Children with Multiple Disorders

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Children with Multiple Disorders

• Ted and Roberta Mann Symposium for Childrens
  Mental Health and Learning Disabilities
• August 15, 2007

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• Identifying Mental Health Disorder(s) in
  Children with an Unrelated Primary Disability

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Common Childhood Disorders

• Cerebral Palsy
• Sleep Disordered Breathing
• Spina Bifida
• Tourrettes Syndrome
• Seizure Disorders
• Downs Syndrome
• Diabetes
• Inflammatory Bowel Disease(s)
• Thyroid Disorders
• Asthma
• Psoriasis, Eczema, and Alopecia
• Cardiac Malformations
• Developmental Delay
• Lymes Disease
• Chronic Fatigue Syndrome (CFS)

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Challenges in Recognizing Mental Health Disorders

• Primary focus on underlying medical illness
• Language/communication difficulties
• Behaviors thought to be a natural result of
  illness (i.e., anger, frustration, depression,
  etc)
• Behaviors arising from treatments
  (antihistamines, prednisone, stimulants, etc)
• Behaviors not initially recognized, but emerging
  with maturation and development (spina bifida,
  diabetes)

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Mental Health Manifestations

• Paying Attention in School (sleep disordered
  breathing)
• School attendance (asthma, inflammatory bowel
  disease, diabetes)
• Verbal and non-verbal learning disabilities
• Active disruptive behaviors, (inflammatory bowel
  disease)
• Passive or shutting down behaviors (diabetes,
  spina bifida)
• Refusal to take standard medications (diabetes,
  asthma)

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Common Errors Parents Face

• Delayed diagnosis of mental health disorder
• Often less accurate
• More severe in nature (not valid)
• Prognosis tends to be more pessimistic (not
  necessarily true)
• Challenge for parents not being believed (youre
  enabling)

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Recognition of Mental Health Disorders

• Diagnosis evolves over time and multiple
  observations
• Diagnosis takes more time ( 6 hours vs. 3 hours)
• Multidisciplinary involvement (pediatricians,
  teachers, psychologists, psychiatrists, social
  workers, Occupational therapists, etc)

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Mental Health Symptoms Defined Differently

• Often non verbal
• Multiple observers
• Often attributed to underlying physical condition
• Parental (and others) denial ( may take 3 visits
  before parental acceptance)
• Educators experience difficulty in accepting
  mental health related behaviors can only see
  the medical disability

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Diagnostic Substitution

• Data is from the Dept of Education (federal and
  state)
• 6-11 year old children
• Enrolled in special ed programs
• In 1994, 0.6 per 1,000
• In 2003, 3.1 per 1,000
• Prevalence based on government sponsored
  screening in 2003-2004 is 5.5 per 1,000
• Corresponds to similar decrease in diagnoses of
  learning disabilities and mental retardation
• Previously children would have been classified as
  having another disorder but now are identified as
  having autism spectrum disorder
• Shattuck, Pediatrics, 2006

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Barriers to Appropriate Treatment

• Fear of causing harm
• Lack of familiarity with psychiatric medications
• Lack of knowledge about drug interactions
• Use of inadequate levels of medications
• Not knowing which drug to use first
• Failure to integrate necessary services (special
  ed, 504) with medical treatment
• Parents are overwhelmed by combination of medical
  and behavioral needs
• What should parents ask?

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Response to Treatment

• Improved behavior at home, in school and among
  peers
• Emotional stability
• Academic improvement
• Improved self awareness and self-advocacy

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Behavioral Symptoms

• Child has more obsessional thoughts and
  compulsive behaviors
• Socially inappropriate behaviors
• Behavior symptoms appear more bizarre
• Social isolation and loneliness (peer rejection)
• Unable to express feelings verbally and instead
  acts out
• Misinterprets problems and generalizes failures
• Unable to recognize others response to his or her
  behaviors
• Inappropriate attention seeking and
  competitiveness

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Parental Response

• Initial denial and reluctance to consider mental
  health disorder
• Preference for simple solutions (diet,
  nutrients, medications alone)
• Reliance on a partial explanation of the childs
  behavior (every frustrated child is depressed)
• Reluctance to mainstream preference for
  dependency and overprotection

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Best Practices Accommodations

• Classroom seating
• Modified academic expectations
• Decreased time in mainstream classes as
  appropriate
• Greater utilization of school nurse
• Training and education of case managers and IEP
  team about mental health needs
• Consideration of homebound services and distance
  learning

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Best Practices School Modifications

• Regular and frequent breaks
• Use of escape places
• Two sets of books and other written materials
• Simplify all directions and communication for
  child and home
• Initially, shorten school day
• Identify and avoid all triggers
• Utilize Functional Behavior Assessments
• Allow the child to explain disabilities to
  classmates if he wishes
• Ensure that the teacher understands the
  disabilities

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Best Practices School Management

• Recognition of difficulties with transitions
• Greater attention to less structured time
  (recess, lunchroom, hallway)
• Assistance with time management and prioritizing
  school activities (extracurricular sports, clubs,
  etc)
• Cueing , signaling when behaviors are socially
  inappropriate or disturbing (nose picking, body
  noises, masturbation, etc)
• Anticipating situations for those children with
  concrete or rigid thinking patterns ( substitute
  teacher, crisis in the classroom)
• Assisting the child to manage frustrations and
  overreactions
• Using the IEP or 504 plan to specify appropriate
  management interventions

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Untreated ADHD Behaviors

• Avoid use of stimulants when
• there is an underlying cardiac condition
• severe obsessive compulsive disorder
  (OCD)
• alcohol/substance abuse

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Adverse Side Effects of Stimulant Medication

• Anorexia
• Insomnia
• Delayed Growth
• Tics
• Stomach Ache
• Social Withdrawl
• Risk of sudden death from cardiac causes and
  stroke (February 2, 2005, Health Canada suspends
  Adderall XR prescribing due to 12 patient deaths
  5 had underlying structural heart defects, 7 died
  from heat exhaustion, dehydration, near drowning,
  rigorous exercise, diabetes, ventricular
  tachycardia and fatty liver)

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Medication Use

• Child is often on multiple medications
• Drug interactions are common
• Awareness of effects on risk for producing
  seizures (lithium)
• Training for school staff in recognizing
  therapeutic and adverse effects of medication
  (sleepiness, agitation, irritability)
• Awareness of side effects that can be beneficial
  (topamax)
• Child does not understand the need for medication
  and medicine becomes a means of asserting
  independence

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Adequate Monitoring and Follow Up

• Regular and frequent office visits
• Scheduling adequate time (minimum of half an
  hour)
• Weekly follow up for first three months
• Supervision and training of therapists to
  understand those children with limited
  communication skills

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What Parents Should Ask

• What is my childs behavioral disorder called?
• What are the best treatments for it, and who are
  the best providers for them?
• How long will my child require treatment?
• What will my child be like in five (5) years?

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Commonly used medications

• Anti-seizure medications are used for
• Aggressive behaviors
• Mood stabilization
• Repetitive and compulsive behaviors
• Anxiety
• Pain relief
• Appetite suppression

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Commonly used medications

• Stimulants are used for
• Improved learning, focus and alertness
• Improved response time
• Reduced motor hyperactivity
• Improved fine motor coordination
• Increasing the ability to inhibit socially
  inappropriate behaviors

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Commonly used Medications

• SSRI Antidepressant medications (fluoxetine)
• Best treatment for anxiety
• Highly effective for obsessional thoughts and
  repetitive behaviors
• Mild depression

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Commonly Used Medications

• Atypicals (risperidol, seroquel,etc)
• Tics
• Aggression and agitation
• Bizarre behaviors
• Hypersexual behaviors
• Appetite suppression and weight loss
• Severe sleep disorders
• Mood stabilization
• Enhancement of antidepressant medication

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Commonly Used Medication

• Lithium
• Aggression
• Sleep disorders
• Mood stabilization
• Enhancement of antidepressants

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Commonly used Medications

• Clonidine
• Aggression
• Sleep Disturbance
• Agitation
• Hyper-motoric behaviors
• Tricyclic Antidepressants (Imipramine)
• Bed wetting
• Pain relief
• Sleep Disorders
• Anxiety, mood disorders
• Focus and attention

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Outcomes

• Higher failure rate of high school graduation
  (1/3)
• Twice the rate of school refusal
• Four fold increase in grade/class failure
• Lower school achievement compared to siblings,
  peers and parental success
• Lower rate of college attendance and emancipation

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• Thank you for coming!