Battery for Children. For infants, the Bayley Scales of Infant

Development may be used to assess motor, language, and problem-

solving skills. Interviews with parents or other caregivers are

used to assess the child's daily living, muscle control,

communication, and social skills. The Woodcock-Johnson Scales of

Independent Behavior and the Vineland Adaptive Behavior Scale

(VABS) are frequently used to test these skills.

RESILIENCE FACTORS IN MENTAL REATRDATION

Immunization against diseases such as measles and Hib prevents

many of the illnesses that can cause mental retardation. In

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addition, all children should undergo routine developmental

screening as part of their pediatric care. Screening is

particularly critical for those children who may be neglected or

undernourished or may live in disease-producing conditions.

Newborn screening and immediate treatment for PKU and

hyperthyroidism can usually catch these disorders early enough to

prevent retardation. Good prenatal care can also help prevent

retardation. Pregnant women should be educated about the risks of

drinking and the need to maintain good nutrition during

pregnancy. Tests such as amniocentesis and ultrasonography can

determine whether a fetus is developing normally in the womb. The

proper social schemes and interventio centres can be iniated at

public and private level to help mentally retarded children.

The sooner the diagnosis of mental retardation is made, the more

the child can be helped. With mentally retarded infants, the

treatment emphasis is on sensorimotor development, which can be

stimulated by exercises and special types of play. It is required

that special education programs be available for retarded

children starting at three years of age. These programs

concentrate on essential self-care, such as feeding, dressing,

and toilet training. There is also specialized help available for

language and communication difficulties and physical

disabilities. As children grow older, training in daily living

skills, as well as academic subjects, is offered.Many day schools

are available to help train retarded children in basic skills

such as bathing and feeding themselves. Extracurricular

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activities and social programs are also important in helping

retarded children and adolescents gain self-esteem.

Counseling and therapy are another important type of treatment

for the mentally retarded. Retarded children are prone to

behavioral problems caused by short attention span, low tolerance

for frustration, and poor impulse control. Behavior therapy with

a mental health professional can help combat negative behavior

patterns and replace them with more functional ones. A counselor

or therapist can also help retarded children cope with the low

self-esteem that often results from the realization that they are

different from other children, including siblings. The most

frequently used therapy used is behavioral therapy.It helps in

regulating the behavior of child, in terms of positive and

neative reinforcements. Similarly, Diaelectic Behavioral therapy

is being used for bio-social support to mentally reatrded. Family

therapy along with interpersonal therapy is used to help family

members create a better bond to assist and groom mentally

retarded child. Sometimes parents and siblings are not able to

accept the mentally retarded child, so these therapies help them.

Counseling can also be valuable for the family of a retarded

child to help parents cope with painful feelings about the

child's condition and with the extra time and patience needed for

the care and education of a special-needs child. Siblings may

need to talk about the pressures they face, such as accepting the

extra time and attention their parents must devote to a retarded

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brother or sister. Sometimes parents have trouble bonding with an

infant who is retarded and need professional help and reassurance

to establish a close and loving relationship.

DESCRIPTION OF SCALES

Vineland Adaptive Behavior Scale (VABS)

The Vineland is designed to measure adaptive behavior of

individuals from birth to age 90. The Vineland-II contains 5

domains each with 2-3 subdomains. The main domains are:

Communication, Daily Living Skills, Socialization, Motor Skills,

and Maladaptive Behavior (optional). The domain scores yield an

adaptive behavior composite. The Vineland-II is a standardized

norm-referenced assessment tool that can be used for: measuring

an individual’s daily functioning measuring deficits in adaptive

behavior clinical diagnosis of autism spectrum disorders,

genetic disorders, developmental delays, emotional and behavioral

disturbances as well as other mental, physical or injury related

conditions ,developmental evaluations ,progress

monitoring ,program planning ,research Average alpha

correlations of test retest were found to range between .76 and

.92 across domains and .91 overall.

Wechsler Preschool and Primary Scale of Intelligence

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The Wechsler Preschool and Primary Scale of Intelligence – Third

Edition (WPPSI-III) is designed to test intelligence (cognitive

ability) in English-speaking children ages 2 years 6 months to 7

years 3 months in the following content areas: Verbal

Reasoning , Concept Formation , Sequential Processing , Auditory

Comprehension, Cognitive Flexibility, Social Judgment ,

Perceptual Organization , Processing Speed The WPPSI-III is a

norm-referenced intelligence assessment tool that can be used to:

measure general cognitive functioning, identify intellectual

giftedness, mental retardation, and cognitive strengths and

weaknesses, guide treatment program development, make placement

decisions in clinical and educational settings, and provide

clinical information for neuropsychological evaluation and

research.

The test-retest reliabilities were calculated, and yielded

correlations in the .70s and .80s for both subtest scores and

composite scores.

Bayley Scales of Infant Development (BSID)

The Bayley Scales of Infant Development (BSID) measure the mentaland motor development and test the behavior of infants from one to 42 months of age. The BSID are used to describe the current developmental functioning of infants and to assist in diagnosis and treatment planning for infants with developmental delays or disabilities. The BSID were first published by Nancy Bayley in The Bayley Scales of Infant Development (1969) and in a second edition (1993).The examiner presents a series of test materials to the child and observes the child's responses and behaviors.

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The test contains items designed to identify young children at risk for developmental delay. BSID evaluates individuals along three scales: Mental scale; Motor scale; and Behavior rating scale. The BSID are known to have high reliability and validity. The mental and motor scales have high correlation coefficients (.83 and .77 respectively) for test-retest reliability

AUTISM DEFINITION

“Autism is a disorder of neural development characterized byimpaired social interaction and communication, and by repetitive behavior.”

Autism is an umbrella term for a wide range of disorders. Clinically, they may be referred to as “Pervasive DevelopmentalDisorders” (PDDs) or “Autism Spectrum. The word “autism” often evokes an image of a person with the most severe disorders.”

The term “spectrum” is crucial to understanding autism, because of the wide range of intensity, symptoms and behaviors, types of disorders, and as always, considerable individual variation. Children with autism spectrum disorders maybe non-verbal and asocial, as in the case of many with “classic” autism, or Autistic Disorder. On the other end of the spectrum are children with a high-functioning form of autism characterizedby individual social skills and play, such as Asperger Syndrome. In the Diagnostic and Statistical Manual (DSM-IV), these diagnostic categories are outlined under the heading of “Pervasive Developmental Disorders (PDDs).” In the DSM-IV, these disorders are defined by deficits in three core areas: social skills, communication, and behaviors and/or interests.

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Types of autism spectrum disorders, or PDDs, include:

Autistic Disorder (299.00)

Rett Syndrome (299.80)

Childhood Disintegrative Disorder (299.10)

Asperger Syndrome (299.80)

Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS)( 299.80)

LEVELS OF AUTISM

Mild: Shows gentleness in manners or speech, it doesn't haveto get in the way of achievements. Children with mild autismor pervasive developmental disorder may have behaviors whichare not so obvious. These children may, in fact, have normalor above-average intellectual ability.

Moderate: Need a fair amount of assistance in life, especially after they become adults. They will not be able to interact easily with others, and they will move away intotheir own worlds unless strongly prompted to pay attention to a parent or teacher. The moderately autistic child will most likely need reminders to attend to such things as hygiene and may not perform well academically.

Severe: Rarely able to live on their own, usually requiring extensive care throughout their lives. They are totally unable to interact with others, in most of the cases. Their language development may not occur at all, or be very late, and they will be awkward with their movements. Severe autistics are often referred to as "low functioning."

CAUSES AND RISK FACTORS

Genetic Causes and Risk

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Genetic factors may be the most significant cause for autism spectrum disorders. Early studies of twins had estimated heritability to be over 90%, in other words, that genetics explains over 90% of whether a child will develop autism. This may be an overestimate; new twin data and models with structural genetic variation are needed. For adult siblings, the risk for having one or more features of the broader autism phenotype mightbe as high as 30%. The genetics of autism is complex. More than one gene may be implicated, different genes may be involved in different individuals, and the genes may interact with each other or with environmental factors. Several candidate genes have been located.But the mutations that increase autism risk have not been identified for most candidate genes. A significant fraction of autism may be highly heritable but not inherited that is, the mutation that causes the autism is not present in the parental genome.

EnvironmentInternal Environment

Risk of autism is associated with several parental inner environments like mother’s age. If mother is of older age then it causes complications during birth. If mother is diabetic then it may also play a role in the development of autism in child. Parental stress is also an important point in the cause ofautism. Uses of psychiatric drugs during pregnancy may also play a little role in development of autism. The biological reasons for this are unknown: possible explanations include increased risk of pregnancy complications, maternal autoimmunity and

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increased risk of chromosomal abnormalities. 2nd child after a short interval of 1st pregnancy may also develop autism.

External Environment

Exposure of pregnant mother to pesticides develops autism.Exposure to mercury & the way may be through cosmetic. Many studies have presented evidence for and against association with infection after birth. Lack of early childhood exposure to microbes or parasites contributes to autism. Lead poisoning has been suggested has possible risk factor for autism as lead blood levels of autistic children have been reported significantly higher than typical.

Vaccine

The scientific consensus is that there is no evidenceof a causal relationship between vaccinations and autism. Despitethis, many parents believe that vaccinations cause autism and therefore delay or avoid immunizing their children under the "vaccine overload" hypothesis that giving many vaccines at once may overwhelm a child's immune system and lead to autism. Even though this hypothesis has no scientific evidence and is biologically implausible. As diseases like measles can cause severe disabilities and death, the risk of a child's death or disability due to not vaccinating a child is significantly largerthan any minute risks due to vaccinating.

Thiomersal

Perhaps the best-known hypothesis involving mercury andautism involves the use of the mercury-based compound Thiomersal.A preservative that has been phased out from most childhood

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vaccinations in developed countries such as USA. Parents may first become aware of autistic symptoms in their child around thetime of a routine vaccination. There is no scientific evidence for a causal connection between Thiomersal and autism, but parental concern about the Thiomersal controversy has led to decreasing rates of childhood immunizations and increasing likelihood of disease outbreaks. Because of public concerns, Thiomersal content was completely removed or dramatically reducedfrom childhood vaccines that contained it in the 1990s; despite this, autism rates continued to climb well into the late 2000s.

Lack of Vitamin D

This theory hypothesizes that autism is caused by vitamin D deficiency, and that recent increases in diagnosed cases of autism are due to medical advice to avoid the sun. The theory has not been studied scientifically.

Premature Birth

In a 2008 study released by the American Academy of

Pediatrics, researchers found that low birth weight and preterm

birth (earlier than 33 weeks gestation) were linked to a doubled

risk for autism, with the chances of developing ASD somewhat

higher for infant girls than boys. However, the study found that

the increased risk for autism was also connected to an increased

risk for other developmental disabilities, such as mental

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retardation. According to the study, low birth weight and early

gestational age did not increase the risk for autism alone.

Autism affects children of all races and nationalities, but certain factors increase a child's risk. They include:

Child`s sex: Boys are three to four times more likely to develop autism than girls are.

Family history: - Families who have one child with autism have an increased risk of having another child with the disorder. It'salso not uncommon for the parents or relatives of an autistic child to have minor problems with social or communication skills themselves or to engage in certain autistic behaviors.

Other disorders: - Children with certain medical conditions have a higher than normal risk of having autism. These conditions include fragile X syndrome, an inherited disorder that causes intellectual problems; tuberous sclerosis, a condition in which benevolent tumors develop in the brain; the neurological disorderTourette syndrome; and epilepsy, which causes seizures.

Parents' ages: - Having an older father (being 40 or older) may increase a child's risk of autism. There may also be a connectionbetween children being born to older mothers and autism, but moreresearch is necessary.

SIGNS AND SYMPTOMS

Following are the signs and symptoms of autism:

Impairment in social interaction:

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Doesn’t know how to connect with others, make friends, and play with other people or share interest and enjoyment.

Little or no eye contact. Prefers to be alone; aloof manner. Gives little or no smiling.

Doesn’t respond when called, sometimes appears to be deaf.

Has flat or uses facial expressions that don't match what heor she is saying.

Sometimes doesn’t like to be hugged, held, cuddled or even touched.

Has trouble understanding other people`s feelings.

Doesn’t imitate your movements and facial expressions.

Doesn’t make noises to get your attention.

Doesn’t ask for help or make other basic requests.

Impairment in communication skills:

Delayed speech and language skills.

Communicates with gestures instead of words.

Does not refer to self correctly (for example, says "you want water" when the child means "I want water").

Gives unrelated answers to questions or responds to a question by repeating it, rather than answering it.

Speaks in an abnormal tone of voice (talks in a flat, robot-like, or sing-song voice) or with an odd rhythm or pitch (e.g. ends every sentence as if asking a question).

Repeats the same words or phrases over and over. Doesn't point or wave goodbye.

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Has difficulty communicating needs or desires. Instead indicates needs by leading adults by the hand.

Behavior:

Has difficulty adapting to any changes in schedule or environment (e.g. throws a tantrum if the furniture is rearranged or bedtime is at a different time than usual).

Gets stuck on a single topic or task (perseveration). Has short attention span. Spends long periods of time watching moving objects such as

a ceiling fan, or focusing on one specific part of an objectsuch as the wheels of a toy car.

Shows extreme restlessness, hyperactivity or extreme passivity.

Follows a rigid routine and insists on sameness (e.g. insists on taking a specific route to school).

Repeats the same actions or movements over and over again, such as flapping hands, rocking, or twirling (known as self-stimulatory behavior).

Shows inappropriate response or no response to loud sounds. Has apparent insensitivity to pain. Rubs surfaces, mouths or licks objects.

ASSESSMENT & DIAGNOSIS

Autism is a complex developmental disorder that affects the brain’s normal development. The cause of autism is unknown and diagnosis relies upon matching the child’s behavior patterns and development with the diagnostic criteria. Autism

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usually emerges in early infancy, and the diagnosis of autism canbe reliably made from two years of age.

In 1980, the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-III) introduced the diagnostic term: Pervasive Developmental Disorder (PDD) to cover a group of disorders of development including autism which presented with abnormalities and impaired functioning across the social, cognitive, emotional and language domains. These impairments were present from the first few years of life.

ASSESSMENT

Diagnosis requires a comprehensive, multi-disciplinary assessment comprising at least: (a) Developmental and family history (b) Observation of the child’s behavior and interaction with others (c) A medical assessment including tests for known causes of developmental delay (e.g. chromosome analysis) and hearing tests (d) A cognitive assessment using appropriate tests such as: Psycho educational Profile-Revised (PEP-R), Wechsler Pre-school and Primary Scale of Intelligence-Revised (WPPSI-R) (Wechsler, 1989) (d) Structured language assessment (e) Structured assessment tools such as the Autism Diagnostic Instrument (ADI) and the Autism Diagnostic Observational Scales (ADOS), clinician completed rating scales e.g. the Childhood Autism Rating Scale (CARS), and parent or teacher completed checklists such as the Developmental Behavior Checklist (DBC) (f)Comprehensive and sensitive feedback to the parents and caregivers about the diagnosis as the first step in developing a plan of intervention and services required.

DSM IV-TR DIAGNOSTIC CRITERIA FOR AUTISTIC DISORDER

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A diagnosis of autistic disorder is made when the following criteria from A, B, and C are all met.

A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):

1. Qualitative impairment in social interaction, as manifested byat least two of the following:

Marked impairment in the use of multiple nonverbal behaviorssuch as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction

Failure to develop peer relationships appropriate to developmental level

A lack of spontaneous seeking to share enjoyment, interests,or achievements with others (e.g., by a lack of showing, bringing, or pointing out objects of interest)

Lack of social or emotional reciprocity

2. Qualitative impairments in communication as manifested by at least one of the following:

Delay in or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)

In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others

Stereotyped and repetitive use of language or idiosyncratic language

Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

3. Restricted, repetitive, and stereotyped patterns of behavior, interest, and activities, as manifested by at least one of the following:

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Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus

Apparently inflexible adherence to specific, nonfunctional routines or rituals

Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)

Persistent preoccupation with parts of objects

TREATMENT AND RESILIENCE FACTORS

Autism is not curable but treatable. An early, intensive appropriate treatment program will greatly improve the outlook for most young children with autism. Treatment is most successfulwhen it is geared toward child’s particular needs. A variety of therapies are available, including:

Applied behavior analysis (ABA)

Medications

Sensory integration therapy

Speech and language therapy

PECS

DIET

Applied behavior analysis (ABA)

The Applied Behavior Analysis (ABA) approach teaches social, motor, and verbal behaviors as well as reasoning skills (e.g., sitting, attending, imitating, direction following, language, social skills, self-help skills). ABA uses one-on-one teaching approach that reinforces the practices of various

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skills. This program is done at child’s home under the supervision of a behavioral psychologist.

Medications

Medicines are often to treat behavior or emotional problems that people with autism may have, including:

Aggression

Anxiety

Attention problem

Hyperactivity

Sleep difficulty

Sensory integration therapy

Sensory integration: Neurological process that organizes sensation from one's own body and the environment. Sensory integration makes it possible to use the body effectively within the environment. Children with autism are believed to have difficulties integrating sensory information.

The aim of this therapy is to improve the ability ofthe brain to process sensory information so that the child will function better in his daily activities. They perform such activities include:

Swinging in a hammock (movement through space);

Dancing to music (sound);

Playing in boxes filled with beans (touch);

Drawling through tunnels (touch and movement through space);

Hitting swinging balls (eye-hand coordination);

Spinning on a chair (balance and vision).

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Speech and Language Therapy

The goal of speech therapy is to improve all aspectsof communication. This includes: comprehension, expression, soundproduction, and social use of language.. Speech therapy may include sign language and the use of picture symbols . At its best, a specific speech therapy program is modified to the specific weaknesses and the environment of the individual child. Speech therapy sessions will vary greatly depending upon the child. If the child is younger than three years old, then the speech therapist will most likely come into the home for a one-hour session. If the child is older than three, then therapy sessions will occur at school or in the therapist’s office. If the child is school age, expect that speech therapy will include one-on-one time with the child, classroom-based activities, and consultations between the speech therapist and teachers and parents.

The sessions should be designed to engage the child in communication. The therapist will engage the child using games and toys chosen specifically for the child. Several different speech therapy techniques and approaches can be used in a single session or throughout many sessions.

Picture exchange communication system (PECS)

PECS uses pictures instead of words to help children tocommunicate. That can help with the development of language skills as it encourages active communication.

When first learning to use PECS, the child is given a set of pictures of favorite foods or toys. When the child wants one of these items, he gives the picture to a communication partner (a parent, therapist, caregiver, or even another child).

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The communication partner then hands the child the food or toy. This exchange reinforces communication.

PECS can also be used to make comments about things seenor heard in the environment. For example, a child might see an airplane overhead, and hand a picture of an airplane to his or her parent. As the child begins to understand the usefulness of communication, the hope is that he will then begin to use naturalspeech.

Family therapy

A variety of approaches to addressing autism feature family involvement. “Floor play”, which may improve social and emotion-regulation skills, involves intensive parent-child play. Collaborative Problem Solving, which aims to increase the abilityof children to manage and think more flexibly, as well as Functional Behavioral Analysis, which focuses on improving behaviors, both involves parent-child interaction. Beyond specific approaches, research and experience have shown that parents can take a number of steps to enhance their children’s development, including focusing on strengths, maintaining consistent routines, encouraging play dates, and utilizing “social stories” to enhance social functioning.

Successful family therapy can generate “positive cycles” that canbenefit all family members. Families can develop more cohesive, orderly, and supportive environments, and become better able to access effective treatment. Autistic children become better equipped to develop themselves socially, emotionally, and academically. As the strengths of autistic children begin to shine through, the positive impact on the whole family creates aneven more nurturing and positive environment for growth and development

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Dietry modifications for autism- The Gluten-free/Casein-free Diet (GfCf)

GfCf diet is found to be helpful in eliminating many ASD behaviors and digestive problems. Requires elimination of wheat, dairy, soy, and often many other foods. Often requires lifestyle change for whole family. Expensive foods are hard to find in someareas. Much of what the diet does can also be accomplished using appropriate enzymes.

DESCRIPTION OF SCALES

Childhood Autism Rating Scale (CARS) is a behavior rating scale intended to help diagnose autism. CARS was developed by Eric Schopler, Robert J. Reichier, and Barbara Rochen Renner. CARS wasdesigned to help differentiate children with autism from those with other developmental delays, such as mental retardation.

CARS is a diagnostic assessment method that rates children on a scale from one to four for various criteria, ranging from normal to severe, and yields a composite score ranging from non-autisticto mildly autistic, moderately autistic, or severely autistic. The scale is used to observe and subjectively rate fifteen items:relationship to people, imitation, emotional response, body, object use, adaptation to change, visual response, listening response, taste-smell-touch response and use, ear and nervousness, verbal communication, non-verbal communication, activity level, level and consistency of intellectual response, general impressions.

Total CARS scores range from a fifteen to 60, with a minimum score of thirty serving as the cutoff for a diagnosis of autism on the mild end of the autism spectrum. It has test retest reliability of .87.

DYSLEXIA

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The word dyslexia has been derived from the Greek morphemes “dys”

and “lex” meaning “difficulty with language” or “difficulty with

words.”

“Dyslexia is a neurological based, often familial disorder which

interferes with the acquisition of language. It is manifested by

difficulties in receptive and expressive language, including

phonological processing, in reading writing, spelling handwriting

and sometimes in arithmetic.”

Dyslexia has been around for a long time and has been defined in

different ways. For example, in 1968, the World Federation of

Neurologists defined dyslexia as "a disorder in children who,

despite conventional classroom experience, fail to attain the

language skills of reading, writing, and spelling commensurate

with their intellectual abilities.”The severity of dyslexia can

vary from mild to severe. National Institutes of Health report

that 60- 80% of those with learning disabilities have problems

with reading and language skills.

SIGNS AND SYMPTOMS

Reading extremely slowly and inaccurately are the most obvious

signs of this disorder. In young children, the following may also

be symptoms:

Not recognizing words that rhyme

Putting letters of a word in a different order

Making mistakes when reading out loud

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Struggling with long reading sessions

Having illegible handwriting

Making spelling mistakes

Difficulty learning a new language

Inability to separate sounds in a word when speaking

Skipping a word or line when reading

They also feel difficulty in:

pronouncing longer words

rhyming

learning the alphabet sequence, days of the week, colors,

shapes, and numbers

learning letter names and sounds

learning to read and write his or her name

learning to identify syllables (cow-boy in cowboy) and

speech sounds (phonemes: b-a-t in bat) in words

sounding out simple words

reading and spelling words with the correct letter sequence

("top" versus "pot")

handwriting and fine-motor coordination

TYPES OF DYSLEXIAThere are several types of dyslexia that can affect the child's

ability to spell as well as read.

Primary Dyslexia

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"Primary Dyslexia" is a genetic form. It is the most common form

of Dyslexia. Dyslexics in this group typically experience

problems with letter and number identification, spelling,

reading, arithmetic, measurement, time, instructions and other

skill sets that are normally performed by the left hemisphere.

These Dyslexics are right brain dominant thinkers.

Right brain thinkers however respond well to learning with the

"big picture" or overview of everything, whole images of words

rather than phonics and relating all learning to real things or

concepts. They see the "forest before the trees". In other words,

they have to see the conclusion of anything before they can see

the parts, sequences or meaning of a subject. The problem for

these Dyslexics is that general teaching methods in many schools

worldwide are organized primarily for the left brain student.

Secondary Dyslexia

Developmental Dyslexia or Secondary Dyslexia is caused by

problems with brain development in a fetus that causes impaired

neurological abilities in word recognition and spelling. The

difficulties and severity of this condition generally improves

with age. The child may experience Dyslexic symptoms throughout

childhood but can perform well in college if they receive proper

instruction. These children generally respond well to phonics.

Trauma Dyslexia

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"Trauma Dyslexia" is caused by a serious illness or brain injury.

Dyslexic symptoms can develop due to damage to the hearing from

continuous flu, cold or ear infections in young children, the

child cannot hear sounds in words or "phonemes" so they have a

difficult time with sounding words out, spelling and learning to

read. Older children or adults develop "Trauma Dyslexia" from a

brain disease or illness that affects their ability to comprehend

language. These people usually can read, spell and write prior to

the trauma.

Dyslexia may affect several different functions. Visual dyslexia

is characterized by number and letter reversals and the inability

to write symbols in the correct sequence. Auditory dyslexia

involves difficulty with sounds of letters or groups of letters.

DSM-IV-TR DIAGNOSTIC CRITERIA FOR DYSLEXIA

The diagnostic criteria for Dyslexia, according to the DSM -IV-TRare as follows:

1. Reading achievement, as measured by individually

administered standardized tests of reading accuracy or

comprehension, is substantially below that expected given

the person's chronological age, measured intelligence, and

age-appropriate education.

2. The disturbance in Criterion A significantly interferes with

academic achievement or activities of daily living that

require reading skills.

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3. If a sensory deficit is present, the reading difficulties

are in excess of those usually associated with it.

Coding note: if a general medical (e.g., neurological)

condition or sensory deficit is present, code the condition on

axis iii.

CAUSES AND RISK FACTORS

There are numerous theories regarding the etiology of dyslexia,

including those implicating deficits in the temporal processing

of auditory and visual stimuli and those that hypothesize

language-specific impairments. The latter category posits that at

a cognitive-linguistic level, dyslexia reflects deficits within a

specific component of the language system, the phonologic module,

which is engaged in processing the sounds of speech. As predicted

by this model, dyslexic persons have difficulty developing an

awareness that words, both spoken and written, can be segmented

into smaller elemental units of sound (phonemes)—an essential

ability given that reading an alphabetic language (English)

requires that the reader map or link printed symbols to sound.

The linguistic abilities related to learning to read involve

phonology, and deficits in phonologic awareness are a strong

predictor of dyslexia. There is some evidence that other

cognitive processes are involved in reading, including

attentional mechanisms, the disruption of which can play a causal

role in reading difficulties.

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Dyslexia is both familial and heritable. Family history is one of

the most important risk factors; approximately 50% of children

who have a parent with dyslexia, 50% of the siblings of dyslexic

persons, and 50% of the parents of dyslexics may have the

disorder. Dyslexia reflects a multifactorial model of the

interaction between genetic and environmental factors. Multiple

genes can influence the disorder, with each gene individually

contributing a small amount of variance and with a single

etiologic factor insufficient to cause or explain dyslexia. The

neural systems are the final common pathway for multiple

influences, and it is unlikely that a single gene or even several

genes cause or explain dyslexia.

Dyslexia is up to four times more likely in boys than girls.

Other groups at risk include:

people with limited vocabulary

children with parents who have reading problems

learners with hearing or speech problems

individuals who have memory issues

History of language delay

History of not attending to the sounds of words

(trouble playing rhyming games with words, or

confusing words that sound alike)

Family history of specific reading difficulty

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ASSESSMENT OF DYSLEXIA

The most important reason for assessing dyslexia is for

effective educational treatment not a label.There is no one

single test which can identify dyslexia, the assessor must have a

strong knowledge of language and reading development, how

dyslexia affects learning in these areas and the required

pedagogy. They must be knowledgeable in current diagnostic test

selection and how to evaluate the results for educational

instruction. Tests used to identify dyslexia:

Wechsler Intelligence Scale for Children-Third Edition

(WISC-III)

Kaufman Assessment Battery for Children (KABC)

Stanford-Binet Intelligence Scale

Bender Gestalt Test of Visual Motor Perception

Test of Auditory Perception (TAPS)

Expressive One-Word Picture Vocabulary Test

Test for Auditory Comprehension of Language

COMORBIDITIES OF DYSLEXIA

Several learning disabilities often occur with dyslexia which

includes

Dysgraphia: A disorder which expresses itself primarily

through writing or typing. In dyslexia, dysgraphia is often

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multi factorial, due to impaired letter writing automaticity

and impaired visual word form.

Dyscalculia: A neurological condition characterized by

difficulty in retrieving rote math facts.

ADHD: A high degree of co-morbidity has been reported

between ADD / ADHD and dyslexia/reading disorders.

TREATMENT AND RESILIENCE FACTORS

While there is currently no cure for dyslexia, there is a range

of specialist interventions and treatments that can help children

with dyslexia with their reading and writing. The amount and type

of intervention necessary will depend on the severity of their

condition.

Educational intervention 

Research has found that early educational interventions, ideally

before a child reaches seven or eight years old, are effective in

achieving long-term improvements in their reading and writing.

There is a large body of good quality evidence that interventions

that focus on improving phonological skills (the ability to

identify and process sounds) are the most effective way of

improving reading and writing. These types of educational

interventions are often referred to as phonics. Phonics is a

system widely used to teach all children to read and write, not

just those with dyslexia.

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Phonics – core elements

Phonics focuses on six core elements:

phonemic awareness

phonics instruction

spelling and writing instruction

fluency instruction

vocabulary instruction

comprehension instruction

These are explained in more detail below.

Phonemic awareness 

Phonemic awareness teaches children how to recognise and identify

phonemes (sounds) in spoken words. For example, it helps a child

to recognise that even very short words, such as "hat" are

actually made up of three phonemes "h", "a", and "t".

Phonics instruction

Phonics instruction teaches children how to sound out printed

words by recognising the written letters that correspond to

spoken phonemes. Phonics also teaches children how to decode

multisyllabic words, such as "crocodile" and apply previous

learned rules so they have a better understanding of new words.

Spelling and writing instruction

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Spelling and writing instruction encourages children to combine

letters and graphemes in order to create words and then, over

time, to use the words to create more complex sentences.

Fluency instruction

Fluency instruction provides children with practice in reading

words accurately. The goal is for a child to be able to read with

a good level of accuracy and speed.

Vocabulary instruction

Vocabulary instruction teaches children to recognise words they

are reading while building and understanding new words.

Comprehension instruction

Comprehension instruction teaches children to monitor their own

understanding while they read. They are encouraged to ask

questions if they notice gaps in their understanding, while also

linking what they are reading to information they have previously

learned.

Phonics – important features

There is also good quality evidence to indicate the most

effective methods of teaching phonics to children with dyslexia

contain these important features:

Structure

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Teaching needs to be highly structured, with development in small

steps, building logically on what has been learnt before.

Multi sensory

Children with dyslexia learn better when they use as many

different senses as possible. An example of multisensory teaching

is where a child is taught to see the letter "a", say its name

and sound, and write it in the air (all at the same time)

Reinforcement

Skills should be reinforced through regular practice because

children with dyslexia often have to "overlearn" skills already

mastered. This helps to improve their automatic recognition

of correct phonemes, letters and rules in reading and writing.

Skill teaching

Early interventions in children with dyslexia should focus on

development of useful skills that can be transferred to other

areas. Trying to teach children to learn and retain big chunks of

information could place unnecessary pressure on their memory.

Breaking down emotional barriers

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Another important feature of any educational intervention is to

recognise that many children with dyslexia can develop emotional

barriers that can make learning more difficult, such as:

anxiety

frustration

low confidence

Therefore, it is important to break down these barriers through

encouragement, empathy and fostering the child’s self-esteem.

Older children

Many older children with dyslexia feel more comfortable working

with a computer than an exercise book. This may be because a

computer uses a visual environment which corresponds more closely

to their method of thinking.Word processing programmes can also

be useful because they have a spellchecker, and an auto-correct

facility that can help to highlight mistakes in your child’s

writing.

Most web browsers and word processing software also have "text-

to-speech" functions, or available "plug-ins", where the computer

reads the text as it appears on the screen.Speech recognition

software can also be used to translate what a person is saying

into written text. This type of software can be useful for

children with dyslexia because their language abilities are often

better than their writing skills. The software can take a

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considerable amount of time and effort to use before it can be

used with speed, but some children may find the

effort worthwhile. There are also many educational interactive

software applications which may provide your child with a more

engaging way of learning a subject, rather than simply reading

from a textbook.

Multiple approaches.

The best way to learn something is to use a multi-sensory

approach. For example, using a digital recorder to record a

lecture, and then listen to it as you read your notes. It is also

recommended to break large tasks and activities down into smaller

steps.

Examples of reasonable adjustments include:

providing with assistance technology, such as voice-

recognition software

allowing extra time for difficult tasks

 information in accessible formats 

Teachers may use techniques involving hearing, vision and touch

to improve reading skills. Helping a child use several senses to

learn for example, by listening to a taped lesson and tracing

with a finger the shape of the letters used and the words spoken

can help him or her process the information.

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If child has a severe reading disability, tutoring may need to

occur more frequently, and progress may be slower. A child with

severe dyslexia may never be able to read well. However, academic

problems don't necessarily mean a person with dyslexia will be

unable to succeed. Students with dyslexia can be highly capable,

given the right resources. Many people with dyslexia are creative

and bright, and may be gifted in mathematics, science or the

arts. Some even have successful writing careers.

DESCRIPTION OF SCALES

Dyslexia Screening Instrument (DSI)

Kathryn B. Coon, MA, Mary Jo Polk, Melissa McCoy Waguespack

(1994) was made to identify dyslexia features. Age Range is of

childrenof 6:0-21:0 years old; Grades 1-12Consists of 33

statements to be rated by the classroom teacher using a five-

point scale.The teacher uses a single tear-off sheet from the

Record Form to rate the student’s behavior on each statement.Use

the scoring program software to quickly obtain results.

Classifications are based on classroom teachers’ observations and

ratings so you receive an “in the moment” view of the student’s

skills. It is ideal for use with assessment of cognitive

abilities and academic skills to determine where academic

difficulties might be occurring. Internal consistency reliability

coefficients for elementary (.99) and secondary (.98) students

are very high. Inter-rater reliability is also high for both

groups (100% and 97% agreement on classification category,

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respectively). Diagnostic accuracy rating for all students was

above 98% accurate.

ATTENTION DEFICIT HYPERACTIVITY DISORDER   (ADHD)

DEFINITION Similar to hyperkinetic disorder in the ICD-10, it is a psychiatric disorder of the neurodevelopmental type in which there are significant problems of attention and/or hyperactivity and acting impulsively that arenotappropriate for a person's age. These symptoms must begin by age six to twelve and be present for more than six months for a diagnosis to be made. In school-aged individuals the lack of focus may result in poor school performance.

SIGNS AND SYMPTOMSAn individual with inattentive concentration may have some or allof the following symptoms:

Be easily distracted, miss details, forget things, and frequently switch from one activity to another

Have difficulty maintaining focus on one task Become bored with a task after only a few minutes, unless

doing something enjoyable Have difficulty focusing attention on organizing and

completing a task or learning something new Have trouble completing or turning in homework assignments,

often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities

Not seem to listen when spoken to Daydream, become easily confused, and move slowly Have difficulty processing information as quickly and

accurately as others

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Struggle to follow instructionsAn individual with hyperactivity may have some or all of the following symptoms

Fidget and squirm in their seats Talk nonstop Dash around, touching or playing with anything and

everything in sight Have trouble sitting still during dinner, school, doing

homework, and story time Be constantly in motion Have difficulty doing quiet tasks or activities

An individual with impulsivity may have some or all of the following symptoms:

Be very impatient Blurt out inappropriate comments, show their emotions

without restraint, and act without regard for consequences

Have difficulty waiting for things they want or waiting their turns in games

Often interrupts conversations or others' activitiesDifficulties managing anger are more common in children with ADHDas are poor handwriting and delays in speech, language and motor development. Although it causes significant impairment, particularly in modern society, many children with ADHD have a good attention span for tasks they find interesting.

People with ADHD more often have difficulties with social skills,such as social interaction and forming and maintaining friendships. About half of children and adolescents with ADHD experience rejection by their peers compared to 10–15 percent of non-ADHD children and adolescents. People with ADHD may have difficulty processing verbal and nonverbal language which can

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negatively affect social interaction. They also may drift off during conversations and miss social cues.

TYPES OF ADHDADHD has three subtypes mentioned below.

Predominantly hyperactive-impulsiveo Most symptoms (six or more) are in the hyperactivity-

impulsivity categories.o Fewer than six symptoms of inattention are present,

although inattention may still be present to some degree. Predominantly inattentive

o The majority of symptoms (six or more) are in the inattention category and fewer than six symptoms of hyperactivity-impulsivity are present, although hyperactivity-impulsivity may still be present to some degree.

o Children with this subtype are less likely to act out or have difficulties getting along with other children. Theymay sit quietly, but they are not paying attention to what they are doing. Therefore, the child may be overlooked, and parents and teachers may not notice that he or she has ADHD.

Combined hyperactive-impulsive and inattentiveo Six or more symptoms of inattention and six or more

symptoms of hyperactivity-impulsivity are present.o Most children have the combined type of ADHD.

ASSOCIATED DISORDERS WITH ADHD In children ADHD occurs with other disorders about 2/3 of the time. Some of the commonly associated conditions include:

Learning disabilities have been found to occur in about 20%-30% of children with ADHD. Learning disabilities can include developmental speech and language disorders and academic skills disorders. ADHD, however, is not considered a learning

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disability but it can still signifcantly impact academic performance.

Tourette syndrome has been found to occur more commonly in theADHD population. This rare neurological disorder is characterized by nervous tics and repetitive mannerisms, such as eye blinks, facial twitches, or grimacing. Other characteristics include clearing of the throat, snorting, or sniffing frequently, or bark out words inappropriately. 

Oppositional defiant disorder (ODD) and conduct disorder (CD),which occur with ADHD in about 50% and 20% of cases respectively. They are characterized by antisocial behaviors such as stubbornness, aggression, frequent temper tantrums, deceitfulness, lying, and stealing. About half of those with hyperactivity and ODD or CD develop antisocial personality disorder in adulthood

Primary disorder of vigilance, which is characterized by poor attention and concentration, as well as difficulties staying awake. These children tend to fidget, yawn and stretch and appear to be hyperactive in order to remain alert and active.

Mood disorders (especially bipolar disorder and major depressive disorder). Boys diagnosed with the combined ADHD subtype are more likely to have a mood disorder. 

Anxiety disorders have been found to occur more commonly in the ADHD population.

Obsessive-compulsive disorder (OCD) can co-occur with ADHD andshares many of its characteristics.

Substance use disorders. Adolescents and adults with ADHD are at increased risk of developing a substance use problem, most commonly with alcohol or cannabis. The reason for this may be due to an altered reward pathway in the brains of ADHD individuals. This makes the evaluation and treatment of ADHD more difficult.

Restless legs syndrome has been found to be more common in those with ADHD and is often due to iron deficiency anaemia.

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Sleep disorders and ADHD commonly co-exist., insomnia is the most common sleep disorder with behavioral therapy the preferred treatment.

DSM-IV-TR CRITERIA OF ADHDDiagnostic criteria for Attention-Deficit/Hyperactivity Disorder A. Either (1) or (2): (1) Inattention: six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree thatis maladaptive and inconsistentwith developmental level:

(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities (b) often has difficulty sustaining attention in tasks or play activities (c) often does not seem to listen when spoken to directly (d) often does not follow through on instructions and fails to finish school work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) (e) often has difficulty organizing tasks and activities (f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolworkor homework) (g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) (h) isoften easily distracted by extraneous stimuli (i) isoften forgetful in daily activities

(2) hyperactivity-impulsivity: six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least6 months to a degree that is maladaptive and inconsistent with developmental level.

Hyperactivity

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(a) often fidgets with hands or feet or squirms in seat (b) oftenleaves seat in classroom or in other situations in which remaining seated is expected (c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) (d) often has difficulty playing or engaging in leisure activities quietly (e) is often "on the go" or often acts as if "driven by a motor" (f) often talks excessively

Impulsivity

(g) often blurts out answers before questions have been completed(h) often has difficulty awaiting turn (i) often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that causedimpairment were present before age 7 years. C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home). D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorders or a Personality Disorder).

CODES FOR DISORDERS

314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type:ifboth Criteria A1 and A2 are met for the past 6 months .314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months

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314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the past 6 months For individuals (especially adolescents and adults) who currentlyhave symptoms that no longer meet full criteria, "In Partial Remission" should be specified.

CAUSES AND RISK FACTORS

BRAIN STRUCTURE

The pathophysiology of ADHD is unclear with there being a number of competing explanations.In children with ADHD there is a general reduction of brain volume, with a proportionally greater decrease in the volume in the left-sided prefrontal cortex. This suggests that inattention, hyperactivity, and impulsivity may reflect frontal lobe dysfunction. Other brain systems related to attention have also been found to differ between people with and without ADHD.

NEUROTRANSMITTERS

Previously it was thought that the elevated number of dopamine transporters in people with ADHD was part of the pathophysiology but it appears that the elevated numbers are due to adaptation toexposure to stimulants.People with ADHD may have a low arousal threshold and compensate for this with increased stimuli,which in turn results in disruption of attention and increases hyperactive behavior..There may additionally be abnormalities in the adrenergic, serotoninergic andcholinergic or nicotinergic pathways.

EXECUTIVE FUNCTIONOne theory of suggests that the symptoms arise from a difficulty in executive functions.Executive functions refers to a number ofmental processes that are required to regulate, control, and

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manage daily life tasks. Some of these impairments include: problems with organizational skills, time keeping, excessive procrastination, concentration problems, processing speed, regulating emotions, using working memory and short-term memory problems. The cause of most cases of ADHD is unknown; however, it is believed to involve interactions between genetic and environmental factors. Certain cases are related to previous infection of or trauma to the brain

GENETICS

Twin studies indicate that the disorder is often inherited from one's parents with genetics determining about 75% of casesGeneticfactors are also believed to be involved in determining whether or not ADHD persists into adulthood.Typically a number of genes are involved, many of which affect dopamine transporters.

DAT1, DRD4,DRD5, 5HTT, HTR1B, SNAP25, ADRA2A, TPH2, MAOA, and dopamine beta hydroxylase are included in this list..A commonvariant of a gene called LPHN3 is estimated to be responsible forabout 9% of cases and when this gene is present people are particularly responsive to stimulant medication.Natural selection may have favored the traits of ADHD as, some women may be more attracted to males who are risk takers, increasing the frequency of genes that predispose to ADHD in the gene pool.As itis more common in children of anxious or stressed mothers, some argue that ADHD is an adaptation that helps children face a stressful or dangerous environment with, for example, increased impulsivity and exploratory behavior.Hyperactivity might have been beneficial, from an evolutionary perspective, in situations involving risk, competition, or unpredictable behavior (i.e. exploring new areas or finding new food sources)

ENVOIRNMENT

Environmental factors are believed to play a lesser role. Alcoholintake during pregnancy can cause fetal alcohol spectrum disorderwhich can include symptoms similar to ADHD.Exposure to

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tobacco smoke during pregnancy can cause problems with central nervous system development and can increase the risk of ADHD.Manychildren exposed to tobacco do not develop ADHD or only have mildsymptoms which do not reach the threshold for a diagnosis. A combination of a genetic predisposition with tobacco exposure mayexplain why some children exposed during pregnancy may develop ADHD and others do not. Children exposed to lead, even low levels, or polychlorinated biphenyls may develop problems which resemble ADHD and fulfill the diagnosis.  Very low birth weight, premature birth and early adversity also increase the risk as do infections during pregnancy, at birth, and in early childhood. These infections include among others: various viruses(measles, varicella, rubella, enterovirus 71) and streptococcalbacterial infection. At least 30 percent of children with a traumatic brain injury latter develop ADHD and about 5 percent of cases are due to brain damage.

A small number of children may react negatively to food dyes or preservatives.  Dietary sugar and the artificial sweetener aspartame appears to have little to no effect; except, possibly in children less than six years of age were sugar may increase inattention.

SOCIETYThe diagnosis of ADHD can represent family dysfunction or a poor educational system rather than an individual problem. Some cases may be explained by increasing academic expectations; with a diagnosis being a method for parents in some countries to get extra financial and educational support for their child.  The youngest children in a class have been found to be more likely tobe diagnosed as having ADHD possibly due to their being developmentally behind their older classmates. Behavior typical of ADHD occurs more commonly in children who have experienced violence and emotional abuse.

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TREATMENTS AND RESILIENCE FACTORS

MedicinesAmphetamine, methylphenidate (long acting) methamphetamine hydrochlorideDextroamphetamine methylphenidate atomoxetine and lisdexamfetamine dimesylate is used as medications for ADHD.

Psychotherapy

Different types of psychotherapy are used for ADHD. Behavioral therapy aims to help a child change his or her behavior. It mightinvolve practical assistance, such as help organizing tasks or completing schoolwork, or working through emotionally difficult events. Behavioral therapy also teaches a child how to monitor his or her own behavior. Learning to give oneself praise or rewards for acting in a desired way, such as controlling anger orthinking before acting, is another goal of behavioral therapy. Parents and teachers also can give positive or negative feedback for certain behaviors. In addition, clear rules, chore lists, andother structured routines can help a child control his or her behavior. Therapists may.

Children with ADHD often benefit from behavior therapy and counseling, which may be provided by a psychiatrist, psychologist, social worker or other mental health care professional. Some children with ADHD may also have other conditions such as anxiety disorder or depression. In these cases, counseling may help both ADHD and the coexisting problem.

As well as taking medication, different therapies can be useful in treating ADHD in children, teenagers and adults. Therapy is also effective in treating additional problems, such as conduct or anxiety disorders, that may appear with ADHD.

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Therapies outlined below can be carried out with the help of a number of healthcare professionals, including:

counsellors – experts trained to provide talking therapies that aim to help people cope better with their life and mental health condition

psychiatrists – qualified medical doctors who have done further training in treating mental health conditions

psychologists – healthcare professionals who specialise in the assessment and treatment of mental health conditions

social workers – experts often used to bridge the gap between mental health services and the wider social service provision, and provide advice on a variety of practical issues

Talking therapy

Psychotherapy is a type of talking therapy, which means you or your child will be encouraged to discuss ADHD and how it affects you. It can help children, teenagers and adults make sense of being diagnosed with ADHD, and can help you to cope and live withthe condition.

Behavior therapy

Behaviour therapy provides support for carers of children with ADHD, and may involve teachers as well as parents. Behaviour therapy usually involves behaviour management, which uses a system of rewards and penalties to encourage your child to try and control their ADHD.If a child has ADHD, we can identify typesof behaviour to be encouraged , such as sitting at the table toeat. Child is then given some sort of small reward for good behaviour, and a small penalty for poor behaviour. For teachers, behaviour management involves learning how to plan and structure activities, and to praise and encourage children for even very small amounts of progress.

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Behavior therapy involves reinforcing desired behaviors through rewards and praise and decreasing problem behaviors by setting limits and consequences. For example, one intervention might be that a teacher rewards a child who has ADHD for taking small steps toward raising a hand before talking in class, even if the child still blurts out a comment. The theory is that rewarding the struggle toward change encourages the full new behavior

Prent Training and Educational Programs

If your child has ADHD, parent training and education programmes can help you learn specific ways of talking to your child, and playing and working with them to improve their attention and behaviour. You may also be offered parent training before your child is officially diagnosed with ADHD.These programmes are usually arranged in groups and can last several weeks. They aim to teach parents and carers about behaviour management (see above), while increasing your confidence in your ability to look after your child and improving the relationship between you and your child.  A few suggestions are as follows.

Follow a routine. It is important to set a time and a place for everything to help a child with ADD/ADHD understand and meet expectations. Establish simple and predictable rituals for meals, homework, play, and bed.

Use clocks and timers. Consider placing clocks throughout the house, with a big one in your child’s bedroom. Allow plenty of time for what your child needs to do, such as homework or getting ready in the morning.

Simplify child’s schedule. Avoiding idle time is a good idea, but a child with ADD/ADHD may become even more distracted and “wound up” if there are too many after-schoolactivities.

Create a quiet place. Make sure your child has a quiet, private space of his or her own. A porch or bedroom can work

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well too—as long as it’s not the same place as the child goes for a time-out.

Set an example for good organization. Set up your home in anorganized way. Make sure your child knows that everything has its place. Role model neatness and organization as much as possible.

Ask about school programs. Take advantage of any special programs your school may have for children with ADHD. Schools are required by law to have a program to make sure children who have a disability that interferes with learningget the support they need.

Talk to your child's teachers. Stay in close communication with child's teachers, and support their efforts to help child in the classroom. Be sure teachers closely monitor child's work, provide positive feedback, and are flexible and patient. Ask that they be very clear about their instructions and expectations.

Ask about having child use a computer in the classroom. Children with ADHD may have trouble with handwriting and sometimes benefit from using a computer.

Social Skills T raining

Social skills training involves your child taking part in role-play situations, and aims to teach them how to behave in social situations by learning how their behaviour affects others. A social skills group teaches children how to “read” others’ reactions and how to behave more acceptably. The social skills group should also work on transferring these new skills to the real world. Teach children social skills, such as how to wait their turn, share toys, ask for help, or respond to teasing. Learning to read facial expressions and the tone of voice in others, and how to respond appropriately can also be part of social skills training.

Cognitive-Behavioral Therapy

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Cognitive behavioural therapy (CBT) is talking therapies that canhelp you manage your problems by changing the way you think and behave.A CBT therapist would try and change how your child feels about a situation, which would in turn potentially change their behaviour

Other methods of treatment

There are other ways of treating ADHD that some people with the condition find helpful, such as cutting out certain foods and taking supplements. However, there is no medical evidence these methods work, and they should not be attempted without medical advice.

Diet

People with ADHD should eat a healthy balanced diet. Do not cut out foods without medical advice.Some people may notice a link between types of food and worsening ADHD symptoms. For example, sugar and caffeine are often blamed for aggravating hyperactivity, and some people feel they have intolerances to wheat or dairy products that may add to their symptoms. If this is the case, keep a diary of what you eat and drink and what behaviour this causes. Discuss this with your GP, who may refer you to a dietitian (a healthcare professional who specialises in nutrition).

Supplements

Some people consider certain supplements, such as omega 3 fatty acid, to be beneficial in people with ADHD. However, there is no medical evidence to support this. If you do wish to try using a supplement, talk to your GP first, as some can react unpredictably with other medication or make it less effective. Also remember that supplements should not be taken long-term, as they can build up to dangerous levels in your body.

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Excercise

People with ADHD should take regular exercise. Read about health and fitness for more information on getting active, and how much activity you and your child should be doing.

DESCRIPTION OF SCALES

CONNERS’ TEACHER RATING SCALE

The CONNERS’ TEACHER RATING SCALE (CTRS; Conners, 1969, 1997a, 1997b) is a commonly used measure of behavioral problems associated with ADHD, which originally was developed as a measureof behavioral change for pharmacological studies (Conners, 1969).The primary version of the CTRS is a 59-item form (CTRS-R:L; Conners, 1997a) that is comprised of six scales (Oppositional, Cognitive Problems/Inattention, Hyperactivity, Anxious-Shy, Perfectionism, and Social Problems) as well as an ‘ADHD Index’ score, a ‘DSM-IV: Inattention’ score, and a ‘DSM-IV: Hyperactivity’ score.It has test retest reliability of .82.

The Vanderbilt Teacher Rating Scale of Autism

The Vanderbilt scales were developed by Mark L. Wolraich, MD and colleagues. Dr. Wolraich is currently the Shaun Walters Professorof Pediatrics at the University of Oklahoma Health Science Centerin Oklahoma City. It has 6 domains (a) Predominantly inattentive subtype (b) Predominantly hyperactive/ impulsive subtype (c) Combined subtype (d) Combined subtype (e) Oppositional-defiant disorder (f) Conduct disorder (g) Anxiety or depression. It has 49 items and it’s a likert-type rating scale. It has test retest reliability of .85.

CONDUCT DISORDER

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Conduct disorder is a childhood behavior disorder characterized

by aggressive and destructive activities that cause disruptions

in the child's natural environments such as home, school, church,

or the neighborhood. The overriding feature of conduct disorder

is the repetitive and persistent pattern of behaviors that

violate societal norms and the rights of other people. It is one

of the most prevalent categories of mental health problems of

children in the United States, with rates estimated at 9% for

males and 2% for females.

DESCRIPTION OF CONDUCT DISORDER AND LINK OF ODD WITH IT

The specific behaviors used to produce a diagnosis of conduct

disorder fall into four groups: aggressive conduct that causes or

threatens physical harm to other people or animals, nonaggressive

behavior that causes property loss or damage, deceitfulness or

theft, and serious violations of rules. Two subtypes of conduct

disorder can be delineated based on the age that symptoms first

appear. Childhood-onset type is appropriate for children showing

at least one of the behaviors in question before the age of 10.

Adolescent onset type is defined by the absence of any conduct

disorder criteria before the age of 10. Severity may be described

as mild, moderate or severe, depending on the number of problems

exhibited and their impact on other people. ODD stands for

Oppositional Defiant Disorder, which has onset earlier than

Conduct disorder. It is less in severity than CD. It is mostly

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focussed on oppsition to authority of parents, teachers and elder

siblings. When it gets worse, it turns into CD.

TYPES OF CONDUCT DISORDER

There are three types of conduct disorder. They are labeled

according to the age at which the symptoms first occur. The three

types of conduct disorder are:

childhood onset (signs of conduct disorder appear before 10

years old)

adolescent onset (signs of conduct disorder appear during

the teenage years)

unspecified onset (the age that conduct disorder first

occurs is unknown)

The codes are mentioned below.

312. Conduct Disorder

312.81 Childhood-Onset Type

312.82 Adolescent-Onset Type

312.89 Unspecified Onset

313.81 Oppositional Defiant Disorder

312.9 Disruptive Behavior Disorder(NOS)

Youngsters who show symptoms (most often aggression) before age

10 may also exhibit oppositional behavior and peer relationship

problems. When they also show persistent conduct disorder and

then develop adult antisocial personality disorder, they should

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be distinguished from individuals who had no symptoms of conduct

disorder before age 10. The childhood type is more highly

associated with heightened aggression, male gender, oppositional

defiant disorder, and a family history of antisocial behavior.

The individual behaviors that can be observed when conduct

disorder is diagnosed may be common, problematic, and chronic.

They tend to occur frequently and are distressingly consistent

across time, settings, and families. Not surprisingly, these

children function poorly in a variety of places. In fact, the

behaviors clustered within the term "conduct disorder" account

for a majority of clinical referrals, classroom detentions or

other sanctions, being asked to stop participating in numerous

activities, and can be extremely difficult (even impossible) for

parents to manage.

The negative consequences of conduct disorder, particularly

childhood onset, may include illicit drug use, dropping out of

school, violent behavior, severe family conflict, and frequent

delinquent acts. Such behaviors often result in the child's

eventual placement out of the home, in special education and/or

the juvenile justice system. There is evidence that the rates of

disruptive behavior disorders may be as high as 50% in youth in

public sectors of care such as juvenile justice, alcohol and

drugs. The overriding feature of conduct disorder is the

repetitive and persistent pattern of behaviors that violate

societal norms and the rights of other people. Youngsters with

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conduct disorder often exhibit aggressive behavior to other

people (bullying, starting fights, etc.) or to animals. They may

also damage others' property.

DSM CRITERIA FOR CONDUCT DISORDER

The Diagnostic and Statistical Manual of Mental Disorders (also

known as the DSM-IV-TR) indicates that for conduct disorder to be

diagnosed, the patient has following criteria.

A. A repetitive and persistent pattern of behavior in which

the basic rights of others or major age-appropriate

societal norms or rules are violated, as manifested by the

presence of three (or more) of the following criteria in

the past 12 months, with at least one criterion present in

the past 6 months:

Aggression to people or animals includes:

engaging in frequent bullying or threatening

often starting fights

using a weapon that could cause serious injury (gun, knife,

club, broken glass)

showing physical cruelty to people

showing physical cruelty to animals engaging in theft with confrontation (armed robbery,

extortion, mugging, purse snatching) forcing sex upon someone

Property destruction includes:

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deliberately setting fires to cause serious damage deliberately destroying the property of others by means

other than fire setting

Lying or theft includes:

breaking into building, car, or house belonging to someone else

frequently lying or breaking promises for gain or to avoid obligations (called "conning")

stealing valuables without confrontation (burglary, forgery,shop lifting)

Serious rule violations include:

beginning before age 13, frequently staying out at night against parents' wishes

running away from parents overnight twice or more or once iffor an extended period

engaging in frequent truancy beginning before the age of 13

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder

Mild severity would mean there are few problems with conduct

beyond those needed to make a diagnosis and all of the problems

cause little harm to other people. Moderate severity means the

number and effect of the conduct problems is between the extremes

of mild and severe. Severe is indicated if there are many more

conduct symptoms than are needed to make the diagnosis (more than

three in the previous twelve months or more than one in the

previous six months), or, the behaviors cause other people

considerable harm.

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CAUSES AND RISK FACTORS

Following are the risk factors of Conduct Disorder

Supervision and behavioral management needs history of sexual and physical abuse Separation, divorce or death of key attachment figures; Evidence of attachment capacity; Educational potential, disabilities, achievements and

learning style; Peer relationships, especially the extent peers are

reinforcing negative behaviors; Family problems and strengths; Eenvironmental factors including disorganized home and lack

of supervision; Presence of neurotoxins such as lead; and Ability to form and maintain relationships.

The etiology of conduct disorder involves an interaction of

genetic/constitutional, familial and social factors. Children who

have conduct disorder may inherit decreased baseline autonomic

nervous system activity, requiring greater stimulation to achieve

optimal arousal. This hereditary factor may account for the high

level of sensation-seeking activity associated with conduct

disorder.Current research focuses on defining neurotransmitters

that play a role in aggression, with serotonin most strongly

implicated.but we cannot specify one specific cause

Parental substance abuse, psychiatric illness, marital conflict,

and child abuse and neglect all increase the risk of conduct

disorder. Exposure to the antisocial behavior of a caregiver is a

particularly important risk factor.Children with conduct

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disorder, while present in all economic levels, appear to be

overrepresented in lower socioeconomic groups.Another common

feature appears to be inconsistent parental availability and

discipline.As a result, children with conduct disorder do not

experience a consistent relationship between their behavior and

its consequences.This early childhood pattern includes

irritability, inconsolability and impaired social

responsiveness.Caregivers, particularly those with psychiatric

conditions and substance abuse problems, may respond to these

children coercively and inconsistently. In addition, these family

groups often experience financial distress, which may further

complicate the situation. These children are also more

susceptible to the rise in peer group influence that typically

occurs in later elementary school.

Criminal behavior, disadvantaged school settings, alcoholism or

other psychiatric impairment, harsh punishment, lax, erratic and

inconsistent discipline, less acceptance of child by parents,

less affection and emotional support, financial hardship,

unemployment, large debt, less attachment, having one parent

frequently dominant, dangerous neighborhoods, unhappy marriage,

interpersonal conflicts ,poor parental monitoring and supervision

are highly contributing factors in developing CD.

TREATMENTS AND RESILIENCE FACTORS

Earlier treatments of youth with conduct disorder relied on legal

processes to declare a child in need of supervision or treatment

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and thus able to be placed in residential settings established

for this purpose. While residential placements may still be used,

recent treatment models have relied less on such restrictive

procedures. Community-based interventions are sometimes called

wrap-around services to describe the intention that they will be

brought to the child's natural environment in a comprehensive and

flexible way. The idea is to target a range of child, parent,

family and social system factors associated with a child's

behavioral problems. treatment that has been used with some

success is the Child Cognitive Behavioral Treatment and Skills

Training which trains children with conduct disorder in anger-

coping, peer coping, and problem-solving skills. Parent

Management Training and family therapy are also used to treat

conduct disorder. Parents learn to apply behavioral principles

effectively, how to play with their children, and how to teach

and coach the child to use new skills. Monitoring of children's

activities and whereabouts by adult caregivers is critical.

Compliance with the evening curfew is essential. For working

parents, telephoning to check on the child or having another

responsible adult ensure that the child is in an appropriate

setting during nonschool hours is important. Monitoring becomes

particularly important during early adolescence when peer group

influences increase. Vulnerable youth are susceptible to peer

influences such as smoking, sexual risk-taking, and alcohol or

other substance abuse. Organized, supervised activities, such as

sports, Scouting, the arts or recreational programs provided by

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churches, schools or agency youth clubs often protect teenagers

from negative peer influences.

Few suggestions are mentioned as follows.

Structure children's activities and implement consistent

behavior guidelines.

Emphasize parental monitoring of children's activities

(where they are, who they are with). Encourage the

enforcement of curfews.

Encourage children's involvement in structured and

supervised peer activities (e. organized sports, Scouting).

Discuss and demonstrate clear and specific parental

communication techniques.

Help caregivers establish appropriate rewards for desirable

behavior.

Help establish realistic, clearly communicated consequences

for noncompliance.

Help establish daily routine of child-directed play activity

with parent(s).

Consider pharmacotherapy for children who are highly

aggressive or impulsive, or both, or those with mood

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disorder.

Medications such as Lithium, Dextroamphetamine (Dexedrine),

methylphenidate (Ritalin) and clonidine along with Cognitive

Behavioral therapy are ver helpful in lowering the rate of

Conduct disorder. A basic ingredient in CBT is to improve the

problem-solving abilities of children and adoles‐cents with

conduct disorder. The training helps them to deal with external

problems thatmay provoke behaviours. The child is first

encouraged to generate potential solutions to aproblem. The child

and the therapist then decide on the best solution and identify

steps in implementing it. The child practices these steps, and

finally the whole process is evaluated. Cognitive behaviour

therapy also challenges adolescents to make conscious choices and

toaccept full responsibility for their choices (Martye 2004).

Cognitive behaviour therapy has

Cognitive behaviour therapy also challenges adolescents to make

conscious choices and to accept full responsibility for their

choices (Martye 2004). Cognitive behaviour therapy hasbeen found

to be very effective in the treatment of all forms of antisocial

behaviours such as stealing (Obalowo, 2004), socially undesirable

behavior, faulty thinking.frustration, recidivism and delinquent

behaviour (Busari & Adejumo 2012). Cognitive Behaviour Therapy

also involves self-management which explains the self- which

believes that individuals have potential for self-actualization.

The proponent of this theory believed that human beingshave

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inherent tendency to develop their “self” in the process of

interpersonal and social experiences, which they have in the

environment (Obalowo, 2004), socially undesirable behavior,

faulty thinking.frustration, recidivism and delinquent behaviour

(Busari & Adejumo 2012). Cognitive Behaviour Therapy al‐so

involves self-management which explains the self- which believes

that individuals havepotential for self-actualization.

DESCRIPTION OF SCALES

The Conduct Disorder Scale (CDS) is an efficient and effective

instrument for evaluating students exhibiting severe behavior

problems who may have Conduct Disorder. It is the only test of

its kind that provides standard scores for use in identifying

students with Conduct Disorder. The 40 items on the CDS describe

the specific diagnostic behaviors characteristic of persons with

Conduct Disorder. These items comprise four subscales

representing the core symptom clusters necessary for the

diagnosis of Conduct Disorder: Aggressive Conduct, Non-aggressive

Conduct, Deceitfulness and Theft, and Rule Violations. It

measures CD from age 5 to 22. It has high test-retest reliability

of .89. It was developed by James.E.Gilliam in 1998.

SEPARATION ANXIETY DISORDER

DEFINITION

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Like many childhood concerns, separation anxiety is normal at

certain developmental stages but separation anxiety that occurs

at later ages is considered a disorder because it is outside of

normal developmental expectations, and because of the intensity

of the child's emotional response. Separation anxiety disorder

occurs most frequently from the ages of five to seven and from 11

to 14. Environmental stimuli and internal cues from the child

himself interact in the presentation of separation anxiety

disorder. However, it is defined by the primary expression of

excessive anxiety that occurs upon the actual or anticipated

separation of thechild from adult caregiver

DESCRIPTION Children experiencing separation anxiety disorder display

significant distress upon separation from parents. Separation

anxiety disorder often becomes problematic for families during

elementary school, although it can also occur in older or younger

children. The child appears fearful because he or she thinks

something horrible will happen to the child or parent while they

are apart. The child's responses to separation may include crying

or becoming angry with the adult in an attempt to manipulate the

situation. When thwarted by the adult's appropriate boundaries,

expectations, and structure then child's distress may become

displaced into other maladaptive or negative behaviors.

Although exposure to a specific stressor is not required for the

development of separation anxiety disorder, in many cases, a

specific incident may precipitate the onset of the disorder (the

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traumatic events of daily boom blasting, for example). Another

common precipitant is the holiday or summer break from school.

Some children experience significant difficulty returning to

school after a relatively short break.

CAUSES AND RISK FACTORS

Envoirnmental changes

Separation anxiety disorder is often precipitated by change or

stress in the child's life and daily routine, such as a move,

death or illness of a close relative or pet, starting a new

school, a traumatic event, or even a return to school after

summer vacation.

GENETIC INFLUENCE

Evidence suggests a genetic link between separation anxiety

disorders in children and a history of panic disorder, anxiety,

or depression in their parents.

PARENT/CHILD ATTACHMENT

Quality of attachment between children and their parents has also

been identified as a factor in separation anxiety disorder. If

the child senses emotional distance, the behaviors may be an

attempt to draw the parent in more closely. The problematic

behaviors can also draw the attention and care of others as well.

DEVELOPMENTAL CONSIDERATIONS

Children develop at different rates when compared to each other.

Furthermore, the rate of development within the same person can

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vary across different types of functioning. A slower rate of

development in the intellectual, social, emotional, or physical

arena can foster anxiety within the child, making the separation

more difficult.

COGNITIVE FACTORS

Children repeatedly worry about what they are afraid of (getting

lost or a parent getting hurt). The thought patterns are repeated

within the child's mind until his emotions are beyond his

control. The child may feel he is unable to think about anything

else other than his fears, which contributes to his anxiety and

irrational behaviors.

BEHAVIORAL FACTORS

The child or adolescent's crying and clinging behaviors may be developed by the child to cope with the feelings of anxiety associated with certain people, environment, or situations, such as attending school. The behaviors serve to distract attention away from the child's negative feelings, while nurturing the anxiety and fear into a greater part of the child's daily experience. For children, the behavioral component often becomes the mode of expression for the anxiety. The behavior may appear manipulative at times, due to the quick disappearance of symptomsonce the threat of separation passes.Stress factors and influence. The child's symptoms may also be affected by a change in caregivers or changes in parents' response to the child in terms of discipline, availability, or daily routine.

DSM-IV-TR CRITERIA OF SEPERATION ANXIETY DISORDER

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DSM-IV-TR has assigned the following criteria to this disorder.

It has assigned the code of 309.21 to this disorder.

A. Developmentally inappropriate and excessive anxiety concerning

separation from home or from those to whom the individual is

attached, as evidenced by three (or more) of the following: 

recurrent excessive distress when separation from home or

major attachment figures occurs or is anticipated 

persistent and excessive worry about losing, or about

possible harm befalling, major attachment figures 

persistent and excessive worry that an untoward event

will lead to separation from a major attachment figure

(e.g., getting lost or being kidnapped) 

persistent reluctance or refusal to go to school or

elsewhere because of fear of separation 

persistently and excessively fearful or reluctant to be

alone or without major attachment figures at home or

without significant adults in other settings 

persistent reluctance or refusal to go to sleep without

being near a major attachment figure or to sleep away

from home 

repeated nightmares involving the theme of separation 

repeated complaints of physical symptoms (such as

headaches, stomachaches, nausea, or vomiting) when

separation from major attachment figures occurs or is

anticipated 

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B. The duration of the disturbance is at least 4 weeks. 

C. The onset is before age 18 years. 

D. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other importantareas of functioning. 

E. The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia or other Psychotic Disorders. In adolescents and adults, is not better accounted for by Panic Disorder with Agoraphobia. 

SYMPTOMS OF SEPERATION ANXIETY DISORDER

RECURRENT EXCESSIVE DISTRESS UPON SEPARATIONThe child may become focused on the separation long before the actual event, or simply at the time of the anticipated separation. The recurrent behavioral pattern does not respond to intervention. The child experiences extreme distress, a highly charged emotional response that is repeated when the child anticipates separation from the caregiver. The child's fears trigger more anxiety and the emotional response intensifies.

PERSISTENT AND EXCESSIVE WORRY The content of the worry may include some type of harm occurringto the child himself or toward the parents, or it may focus on becoming lost or separated indefinitely from the parent or caregiver.

REPETITIVE NIGHTMARESThe child may experience repeated nightmares with themes of beingchased, harmed, or separated from her family. Dreams are often a way of exploring and making sense of daily life, children with separation anxiety disorder report nightmares that represent their irrational fears or preoccupation with disaster.

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COMPLAINTS OF PHYSICAL SYMPTOMSThe child may feign illness to avoid separation, or the child mayactually experience nausea upon separation. If allowed to continue, the child may develop psychosomatic symptoms (physical symptoms with a psychological origin) that prevent the child fromattending or fully participating in school activities

PERSISTENT RELUCTANCE TO ENGAGE IN AGE-APPROPRIATE ACTIVITIES The child may refuse to attend school because of preoccupation about separation from the parent. The child may also experience reluctance to be alone at home or at school without another adultbeing immediately available. The child may resist sleep without an adult present. The disorder causes significant disruption in the child's daily routine and may decrease the ability to performpreviously mastered tasks. The child may appear to have reverted to behaviors from a younger age. The intensity of her emotions blocks the child's ability to communicate her feelings in ways other than through behaviors.

ENMESHMENT OR UNUSUAL INTEREST IN PARENTS' SCHEDULES The child wants to know all the details of the daily routine, a behavior which minimizes the anxiety the child is feeling.

QUICK RESOLUTION OF SYMPTOMSIt may be hard for parents to accept the reality of the disorder because the symptoms often disappear quickly when separation doesnot occur. It is this component that can feel manipulative to those in the child's life.

DIAGNOSIS OF SEPERATION ANXIETY

The mental health professional will usually make the diagnosis ofseparation anxiety disorder based on information gathered during an interview process involving the parent(s) and the child.

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Separation anxiety disorder is generally diagnosed by history, including parental report; however, a few measures of general anxiety exist that can be used to supplement the history. These include Pediatric Anxiety Rating Scale, Children's Global Assessment Scale, Children's Anxiety Scale, Screen for Child Anxiety Related Emotional Disorders (SCARED-R), Multi-DimensionalAnxiety Scale for Children, and Achenbach's Child Behavior Checklist. Duration of disturbance prior to diagnosis is a minimum of four weeks, occurring prior to the age of 18 years. Hedisorder is described as "early onset" prior to the age of six years, and is generally not diagnosed after the age of 18. However, some researchers are describing another type of separation anxiety experienced by parents when their adolescents leave home. Readers may recognize this stage of life as the "empty nest syndrome"; however, no such formal diagnosis exists for a parental form of separation anxiety.

TREATMENTS AND RESILIENCE FACTORS

There are many risilience factors that help child improve his cognitive skills. The children of higher IQ, better adjustment skills and emotional intelligence are better able to cope with Seperation Anxiety Disorder. The parents having higher educationare better able to understand the condition of child and diagnosehim to a specialist. Similarly, High SES is also a reslience factor. Similarly having parents of cool temperament also helps in understanding child’s state. The social, moral and emotional support is very much needed.

The most effective treatments for separation anxiety disorder involve parents, as well as school personnel when appropriate. Giving the child a sense of safety and security is key to successful treatment. Current treatment methods combine some form

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of group or individual cognitive behavioral intervention. A number of treatment options are discussed below.

Cognitive-behavioral therapy

Cognitive-behavioral therapy is a treatment approach designed to alter a person's thoughts, beliefs, and images as a way of changing behavior. In treating a child with separation anxiety disorder, the goal is to help the child label her fears and identify the irrational beliefs and assumptions underlying her fears. By confronting and correcting her false beliefs, a parent can help his or her child become less anxious about separation.

Imagery

With imagery, a child uses his imagination to see himself being successful in a stressful situation.

Modeling

Parents and teachers can be helpful in modeling appropriate behaviors and coping mechanisms at home and at school

Systematic desensitization

A child with separation anxiety disorder may be taught relaxationtechniques for managing her anxiety, and, as a result, can spend longer and longer periods of time at school without a caregiver present by teaching her.

Positive role models

Using positive role models, whether in real life or in books, canalso be helpful for children. Reading books about other children successfully separating from their caregiver can give the anxiouschild the confidence that he can do it, too. Watching his friendscalmly separate from their caregivers can also empower the child to do the same.

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Behavior modification

Behavior modification uses a system of rewards and reinforcementsto change behavior. This method has been shown to be effective ina majority of cases involving children and separation anxiety disorder, even at one-year follow-up.

Reminders

Small items that remind the child of his bond with his parents can sometimes be helpful in managing the child's anxiety. Typicalobjects could include a smooth stone in the child's pocket, a picture of the family in the child's notebook, or a friendship bracelet.

Distraction and altruism

Distraction and altruism is another strategy that can be useful in treating separation anxiety disorder. Helping the child focus on things outside himself can provide a healthy distraction

Medication management

Medication is helpful in certain cases where the anxiety is so debilitating that the child is unable to participate in other forms of treatment, or go about his daily routine. Medication management most often involves some type of anti-anxiety or anti-depressive drug.

PROGNOSIS OF SEPERATION ANXIETY DISORDER

Over 60% of children participating with their parents in cognitive-behavioral treatment are successful in managing their symptoms without medication. Symptoms generally do not re-appear in exactly the same way as the initial presentation; however, thechild may have a heightened sensitivity to normal life transitions, such as changing schools. Families can help childrencope with these transitions by visiting the new school, meeting

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teachers, and getting to know some students. Separation anxiety disorder has a poorer prognosis in environments where threat of physical harm or separation actually exists.

Existence of other conditions, such as autism, decreases the likelihood of a positive prognosis. Presence of separation anxiety disorder in childhood is sometimes associated with early onset panic disorder in adults. Studies indicate a lower prevalence of alcohol use and suicidal ideation in children or adolescents who experience separation anxiety disorder. Depression is commonly associated with anxiety disorders. Developing social skills can also be negatively affected by separation anxiety disorder.

DESCRIPTION OF SCALES

SCREEN FOR CHILDHOOD ANXIETY RELATED EMOTIONAL DISORDERS(SCARED)

Developed by Boris Birmaher, Suneeta Khetarpal, Marlane Cully,David Brent , and Sandra McKenzie, (1995)

The SCARED is a child and parent self-report instrument used to screen for childhood anxiety disorders including general anxiety disorder, separation anxiety disorder, panic disorder, and socialphobia. In addition, it assesses symptoms related to school phobias. The SCARED consists of 41 items and 5 factors that parallel the DSM-IV classification of anxiety disorders. The child and parent versions of the SCARED have moderate parent-child agreement and good test-retest reliability (.81), and discriminant validity (.91), and it is sensitive to treatment response. Children ages 8-18 years are target population

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THERAPIES USED MOST FREQUENTLY IN TREATMENTOF CHILDHOOD DISORDERS

BEHAVIORAL THERAPY IN REALTION TO COGNITIVE THERAPIES

(COGNITIVE-BEHAVIORAL THERAPY)

Although existing treatment approaches differ in their emphasis and prioritization of CBT methods, various therapy components target the core areas of impairment in PBD. A primary component is psychoeducation to build the family's understanding of the symptoms, etiology, and chronicity of disorders. Treatment also focuses on the development of affect regulatory strategies, including self-monitoring of mood states, recognizing and labeling feelings, and coping skills to manage expansive, negative, and irritable moods. In addition, youth and parents maybe instructed in cognitive restructuring techniques to reduce negative thought patterns (e.g., thought stopping, reframing situations positively, modifying thoughts, and use of positive self-talk/mantras during difficult situations). Further, parent training in behavioral management strategies that is incorporatedto help families prevent and cope with these disorders. Strategies include establishing simple and predictable routines, minimizing transitions, emphasizing the timing and tone of interactions (e.g., helping to soothe and contain the child and enforcing consequences only once the behavior has stabilized), and using positive reinforcement. Youth and parents are also engaged in problem-solving skills training to target interpersonal and family difficulties, as well as to enhance self-efficacy related to coping with the disorder. Similarly, social skills’ training focuses on role-play, listening and communication skills, and empathy to improve the interpersonal difficulties. Finally, parents are encouraged to engage in

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pleasant, relaxing activities and to utilize their support networks to help cope with the demands of caring for a child .

Cognitive behavioral treatment models have shown promising results among youth when incorporated as an adjunct to pharmacotherapy in many disorders. Studies indicate that individual/family- and group-based formats of child- and family-focused CBT (CFF-CBT), a manual-based model that incorporates thetreatment methods described above, resulted in improved symptoms and psychosocial functioning among youth. A randomized controlledtrial is currently underway to further establish the efficacy of CFF-CBT. In addition, a multi-family psychoeducation group psychotherapy model (MFPG; a group treatment for parents and children that focuses on psychoeducation, problem-solving, and coping skills) is associated with improvement in symptom severity. Last, a family-focused treatment model for adolescents (FFT-A), which includes psychoeducation, communication training, and problem-solving training, has been shown to improve the situation.

It can be thought of as a comprehensive approach to treatment that includes a variety of therapeutic techniques: (1) awareness training; (2) function-based interventions; (3) self-monitoring; (4) habit reversal training; (5) aversion; (6) massed practice; (7) relaxation training; (8) social support; and (9) stimulus control

Comprehensive treatment for ADHD should always include a strong psychosocial (that is, not medical) component. In fact, many professionals believe that effective psychosocial intervention isthe backbone of good treatment for ADHD. Moreover, research evidence has demonstrated that when medication is utilized as theonly form of treatment, it has not been shown to improve long-term outcomes for children with ADHD. If psychosocial treatments alone are insufficient, however, medication can be a useful

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addition for many children, yielding a combination approach that may be more effective than psychosocial treatments alone. The scientific literature on treatment for ADHD has shown that behavior therapy is the only type of psychosocial treatment that is effective for ADHD. There are three components to effective behavioral interventions for children with ADHD: parenting training, teacher consultation/school interventions, and child-focused treatments. Although teaching parents more effective waysof dealing with their children is the most important aspect of psychosocial treatment for ADHD, ideally parent, teacher, and child interventions should be integrated to yield the best outcome. Three points are essential: (1) start with goals that the child can achieve and improve in small steps; (2) be consistent--across different times of the day, different settings, and different people; (3) don't expect instant changes--teaching and learning new skills take time, and children's improvement will be gradual; (4) constantly monitor the child's response and adjust treatment as necessary; and (5) begin intervention as early as possible--although behavior modification works for all ages, early treatment is more effective than later intervention.

CBT is the primary type of treatment used for separation anxiety disorder. Such therapy is focused on teaching children several major skills, such as how to recognize anxious feelings regardingseparation and to identify their physical reactions to anxiety. They are taught to identify their thoughts in anxiety provoking separation situations, and are taught to develop a plan to cope adaptively with the situation.

In cognitive-behavioral therapy, children are also taught to evaluate the success of the coping strategies they employed. In addition, behavioral strategies such as modeling, role-playing, relaxation training, and reinforced practice are used. Children

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are guided in developing a list of situations that are challenging for them, such as attending a birthday party without their parent, or staying home with a sitter. Children are taught to implement their coping skills while gradually facing each of these situations. Children’s successes are praised highly by the therapist and by parents.

Recent research has suggested that incorporating parents more centrally into the treatment of children with anxiety disorders can be extremely useful in reducing children’s anxious behavior and may enhance treatment effectiveness and maintenance. Parents are often taught new ways to interact with their children so thatthe child’s fears are not inadvertently reinforced. Parents are also taught ways to give children ample praise and positive reinforcement for brave behavior.

For younger children who have more difficulty in identifying their thoughts, a form of play therapy may be used. Play therapy uses toys, puppets, games, and art materials for expression of feelings. The therapist validates the child’s feelings, and helpsthe child understand some of the reasons behind them. The therapist then provides alternative ways of coping with the feelings that a younger child can relate to.

Treatment plans for cognitive behavioral therapy for conduct disorder incorporate impulse control and anger management training with the teaching of enhanced communication techniques. The adolescent is given the skills to effectively solve problems without violating rules or the rights of others. Self-control is gained through consistent encouragement for appropriate behavior.

This type of treatment plan incorporates the family into the healing process. Parents are taught ways to bond with the child, with an emphasis on teaching parents how to use positive reinforcement for appropriate behavior. Parent management

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training can reverse the feelings of alienation often suffered byadolescents with a conduct disorder, making the child more amenable to positive change

Social skills’ training teaches the adolescent how to interact inways that foster healthy relationships with peers and others. Behavioral treatment plans may begin with role-playing that expands into assignments to offer emotional support to a person or to provide assistance to a peer in need. These assignments arecompleted and the results discussed with the therapist

PSYCHODYNAMIC THERAPY

(INTERPERSONAL THERAPY)

Interpersonal therapy is a manual-based treatment. That means thetherapist strictly adheres to a treatment process whose effectiveness is supported by evidence.

According to the International Society for Interpersonal Therapy,there are three components to depression.

symptom formation social functioning personality issues

IPT is a short-term treatment option that typically consists of 12 to 16 one-hour weekly sessions. Because it is so brief, IPT does not address personality issues. Instead, the therapist focuses on identifiable problems in how an individual interacts with or doesn't interact with others. When those problems are addressed, the patient realizes a benefit in his or her experience of symptoms.

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Except to check on their severity and the effect of the various treatments, symptoms are not addressed in therapy sessions. Instead the therapist works collaboratively with the patient, either individually or in a group, to identify and then address one or two significant problems in his or her interactions. The number of problems addressed is deliberately limited to one or two for the whole course of treatment. The result is an intense focus on how to make the necessary adjustments in interpersonal situations

Interpersonal psychotherapy (IPT) is a brief, time limited psychotherapy that was initially developed in the late 1960s for the treatment of adult depression (Weissman, Markowitz, & Klerman, 2000). The underlying assumption of IPT is that the quality of interpersonal relationships can cause, maintain, or buffer against depression.

When you wish to choose an interpersonal therapist for your child, it is important to decide whether your child works better with males or females. If your child does not work well with malefigures, it may be better to choose a therapist that is female orvise versa. Ensuring that your child is comfortable with the therapist they will be seeing is crucial to the success of the thera

Interpersonal therapy is a descendant of psychodynamic therapy, itself derived from psychoanalysis, with its emphasis on the unconscious and childhood experiences. Symptoms and personal difficulties are regarded as arising from deep, unresolved personality or character problems. Psychodynamic psychotherapy isa long-term method of treatment, with in-depth exploration of past family relationships as they were perceived during the client's infancy, childhood, and adolescence.

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With issues involving interpersonal disputes, the therapist workswith the patient to define how serious the issue has become in terms of how difficult it is to move beyond it.

For issues involving grief, the therapist facilitates the grieving process to help the patient move beyond it. Two important techniques used to do this are:

Empathetic listening, which provides support and a safe outlet for the patient's feelings.

Clarification, which is a technique for helping the patient examine his or her own misconceptions about the situation.

With interpersonal deficits, the therapist will work with the patient to explore past relationships or the current relationshipthe patient has with the therapist. The goal is to identify patterns, such as excess dependency or hostility, which interferewith forming and maintaining good relationships. Once those patterns are distinguished, the focus turns to modifying them. Then, with the therapist's guidance and assistance, the patient is urged to make new relationships and to apply the therapeutic adjustments that have been made.

Throughout this portion of the therapy, the therapist would use anumber of different techniques, including among others:

Clarification, which has the purpose of helping you recognize and get beyond your own biases in understanding and describing your interpersonal issues.

Supportive listening. Role playing. Communication analysis. Encouragement of affect, which is a process that will let

you experience unpleasant or unwanted feelings and emotions

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surrounding your interpersonal issues in a safe therapeutic environment.

The entire focus of the sessions will be on addressing the identified issues. This is hard for some individuals to get used to -- especially those who are familiar with more traditional, open-ended and introspective approaches to therapy. It may take you several weeks before your own primary focus shifts to the IPTapproach.

Another important aspect of the IPT process is an emphasis on terminating therapy. From the beginning the patient is aware thattherapy is defined by a limited amount of time. In the final fouror so weeks of therapy, the sessions will turn to termination issues.

With IPT, termination of therapy is seen as a loss to be experienced by the patient. So you would be asked to consider what the loss means to you. What issues does it bring up, and howcan you apply the interpersonal adjustments that you've learned to make over the course of therapy to evaluating and getting through the loss? The idea is for the patient to become more aware of his or her ability to deal with interpersonal problems that have kept him or her from being able to actively manage the symptoms of depression.

HUMANISTIC THERAPY

(PERSON CENTERED THERAPY)

The goal of person-centered therapy is to find congruence betweenthe patient’s ideal self and self-concept.  To do this, patients must accept characteristics of themselves which they have rejected or denied.

Person-centered therapy process

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Person-centered therapy is a non-directive therapy.  This means that the therapist does not deliberately steer the therapy in a specific direction, ask questions, interpret information, or offer treatments. Instead, the therapist is there to create an environment which is conducive to openness.

According to Rogers, people will naturally move towards growth and healing if they are in a nurturing relationship.  By creatinga nurturing relationship, the patient will be able to solve his or her own problem.  Roger named are six conditions of the nurturing relationship which must be present for personality changes to occur.

Two people are in a psychological contact One person (the patient) has an incongruent self-concept and

self ideal. The second person (the therapist) is congruent The therapist gives unconditional positive regard The therapist expresses empathy The patient perceives the therapists unconditional positive

regard and empathy

There is no set method or process used in person-centered therapy.  Rather, the patient will lead the course of the session.  The role of the therapist is not to counsel, diagnose or treat but rather to create a relationship which the patient can use to explore his or her sense of self.  Person-centered therapy will not generally use methods like questioning, interpretation, offering treatments, or diagnosing. The therapistis not there to “figure out” the patient.

While there is no specific theme of person-centered therapy, the focus is always on the person and not the person’s problems. Further, the therapy typically focuses on the present or future rather than attempting to explain the past.

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The role of the therapist

In person-centered therapy, the therapist does not attempt to directly change the patient.  Under the tenets of the therapy, this is not possible because the patient is solely responsible for his or her own feelings and progress.  Further, the therapistshould not interpret data because only the patient has a true sense of his or her subjective self.

Instead of attempting to diagnose or steer therapy, person-centered therapists serve as instruments of change. They form genuine, empathetic relationships with the patient and work to create an atmosphere conducive to openness.  It is common for thetherapist to share his or her own experiences in order to serve as a role model of congruence or someone striving for the ideal self. The therapist must be open, honest and transparent.  Person-centered therapists will not maintain professional personas.

A person-centered therapist will always give unconditional positive regard.  Through the relationship, the patient will become aware of his or her true self and build a congruency between self-concept.

Person-centered therapy compared to other approaches

Person-centered therapy has been challenged because it does not have a structure.  Further, the success of person-centered therapy depends on the development of a conditional relationship which could in itself be unhealthy. There are some limitations toperson-centered therapy.  Because the therapist in person-centered therapy is non-directive, he or she could end up being dogmatic.  Some patients may experience irritation by the lack ofinput from the therapist.  Also, person-centered therapy is very

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limited in situations where patients are unwilling to communicateor are deceptive.

Despite the limitations of person-centered therapy, it has becomevery popular.  Many patients and therapists embrace the core ideas that the patient is capable of resolving his/her own problems without direction.  Also popular is the focus of therapyon present issues rather than dwelling on the past.

Some studies show that the success of any therapy is not so much dependent on the method being used by rather the relationship between the therapist and the patient.  As this relationship is the core of person-centered therapy, this could be the reason whyit is such an effective treatment.

Is person-centered therapy effective?

Person-centered therapy has been used successfully for treating awide range of psychological disorders.  However, patients should be willing to engage in therapy and also ready to commit to a long-term relationship with the therapist.

LIST OF SCALES TO ASSESS CHILDHOOD DISORDERS AVAILABLEIN NATIONAL INSTITUTE OF PSYCHOLOGY, QAU

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http://alhefzi.com/G34/Pedia2/Seminars/Mental%20Retardation.ppt

http://www.pearsonclinical.com/language/products/100000479/dyslexia-screening-instrument-dsi.html?

Pid=0158061004&Mode=summary#details

http://filpsydyslexia.blogspot.com/2007/10/diagnostic-criteria-dsm-iv-tr-2000.html

http://www.cba-va.org/blog/bid/85490/Criteria-and-Assessment-of-Dyslexia-and-Dysgraphia

http://w.pearsonclinical.com/language/products/100000479/dyslexia-screening-instrument-dsi.html?

Pid=0158061004&Mode=summary

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http://www.sheknows.com/sheknows-cares/articles/804624/the-official-dsm-ivtr-diagnostic-criteria-for-autistic-disorder

http://www.healthline.com/health/conduct-disorder

http://www.healthline.com/search?q1=sepration+anxiety+disorder&submitbtn=

http://behavenet.com/node/21498

http://psychology.about.com/od/psychotherapy/a/cbt.htm