ADD and ADHD: An Overview for School Counselors

ADD and ADHD: An Overview for School Counselors. ERIC Digest. by Pledge, Deanna S. 

INTRODUCTION

School counselors are often consultants for parents and teachers on problems that children and adolescents face. Attention deficit is one such problem. It is frequently misunderstood, presenting a challenge for parents and teachers alike. The counselor is a resource for initial identification and interventions at home and in the classroom. The counselor must have at least a working knowledge of typical symptoms and likely responses to environmental demands in order to be an effective resource on attention deficit. 

ETIOLOGY

Attention Deficit Disorder without Hyperactivity (ADD) or with Hyperactivity (ADHD) continues to be a misunderstood diagnosis by many. Some parents and teachers still hold a perception that the label simply provides an excuse for disruptive behavior; however, studies continue to support a biochemical or organic basis to the disorder. 

Presentation of symptoms can be affected by family interactions, school expectations, and other demands placed on the individual child. Part of the reason that attention deficit is usually diagnosed in school age children (e.g., first to third grade) is attributable to the demands placed on the child when beginning school (American Psychiatric Association [APA], 2000). The structure at school differs from that in the home or preschool environment. 

Typical predisposing factors within the individual, as well as in the family history, are being identified in the literature (Chi and Hinshaw, 2002). For example, a history of alcoholism, smoking, or depression in parents can be predisposing factors (Mick, Biederman, Faroane, Sayer, and Kleinman, 2002). Certain physiological markers, such as frequent early ear infections (Combs, 2002), have also been associated with the presentation of attention deficit. Physical complications can be a factor in the development of language and reading disabilities that are associated with attention deficit for between 45% and 60% of those diagnosed (Lloyd, Hallahan, Kauffman, and Keller, 1998). 

Attention Deficit Disorder presents in a slightly different way for each individual, partially due to the factors noted above. Although there is a cluster of symptoms usually associated with the disorder, the individual presentation can be just as varied as the predisposing factors. 

SYMPTOMS AND DIAGNOSIS

Diagnosis in children and adults is usually made by history, self- report, and observation from significant others in the person's life. Central to diagnosis in children are the symptoms in the general areas of inattention, impulsivity, and hyperactivity (APA, 2000). In adults, the most prominent symptom is inattention (Stern, Garg, and Stern, 2002). 

Symptoms of attention deficit can be mimicked by emotional disorders, e.g., reaction to abuse, depression or anxiety (APA, 2000). If therapy is not successful in addressing underlying emotional concerns, medication may be used with positive results just as in the case of more classic symptoms of ADHD. In those cases where early abuse or neglect has been instrumental in affecting the neurology of the individual, the actual outcome, and thus treatment, may not differ significantly from other cases of ADHD. Difficulty sleeping is often seen with attention deficit, particularly for those with hyperactivity (Stein, Pat-Horenczyk, Blank, Dagan, Barak, and Gumpel, 2002). Sleep problems can also be exacerbated by medication use. 

Other disorders may co-occur with Attention Deficit Disorder. Those commonly observed include: Tourette's, Obsessive-Compulsive Disorder, Depression, Autism, Oppositional Defiant Disorder (ODD), or Conduct Disorder (CD) (Burns and Walsh, 2002). The relationship between ADHD, ODD, and CD is often presented on a continuum or as a progressive relationship. Symptoms of ADHD often present initially, followed by ODD, and ultimately CD for a small percentage of those with initial attention problems. Individual characteristics, family factors, and life experiences all interact to push some individuals through this continuum to more serious behavioral concerns. The comorbidity of other disorders or symptoms often makes successful treatment more difficult. Other features of ADHD include differences in level of executive functioning between those who present with hyperactivity and those who do not (Klorman, Hazel-Fernandez, Shaywitz, Fletcher, Marchione, Holahan, Stuebing, and Shaywitz, 1999). Deficits in executive functioning are associated with greater hyperactivity and impulsivity. These differences in executive functioning include an inability to self-monitor and self-control. 

Prevalence estimates for ADHD and ADD are between 3 to 7% of school age children (American Psychiatric Association, 2000). 

TREATMENT OPTIONS

Effective treatment usually combines medication and therapy, including behavioral interventions aimed at increasing structure at home and school. Parents and teachers are active participants in successful treatment efforts. Stimulants are the most commonly used medications, with some use of anti-depressants, for co-morbid conditions of depression and anxiety (Shatin and Drinkard, 2002). Other interventions include parent training and family therapy, individual therapy, support groups, and social skills training. Providing structure for these individuals, and helping children learn to provide structure for themselves, are at the core of successful interventions (Shapiro, DuPaul and Bradley-Klug, 1998). 

Although medication is often part of a successful treatment approach, school personnel are usually not directly involved in recommending a prescription. Diagnoses and prescriptions can only be provided by the family physician, pediatrician, or psychiatrist. Even the process of referral can expose a school to liability for financial responsibility, so the counselor needs to be aware of the manner in which any conversation about medication or referral takes place. 

INTERVENTIONS: COUNSELING, CONSULTATION, AND SUPPORT

The counselor's role in enhancing the academic performance of students with ADD or ADHD often involves consultation with teachers around classroom interventions, as well as providing support and education to parents. In addition to basic behavioral interventions, coping skills, social skills, and self-monitoring skills are important tools that can be reviewed through various modalities, including individual counseling, group sessions, or classroom guidance modules. Providing workshops in the evening with separate sessions for parents and children can be a resource welcomed by parents. Such efforts may be jointly offered with community support groups. 

Parents often need information about appropriate expectations for behavior and school work, positive parenting techniques, and support groups at the school or in the community, such as CHADD (a support group for children and adults with attention deficit disorder). For example, a counseling newsletter to parents can provide descriptions of ADD, such as the fact that disruptive behaviors observed at school may not be observed at home, or that behavior can be inconsistent - at times under the child's control, and impulsive at others. Information and support can help parents in making the decision to seek an evaluation. 

Typical challenges for students with ADD or ADHD include: 1) organizational problems; 2) problems with transitions; 3) acting as if rules don't apply to them; 4) adopting a negative attitude out of frustration in academic tasks, social interactions, or as a defense against low self esteem; 5) experiencing isolation or exclusion from peers; 6) poor grades as a result of rushing through assignments, incomplete work, or distractibility in class; 7) impulsive behavior; 8) difficulty sustaining attention; 9) different learning styles; or 10) disruption of sleep or appetite, as a result of ADD or medication. These students often describe feeling bored at school, and may appear oppositional (APA, 2000). Motivation around academic tasks or conforming to rules can be a challenge for these students. 

A simple intervention that has proven successful includes "chunking" or organizing assignments into smaller sections. This makes successful completion a more likely outcome, and if applied to in-class assignments, allows the student a legitimate reason to get up and walk to the teacher's desk. Even such a small amount of movement can help discharge energy that is so critical for these students. It is for this reason that a common consequence for not completing homework (i.e., losing recess) is actually counter-productive with overactive children. 

It is also important to remember the lack of self-monitoring ability as being central for many of these individuals. Teachers and parents can help children and adolescents develop this skill. Mechanisms to increase self-awareness include external monitoring systems such as checklists in the classroom. Additionally, the teacher can provide verbal cues such as asking the class to, "Stop and check - where is your mind?" Or the teacher can use physical monitoring cues for particular students, e.g., a simple tap on the shoulder to help them self-monitor. These cues are general enough to ensure that students don't feel ostracized by their use. 

PROGNOSIS

Symptoms of attention deficit continue throughout adulthood, although symptoms of hyperactivity generally do not. Recent estimates as high as 50% have been made regarding the continuation of symptoms into adulthood (Stern, Garg and Stern, 2002). It is noted that the gender ratio in adulthood (approximately twice as frequent for males) is more equal than in childhood (estimates ranging from 6 to 10 males for every 1 to 3 females; APA, 2000). 

RESOURCES

Children and Adults with Attention Deficit Disorder (CHADD) CHADD website: http://www.chadd.org/ CHADD National Call Center 1-800-233-4050 
Attention Deficit Disorder Association Website: http://www.add.org 

American Academy of Child & Adolescent Psychiatry Website: http://www.aacap.org/ 

REFERENCES

American Psychiatric Association (APA), 2000. Diagnostic and Statistical Manual of Mental Disorders (4th ed.), Text Revision. Washington, D.C.: American Psychiatric Association. 

Burns, G.L. & Walsh, J.A. (2002). The influence of ADHD-hyperactivity/impulsivity symptoms on the development of oppositional defiant disorder symptoms in a 2-year longitudinal study. Journal of Abnormal Child Psychology, 30(3), 245-257. 

Chi, T.C. & Hinshaw, S.P. (2002). Mother-child relationships of children with ADHD: the role of maternal depressive symptoms and depression-related distortions. Journal of Abnormal Child Psychology, 30(4), 387-401. 

Combs, J.T. (2002). Lack of right ear advantage in patients with attention-deficit/hyperactivity disorder. Clinical Pediatrics, 41(4), 231-235. 

Klorman, R.; Hazel-Fernandez, L.A.; Shaywitz, S.E.; Fletcher, J.M.; Marchione, K.E.; Holahan, J.M.; Stuebing, K.K.; & Shaywitz, B.A. (1999). Executive functioning deficits in attention-deficit/hyperactivity disorder are independent of oppositional defiant or reading disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 38(9), 1148-1156. 

Lloyd, J.W.; Hallahan, D.P.; Kauffman, J.M.; & Keller, C.E. (1998). Academic problems. In R.J. Morris & T.R. Kratochwill (Eds.). The practice of child therapy (pp. 167-198). Boston: Allyn & Bacon. 

Mick, E.; Biederman, J.; Faroane, S.V.; Sayer, J.; & Kleinman, S. (2002). Case-control study of attention-deficit hyperactivity disorder and maternal smoking, alcohol use and drug use during pregnancy. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 378-385. 

Shapiro, E.S.; DuPaul, G.J.; & Bradley-Klug, K.I. (1998). Self-management as a strategy to improve classroom behavior of adolescents with ADHD. Journal of Learning Disabilities, 31, 545-555. 

Shatin, D. & Drinkard, C.R. (2002). Use of drugs to treat ADHD and depression in youth steadily increased. Pain and Central Nervous System Week, 19-24. 

Stein, D.; Pat-Horenczyk, R.; Blank, S.; Dagan, Y.; Barak, Y.; & Gumpel, T.P. (2002). Sleep disturbances in adolescents with symptoms of attention-deficit/hyperactivity disorder. Journal of Learning Disabilities, 35(3), 268-276. 

Stern, H.P.; Garg, A.; & Stern, T.P. (2002). When children with attention-deficit/hyperactivity disorder become adults. Southern Medical Journal, 95, 985-992.

Depression and Disability in Children and Adolescents. ERIC Digest

ERIC Identifier:  ED482340
Publication Date: 2003-08-00
Author: Guetzloe, Eleanor
Source: ERIC Clearinghouse on Disabilities and Gifted Education

Depression and Disability in Children and Adolescents. ERIC Digest.

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

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

Major Depressive Disorder

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

Dysthymic Disorder

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

Bipolar Disorder

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

Other Disabilities Associated With Depressive Disorders

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

The Link Between Depression and Suicide.

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

Causal Factors Related to Depression

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

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

Diagnosis and Assessment of Depressive Illness in Young People

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

Treatment of Depressive Disorders

Treatment approaches for children and adolescents include psychosocial interventions (e. g., cognitive behavior therapy) and medication, as well as traditional psychotherapy. Two forms of cognitive therapy (i.e., self-control therapy for prepubertal children and coping skills for adolescents) have been judged as probably effective (Kaslow & Thompson, 1998).

A number of medications are commonly prescribed for children and adolescents with depression, but many of these have not yet been subjected to sufficient study. Effective treatment requires intervention by both medical and mental health professionals, with support from all others who come in contact with the young person; and is therefore not within the purview of the school alone.

School and Classroom Intervention

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

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

Summary

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

Resources

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

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

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

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

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

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

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

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

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

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

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

U. S. Department of Health and Human Services (2003). Mood disorders. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administraion, The Center for Mental Health Services, National Institutes of Health, National Institute of Mental.http://www.mentalhealth.org/publications/allpubs/ken98-0049/default.asp

Depression & Bipolar Support Alliance (DBSA)
www.DBSAlliance.org

National Alliance for the Mentally Ill (NAMI)
http://www.nami.org

National Foundation for Depressive Illness, Inc.
http://www.depression.org

National Institute of Mental Health
http://www.nimh.nih.gov

National Mental Health Association (NMHA)
http://www.nmha.org

Psychodiagnosis for Counselors: The DSM-IV. ERIC Digest

ERIC Identifier: ED366890 
Publication Date: 1994-04-00 
Author: Hinkle, J. Scott 
Source: ERIC Clearinghouse on Counseling and Student Services Greensboro NC. 

Psychodiagnosis for Counselors: The DSM-IV. ERIC Digest.

The profession of counseling is growing rapidly as reflected by the proliferation of professional community mental health counseling graduate programs. Graduates of these programs are providing counseling services in mental health centers, psychiatric hospitals, employee assistance programs, and various other community settings. At the foundation of effective mental health care is problem conceptualization and treatment planning which rely on the establishment of a valid diagnosis. This has caused an increase in the number of graduate community mental health counseling programs requiring course work in abnormal behavior, psychopathology, and psychodiagnosis. As a result, utilization of the "Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition" (DSM-IV) (APA) (1994) also has been dramatically increased in counselor education training. Skill in its use is undoubtedly necessary when assessing counseling clients seeking services in community mental health settings.

Utilization of the DSM-IV within the counseling profession is not, however, without controversy. Assigning a diagnosis to a client is uncomfortable for many counselors. The disadvantages associated with using the DSM have included the promotion of a mechanistic approach to mental disorder assessment, the false impression that the understanding of mental disorders is more advanced than is actually the case, and an excessive focus on the signs and symptoms of mental disorders to the exclusion of a more in-depth understanding of the client's problems including human development. Relatedly, Wakefield (1992) has recently argued that the DSM concept of "mental disorder" would better serve people if it were referred to as a "harmful dysfunction." He has based this on numerous citations that have suggested psychodiagnosis is used to control or stigmatize behavior that is actually more socially undesirable than disordered.

Conversely, advantages to implementing the DSM have included the development of a common language for discussing diagnoses, an increase in attention to behaviors, and facilitation of the overall learning of psychopathology. Seligman (1990) has indicated that knowledge of diagnosis is important for counselors so that they may provide a diagnosis for clients with insurance coverage and inform clients if their counseling will be covered by medical insurance. In addition, a DSM diagnosis assists with accountability and record keeping, treatment plan, communication with other helping professionals, and identification of clients with issues beyond areas of expertise.

MAJOR PSYCHODIAGNOSTIC FEATURES OF THE DSM-IV

According to the DSM-IV, mental disorders are conceptualized as clinically significant behavioral or psychological syndromes or patterns that occur in a "person" and are associated with "distress" (a painful symptom) or "disability" (impairment in one or more important areas of functioning) or with increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, the syndrome or pattern must not be an expectable response to a particular event (APA, 1994).

Although the DSM system can be difficult to interpret for those with limited clinical experience or personal familiarity with mental disorders, it is relatively easy for experienced counselors to learn. Each DSM-IV contains specific diagnostic criteria, the essential features and clinical information associated with the disorder, as well as differential diagnostic considerations. Information concerning diagnostic and associated features, culture, age, and gender characteristics, prevalence, incidence, course and complications of the disorder, familial pattern, and differential diagnosis are included. Many diagnoses require symptom severity ratings (mild, moderate, or severe) and information about the current state of the problem (e.g., partial or full remission).

The DSM-IV contains fifteen categories of mental disorders. "Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence" focuses on developmental disorders and other childhood difficulties. "Delirium, Dementia, Amnestic and Other Cognitive Disorders" include Alzheimer's conditions and Vascular Dementia. "Mental Disorders Due to a General Medical Condition" include anxiety and mood difficulties as well as personality change due to physical complications. "Substance Related Disorders" consist of drug and alcohol abuse and dependence. "Schizophrenia and Other Psychotic Disorders" are a continuum of difficulties that stress lack of contact with reality as well as Delusional Disorders. "Mood Disorders" and "Anxiety Disorders," including Major Depression and Posttraumatic Stress Disorder are featured diagnoses often used by counselors. "Somatoform Disorders, Factitious Disorders, Dissociative Disorders, Sexual and Gender Identity Disorders, Eating Disorders, Sleep Disorders, Impulse Control Disorders, Adjustment Disorders," and "Personality Disorders" are among the other diagnostic categories in the DSM-IV. In addition, several lesser disorders referred to as V Codes are included (e.g., Parent-Child Relational Problem, Partner Relational Problem, Bereavement, and Occupational Problem). Due to the V Codes' "minor status," they are typically not covered by third party payers.

THE MULTIAXIAL SYSTEM

Diagnoses in the DSM-IV are coded by the "multiaxial system" which incorporates five axes. All diagnoses except for Personality Disorders are coded on Axis I. Only Personality Disorders and Mental Retardation are coded on Axis II. Axis III is for physical disorders and conditions. Axes IV and V represent Severity of Psychosocial and Environmental Problems and Global Assessment of Functioning (GAF), respectively, and are used for treatment planning and prognosticating. For example, a full multiaxial diagnosis would be presented as:

AXIS I:

--309.00 Adjustment Disorder with Depressed Mood

--V61.12 Partner Relational Problem

AXIS II:

--799.90 Diagnosis deferred on Axis II

AXIS III: None

AXIS IV:

--Psychosocial stressors: change of jobs

--Severity: 3 - Moderate (acute circumstances)

AXIS V:

--Current GAF: 66

--Highest GAF Past Year: 80

When considering a DSM-IV diagnosis, the frequency, intensity, and duration of symptoms as well as premorbid functioning must be addressed.

SOCIOCULTURAL IMPLICATIONS

Professional counselors utilizing DSM-IV diagnoses yield sizeable power that can be interpreted as oppressive to some groups of people. Third party interests (i.e., insurance carriers) also may bring nonscientific values into the diagnostic process.

In accurate psychodiagnosis depends on ethnocultural and linguistic sensitivity (Malgady, Rogler & Constantino, 1987). Clients of lower socioeconomic class may experience, define, and manifest mental disorders differently from middle- and upper-class clients. Moreover, the DSM's lack of focus on the problematic features of a social context may be perpetuating the oppression of certain groups of people (e.g., women).

Gender and race of clinician also have been found to impact an accurate psychodiagnosis (Loring & Powell, 1988). Counselors using the DSM-IV will need to be keenly aware of the implications associated with its use as well as the impact a diagnosis may have on a client's treatment--within and outside of the counseling process.

In conclusion, the DSM-IV is not the only psychodiagnostic nomenclature in existence, but it is the most popular and is here to stay. Counselors have utilized it in a professional manner in the past, use the DSM-IV today, and will use the DSM-V in the future. An up-to-date understanding of this diagnostic system and its vast implications in counseling will be imperative to the effective and ethical delivery of professional community mental health counseling services.

RESOURCE DOCUMENTS

American Psychiatric Association. (1994). "Diagnostic and statistical manual of mental disorders" (4th ed.). Washington, DC: Author.

Loring, M. & Powell, B. (1988). Gender, race, and DSM-III: A study of the objectivity of psychiatric diagnostic behavior. "Journal of Health and Social Behavior," 29, 1-22.

Hinkle, J. S. (in press). The DSM-IV is coming: Prognosis and implications for mental health counselors. "Journal of Mental Health Counseling."

Malgady, R. G., Rogler, L. H., & Constantino, G. (1987). Ethnocultural and linguistic bias in mental health evaluation of Hispanics. "American Psychologist," 42, 228-234.

Pavkov, T. W., Lewis, D. A., & Lyons, J. S. (1989). Psychiatric diagnoses and racial bias: An empirical investigation. "Professional Psychology: Research and Practice," 20, 364-38.

Perry, S., Frances, A., & Clarkin, J. (1990). "A DSM-III-R casebook of treatment selection." New York: Brunner/Mazel.

Seligman, L. (1990). "Selecting effective treatments: A comprehensive systematic guide to treating adult mental disorders." San Francisco: Jossey-Bass.

Wakefield, J. C. (1992). The concept of mental disorder: On the boundary between biological facts and social values. "American Psychologist," 47, 373-388. 

Auditory Processing Disorders: An Overview

ERIC Identifier: ED474303 
Publication Date: 2002-12-00 
Author: Ciocci, Sandra R. 
Source: ERIC Clearinghouse on Disabilities and Gifted Education Arlington VA. 

Auditory Processing Disorders: An Overview. ERIC Digest.

Children who have difficulty using information they hear in academic and social situations may have central auditory processing disorder (CAPD), more recently termed auditory processing disorder (APD). These children typically can hear information but have difficulty attending to, storing, locating, retrieving, and/or clarifying that information to make it useful for academic and social purposes (Katz & Wilde, 1994). This can have a negative impact on both language acquisition and academic performance.

WHAT IS CENTRAL AUDITORY PROCESSING?

When the ears detect sound, the auditory stimulus travels through the structures of the ears, or the peripheral auditory system, to the central auditory nervous system that extends from the brain stem to the temporal lobes of the cerebral cortex. The auditory stimulus travels along the neural pathways where it is "processed," allowing the listener to determine the direction from which the sound comes, identify the type of sound, separate the sound from background noise, and interpret the sound. The listener builds upon what is heard by storing, retrieving, or clarifying the auditory information to make it functionally useful.

WHAT IS A DISORDER OF AUDITORY PROCESSING?

APD is an impaired ability to attend to, discriminate, remember, recognize, or comprehend information presented auditorily in individuals who typically exhibit normal intelligence and normal hearing (Keith, 1995). This definition has been expanded to include the effects that peripheral hearing loss may contribute to auditory processing deficits (Jerger & Musiek, 2000). Auditory processing difficulties become more pronounced in challenging listening situations, such as noisy backgrounds or poor acoustic environments, great distances from the speaker, speakers with fast speaking rates, or speakers with foreign accents (Sloan, 1998).

WHAT ARE THE BEHAVIORS OF CHILDREN WITH APD?

Children who have auditory processing disorders may behave as if they have a hearing loss. While not all children present all behaviors, Keith (1995) offers the following examples of behaviors that may be displayed by children who have APD:

* Inconsistent response to speech

* Frequent requests for repetition (What? Huh?)

* Difficulty listening or paying attention in noisy environments

* Often misunderstanding what is said

* Difficulty following long directions

* Poor memory for information presented verbally

* Difficulty discerning direction from which sound is coming

* History of middle ear infection.

WHAT ARE ACADEMIC CHARACTERISTICS OF CHILDREN WHO HAVE APD?

In addition to the preceding behaviors, children may also present a variety of academic characteristics that may lead teachers and parents to suspect APD. Baran (1998) offers the following characteristics. Again, all children will not present all characteristics.

* Poor expressive and receptive language abilities

* Poor reading, writing, and spelling

* Poor phonics and speech sound discrimination

* Difficulty taking notes

* Difficulty learning foreign languages

* Weak short-term memory

* Behavioral, psychological, and/or social problems resulting from poor language and academic skills.

HOW IS APD DIAGNOSED?

Given the complexity of auditory processing disorders, it is important to involve a multidisciplinary team including psychologists, physicians, teachers, parents, and of course, audiologists and speech-language pathologists. Audiologists diagnose the presence of APD (hearing and processing problems), and speech-language pathologists evaluate a child's perception of speech and receptive- expressive language use. Other team members conduct additional assessments to determine a child's educational strengths and weaknesses. Checklists that ask teachers and parents to observe the child's auditory behaviors may be used to determine a need for the APD evaluation. The parent's description of the child's auditory behavior at home is an especially important contribution to the diagnosis of APD.

WHAT DOES THE AUDIOLOGIST DO?

The audiologist assesses the peripheral and central auditory systems using a battery of tests, which may include both electrophysiological and behavioral tests. Peripheral hearing tests determine if the child has a hearing loss and, if so, the degree to which the loss is a factor in the child's learning problems. Assessment of the central auditory system evaluates the child's ability to respond under different conditions of auditory signal distortion and competition. It is based on the assumption that a child with an intact auditory system can tolerate mild distortions of speech and still understand it, while a child with APD will encounter difficulty when the auditory system is stressed by signal distortion and competing messages (Keith, 1995). The test results allow the audiologist to identify strengths and weaknesses in the child's auditory system that can be used to develop educational and remedial intervention strategies.

HOW SHOULD TEST RESULTS BE INTERPRETED?

As with any kind of evaluation, test results should be interpreted with caution. The effects of neurological maturation may influence test results for children under the age of 12 years. A true diagnosis of APD cannot be determined until that time (Bellis, 1996). However, there are much younger children whose auditory behaviors, language, and academic characteristics indicate that APD is a strong possibility, and even without a formal diagnosis, these children would benefit from intervention. Remediation should address their strengths and areas of need based on available speech-language and psychoeducational testing.

IS THERE A RELATIONSHIP BETWEEN APD AND ADHD?

The behaviors of children with APD and ADHD may be very similar, especially with regard to distractibility. Given what is presently known, APD and ADHD do not appear to be a single developmental disorder. Each can occur independently, or they can coexist. This is a prime example of where the team approach to evaluation is critical, as the team can rule out the presence of ADHD or determine its contribution to the potential educational impact on the child.

WHAT CAN BE DONE TO HELP CHILDREN WITH APD IN THE CLASSROOM?

Traditional educational and therapeutic approaches can be employed to remediate areas of need in language, reading, and writing. Many techniques that have shown to be effective with children with APD would be beneficial to all children, with and without APD, if the strategies employed are specific to the child's areas of need (Bellis, 1996; Chermak & Musiek, 1997; Sloan, 1998). Some of these are described below:

* Modify the environment by reducing background noise and enhancing the speech signal to improve access to auditory information:

- Eliminate or reduce sources of noise in the classroom (air vent, street traffic, playground, hallway, furniture noises, etc.).

- Use assistive listening devices (ALDs) such as a sound field amplification system or an FM auditory trainer.

- Allow preferential or roving seating to ensure that the child is seated as close to the speaker possible.

- Allow the child to use a tape recorder and/or a peer note taker.

- Ensure that the speaker gets the child's attention before speaking, and considers using a slower speaking rate, repeating directions, allowing time for the child to respond to questions, pausing to allow the child to catch up, and presenting information in a visual format through overheads, illustrations, and print.

* Teach the child to use compensatory strategies, "meta" strategies, or executive functions to teach how to listen actively. The child should:

- Learn to identify and resolve difficult listening situations.

- Develop skills to understand the demands of listening: attending, memory, identifying important parts of the message, self-monitoring, clarifying, and problem solving.

- Develop memory techniques: verbal rehearsal (reauditorization), mnemonics (chunking, cueing, chaining).

- Encourage use of external organizational aids: checklist, notebook, calendar, etc.

- Develop vocabulary, syntax, and pragmatic skills to facilitate language comprehension.

* Provide auditory training to remediate specific auditory deficits:

- Children who have poor reading, writing, and spelling skills may benefit from phonological awareness activities.

- Auditory closure activities may assist children in filling in or predicting the information they are listening to in the classroom and conversations.

- Instruction in interpreting intonation, speaking rate, or vocal intensity, and in the relationship between syllable and word may assist children in determining important parts of the message.

- When the child has demonstrated success on the above tasks in a quiet environment, give the child practice engaging in the same tasks in an environment that includes background noise.

- Explore the use of commercially available computer programs designed to develop the child's attention to the phonological aspects of speech. These should be recommended by a professional who can determine their applicability to the child's needs.

RESOURCES

American Speech-Language-Hearing Association. Task Force on Central Auditory Processing Disorders. (1995). Central auditory processing: Current status of research and implications for clinical practice. Rockville, MD: Author.

Baran, J. A. (1998). Management of adolescents and adults with central auditory processing disorders. In Masters, M. G., Stecker, N. A., & Katz, J. (Eds.). Central auditory processing disorders: Mostly management. Needham Heights, MA: Allyn and Bacon, 195-214.

Bellis, T. J. (1996). Assessment and management of central auditory processing disorders in the educational setting: From science to practice. San Diego, CA: Singular Publishing Group, Inc.

Chermak, G. D. & Musiek, F. E. (1997). Central auditory processing disorders: New perspectives. San Diego, CA: Singular Publishing Group, Inc.

Jerger, J. & Musiek, F. E. (2000). Report on the consensus conference on the diagnosis of auditory processing disorders in school-aged children. Journal of the American Academy of Audiology, 11, 467-474.

Katz, J. & Wilde, L. (1994). Auditory processing disorders. In Katz, J. (Ed).Handbook of clinical audiology. (4th edition.). Baltimore, MD: Williams and Wilkins, (4th ed.). 490-502.

Keith, R. W. (1995). Tests of central auditory processing. In Roeser, R. J. & Downs, M. P. (Eds.). Auditory disorders in school children. New York, NY: Thieme Medical Publishers, Inc., 101-116.

Sloan, C. (1998). Management of auditory processing difficulties: A perspective from speech-language pathology. Seminars in Hearing, 19, 367-398.

Diagnosing Communication Disorders in Culturally and Linguistically Diverse Students

ERIC Identifier:  ED482343
Publication Date: 2003-10-00
Author: Crowley, Catherine J.
Source: ERIC Clearinghouse on Disabilities and Gifted Education

Diagnosing Communication Disorders in Culturally and Linguistically Diverse Students. ERIC Digest.

The disproportionate referral of bilingual and culturally diverse students to special education and related services is a pressing challenge in public school systems. Not only are unnecessary services a drain on resources, but they are harmful to children, taking them away from the classroom and inevitably stigmatizing them. In addition, an incorrect diagnosis may mean that a child does not receive the services he or she does need.

Accurate assessment of culturally and linguistically diverse students is difficult in any area. Assessing the speech and language skills of these students is even more challenging. The evaluator must make the crucial differential diagnosis between a communication disorder and something else. This "something else" could have a cultural basis, such as a mismatch between demands of school and home, or a linguistic basis, such as evidence of the normal process of second language acquisition or speaking a non-standard dialect of English. This digest describes the current preferred practice in the assessment of communication disorders in culturally and linguistically diverse students.

What qualifies as a communication disorder?

For any student, communication skills are disordered if they deviate sufficiently from the norms and expectations of the student's speech community.

The challenge with culturally and linguistically diverse students is that many of the traditional assessment tools and benchmarks are not based upon their speech communities. Instead, they generally are based upon the "mainstream" or "standard" dialect of American English, known as "Standard American English" (SAE). (This dialect is often identified as the one spoken by newscasters or in educational settings.) While it is critical that students acquire this dialect, evaluators cannot identify students with a communication disorder because they speak a different dialect.

Why not use test scores to identify a communication disorder?

The limitations of speech and language tests in accurately discriminating typical and impaired language speakers of SAE are widely known (McCauley & Swisher, 1984). So, before reporting any test scores, the evaluator analyzes the test's quality and applicability. To do this, the evaluator considers:

• Construct validity. How accurate is the test in distinguishing typically developing students from students with communication disorders?
• Content validity. Do the test items make sense?
• Normative sample. Did significant numbers of the subjects used to norm the test have similar linguistic and cultural backgrounds as the student being evaluated?
• Reliability. Are the test results consistent for a student even if the test is given again or given by a different evaluator?

An analysis of the quality and applicability of currently available tests reveals that none meets acceptable standards (McCauley & Swisher, 1984). The use of scores derived from such tests causes inaccurate identification of students with communication disorders, which has "serious" "social consequences" (Plante & Vance, 1994, p. 21).

With English language learners, the use of translated versions of speech and language tests pose even greater problems. For example, many translations provide word-for-word translations which do not account for a lack of equivalent linguistic forms in the second language. Additionally, translated tests do not consider the effects of second language acquisition on a student's performance. As a result, scores from these translated versions should not be used to diagnose a communication disorder.

How does the evaluator determine whether a student has a communication disorder?

Before deciding whether a communication disorder exists, the evaluator first accumulates a good deal of information about the student's communication skills. The evaluator approaches this phase as both an anthropologist and a detective. Critical information includes:

• Comprehensive data concerning the student's significant current and past exposure to particular languages and dialects, and consideration of the student's proficiencies in those languages and dialects.
• Data about the student's speech and language skills in a number of settings and covering different types of language, such as social language and more demanding uses such as for comparison, synthesis, and problem solving. This can be gathered by direct observation and elicitation, by interviewing people who can provide that information, and by reviewing historical information on the student's speech and language skills.
• Parent/long-time caregiver reports (this may be the most valuable information) including:
  • Developmental history and significant medical history;
  • Information on the parent's education and;
  • The parent's judgment as to:
    1. how the student's speech and language development compares to his/her siblings at the same age, or to the student's peers in his/her speech community;
    2. whether there is a history of speech-language problems in the student's family and/or;
    3. whether there is a history of academic problems in the student's family (Dale, 1996; Restrepo, 1998).
• Teacher interviews and portfolio reviews on overall school performance, both currently and historically.
• Tasks designed to probe particular areas of speech and language, whether using standardized or nonstandardized tools, including:
  • Grammatical development compared to the norms of the student's speech community;
  • Ability to comprehend and integrate information the student hears and reads in his/her school and community;
  • Ability to organize and integrate ideas and information so the student can express himself/herself when participating in classroom discussions and in written work;
  • Development of curriculum-based language skills such as phonological awareness, language-based memory skills, vocabulary development, and language-based literacy and math skills.
• Information on the student's ability to learn, generally elicited through dynamic assessment methods, to aid in determining whether the student's incorrect response was due to a lack of prior exposure to the test's task requirement or content, or a true communication disorder.

How does the evaluator analyze the information?

After all the critical information is gathered, the evaluator analyzes a number of factors to determine whether any apparent difficulties are due to a true communication disorder or to something else-such as a communication difference or a lack of prior exposure. To make this differential diagnosis, the evaluator applies available research on the norms of a student's speech community. Often the research is limited. The evaluator applies his/her own knowledge base, and may enlist the help of someone who knows the student's linguistic and cultural background and who can, with proper training, provide valuable information on these critical factors:

• Sociolinguistics. The evaluator considers how social and cultural factors might have influenced the quality and quantity of information gathered. For example, a student might be reticent to talk 1) with an adult she/he does not know, 2) about something the student is not interested in, or 3) in an unfamiliar setting. The evaluator also considers how the particular information-gathering tasks might be culturally unfamiliar to the student. Depending on the student's speech community, examples of unfamiliar tasks might include tasks requiring that the student 1) answer questions that the evaluator already knows the answers for; 2) tell stories if the student did not have experience telling or hearing stories; or 3) label objects when that is not commonly done at home (Heath, 1982).
• Prior educational experiences. The evaluator distinguishes between the effect of poor educational experiences and a true communication disorder. Substandard school instruction may impact many aspects including the fund of general knowledge, vocabulary skills, problem solving skills, literacy skills, and, of course, success in meeting curriculum standards.
• Linguistics. The evaluator adjusts his/her linguistic criteria based upon characteristics of second language learning; amount and quality of exposure to various dialects the student produces; and variations as to when certain developmental benchmarks are met in different languages and dialects. This linguistic knowledge also enables the evaluator to distinguish an accent from an articulation or phonological delay.

In the end, the evaluator analyzes the data to determine

• whether the student has a communication disorder, and
• if so, the level of severity of that disorder.

The written report contains sufficient information, including quoting and describing actual speech and language performance data, to enable a reader to understand how the evaluator forms his/her clinical judgment, based upon an analysis of all the accumulated information.

Terminology

Culturally diverse: Describes an individual or group that is exposed to, and/or immersed in, more than one set of cultural beliefs, values, and attitudes.

Dialect: Describes a variety of a language. Dialects are seen as applicable to all languages and all speakers. All languages are analyzed into a range of dialects, which reflect the regional and social background of their speakers.

Linguistically diverse: Describes an individual or group that is exposed to, and/or immersed in, more than one language or dialect.

Speech community: A group of people who share at least one speech variety in common. Members of bilingual/bidialectal communities often have access to more than one speech variety. The selection of the specific variety depends upon such variables as the participants, the topic, the function, and the location of the speech event.

References

Dale, P. (1996). Parent report assessment of language and communication. In K. Cole, P. Dale and D. Thal (Eds.), Assessment of Communication and Language. Baltimore: Paul H. Brooks.

ERIC Clearinghouse on Disabilities and Gifted Education. (2000). Assessment of Culturally and Linguistically Diverse Students for Special Education Eligibility (ERIC EC Digest #E604). Arlington, VA: Author.

Heath, S.B. (1982). What no bedtime story means: Narrative skills at home and school. Language in Society (Vol. II). New York: Cambridge, pp. 49-6.

McCauley, R.J. & Swisher, L. (1984). Psychometric review of language and articulation tests for preschool children. Journal of Speech and Hearing Disorders, 49, 34-42.

Plante, E. & Vance, R. (1994). Selection of preschool language tests: A data-based approach. Language, Speech, and Hearing Services in Schools, 25, 15-24.

Restrepo, M.A. (1998). Identifiers of Predominantly Spanish-Speaking Children with Language Impairment, Journal of Speech, Language and Hearing Research , 1398-1411.

Children with Communication Disorders

ERIC Identifier: ED321504 
Publication Date: 1990-00-00 
Author: 
Source: ERIC Clearinghouse on Handicapped and Gifted Children Reston VA. Children with Communication Disorders. ERIC Digest #E470 (Revised #419). 

The term COMMUNICATION DISORDERS encompasses a wide variety of problems in language, speech, and hearing. Speech and language impairments include articulation problems, voice disorders, fluency problems (such as stuttering), aphasia (difficulty in using words, usually as a result of a brain injury), and delays in speech and/or language. Speech and language delays may be due to many factors, including environmental factors or hearing loss. 

Hearing impairments include partial hearing and deafness. Deafness may be defined as a loss sufficient to make auditory communication difficult or impossible without amplification. There are four types of hearing loss. Conductive hearing losses are caused by diseases or obstructions in the outer or middle ear and can usually be helped with a hearing aid. Sensorineural losses result from damage to the sensory hair cells of the inner ear or the nerves that supply it and may not respond to the use of a hearing aid. Mixed hearing losses are those in which the problem occurs both in the outer or middle ear and in the inner ear. A central hearing loss results from damage to the nerves or brain. 

Many communication disorders result from other conditions such as learning disabilities, cerebral palsy, mental retardation, or cleft lip or cleft palate. 

HOW MANY CHILDREN HAVE COMMUNICATION DISORDERS?

The overall estimate for speech and language disorders is widely agreed to be 5% of school-aged children. This figure includes voice disorders (3%) and stuttering (1%). The incidence of elementary school children who exhibit delayed phonological (articulation) development is 2% to 3%, although the percentage decreases steadily with age. 

Estimates of hearing impairments vary considerably, with one widely accepted figure of 5% representing the portion of school-aged children with hearing levels outside the normal range. Of this number, 10% to 20% require some type of special education. Approximately one-third of students who are deaf attend residential schools. Two-thirds attend day programs in schools for students who are deaf or day classes located in regular schools. The remainder are mainstreamed into regular school programs. 

WHAT ARE SOME CHARACTERISTICS OF CHILDREN WITH COMMUNICATION DISORDERS?

A child with speech or language delays may present a variety of characteristics including the inability to follow directions, slow and incomprehensible speech, and pronounced difficulties in syntax and articulation. SYNTAX refers to the order of words in a sentence, and ARTICULATION refers to the manner in which sounds are formed. Articulation disorders are characterized by the substitution of one sound for another or the omission or distortion of certain sounds. 

Stuttering or dysfluency is a disorder of speech flow that most often appears between the ages of 3 and 4 years and may progress from a sporadic to a chronic problem. Stuttering may spontaneously disappear by early adolescence, but speech and language therapy should be considered. 

Typical voice disorders include hoarseness, breathiness, or sudden breaks in loudness or pitch. Voice disorders are frequently combined with other speech problems to form a complex communication disorder. 

A child with a possible hearing problem may appear to strain to hear, ask to have questions repeated before giving the right answer, demonstrate speech inaccuracies (especially dropping the beginnings and endings of words), or exhibit confusion during discussion. Detection and diagnosis of hearing impairment have become very sophisticated. It is possible to detect the presence of hearing loss and evaluate its severity in a newborn child. 

Students who speak dialects different from standard English may have communication problems that represent either language differences or, in more severe instances, language disorders. 

WHAT ARE THE EDUCATIONAL IMPLICATIONS OF COMMUNICATION DISORDERS?

Many speech problems are developmental rather than physiological, and as such they respond to remedial instruction. Language experiences are central to a young child's development. In the past, children with communication disorders were routinely removed from the regular class for individual speech and language therapy. This is still the case in severe instances, but the trend is toward keeping the child in the mainstream as much as possible. In order to accomplish this goal, teamwork among the teacher, speech and language therapist, audiologist, and parents is essential. Speech improvement and correction are blended into the regular classroom curriculum and the child's natural environment. 

Amplification may be extremely valuable for the child with a hearing impairment. Students whose hearing is not completely restored by hearing aids or other means of amplification have unique communication needs. Children who are deaf are not automatically exposed to the enormous amounts of language stimulation experienced by hearing children in their early years. For deaf children, early, consistent, and conscious use of visible communication modes such as sign language, finger spelling, and cued speech and/or amplification and aural/oral training can help reduce this language delay. Some educators advocate a strict oral approach in which the child is required to use as much speech as possible, while others favor the use of sign language and finger spelling combined with speech, an approach known as TOTAL COMMUNICATION. There is increasing consensus that whatever system works best for the individual should be used. 

Many children with hearing impairments can be served in the regular classroom with support services. In addition to amplification, instructional aids such as captioned films and high interest/low vocabulary reading materials are helpful. For most children with hearing impairments, language acquisition and development are significantly delayed, sometimes leading to an erroneously low estimate of intelligence. 

Students whose physical problems are so severe that they interfere with or completely inhibit communication can frequently take advantage of technological advances that allow the individual to make his or her needs and wants known, perhaps for the first time. 

ADDITIONAL READING

Adams, J. W. (1988). You and Your Hearing-Impaired Child: A Self-Instructional Guide for Parents. Washington, DC: Gallaudet University Press. 

Freeman, R. D., Carbin, C. F., & Boese, R. J. (1981). Can't Your Child Hear? A Guide for Those Who Care about Deaf Children. Baltimore: University Park Press. 

Grant, J. (1987). The Hearing Impaired: Birth to Six. Boston: Little, Brown. 

Hixon, T. J., Shribers, L. D., & Saxman, J. H. (Eds.). (1980). Introduction to Communication Disorders. Englewood Cliffs, NJ: Prentice-Hall. 

King, R. R. & Sommers, R. K. (1986). Talking Tots: Normal and Impaired Communication Development of Preschool Children. Danville, IL: Interstate Printers and Publishers. 

Luterman, D. (1987). Deafness in the Family. Boston: Little, Brown. 

Miller, A. L. (1980). Hearing Loss, Hearing Aids, and Your Child. Springfield, IL: Charles C Thomas. 

Moores, D. F. (1987). Educating the Deaf: Psychology, Principles, and Practices (3rd ed.). Boston: Houghton Mifflin. 

National Information Center on Deafness, & National Association of the Deaf. (1987). Deafness: A Fact Sheet. Washington, DC: Author. 

Ogden, P., & Lipsett, A. (1982). The Silent Garden: Understanding the Hearing Impaired Child. New York: St. Martin's. 

Oyer, H. J., Crowe, B., & Haas, W. H. (1987). Speech, Language, and Hearing Disorders: A Guide for the Teacher. Boston: Little, Brown. 

Schwartz, S. (Ed.). (1987). Choices in Deafness: A Parent;s Guide. Rockville, MD: Woodbine House. 

Van Hattum, R. J. (Ed.). (1980). Communication Disorders. AN Introduction. New York: Macmillan. 

Children and Post Traumatic Stress Disorder: What Classroom Teachers Should Know

ERIC Identifier: ED460122 
Publication Date: 2001-09-00 
Author: Grosse, Susan J. 
Source: ERIC Clearinghouse on Teaching and Teacher Education Washington DC., ERIC Clearinghouse on Counseling and Student Services Greensboro NC. 

Children and Post Traumatic Stress Disorder: What Classroom Teachers Should Know. ERIC Digest.

Post traumatic stress disorder: development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (APA, 1996).

School children may be exposed to trauma in their personal lives or, increasingly, at school. Classroom teachers can help prepare children to cope with trauma by understanding the nature of trauma, teaching children skills for responding to an emergency, and learning how to mitigate the after-effects of trauma.

PTSD RELATED TRAUMA

By the very unexpected nature of trauma, one can never totally prepare for it. And because each individual responds differently to emotional upset, it is impossible to predict trauma after-effects. Under certain circumstances, trauma can induce Post Traumatic Stress Disorder (PTSD). Unrecognized/untreated PTSD can have a lifelong negative impact on the affected individual. Teachers, who spend up to eight hours each day with the children in their charge, can influence the outcome of a child's response to trauma stress by creating an environment in which PTSD is less likely to develop to the point of life impact.

Not all emotionally upsetting experiences will cause PTSD. Trauma sufficient to induce PTSD has specific characteristics and circumstances, including situations

* perceived as life-threatening,

* outside the scope of a child's life experiences,

* not daily, ordinary, normal events,

* during which the child experiences a complete loss of control of the outcome, and

* when death is observed.

Disasters, violence, and accidents are just some of the experiences that can lead to PTSD. Preparing children for trauma involves giving them skills and knowledge to survive the experience and emerge with as little potential as possible for developing PTSD.

SKILLS TO SURVIVE TRAUMATIC EXPERIENCES

Survival skills for traumatic experiences are essentially emergency action plans.Carrying out emergency action plans not only helps a child retain some personal control, but increases the potential for a healthy outcome. Children must know how to:

* Follow directions in any emergency (i.e., stay in their classroom during a lock down)

* Get help in any type of emergency (i.e., dial 911 or call a neighbor)

* Mitigate specific emergencies (i.e., take shelter during a tornado)

* Report the circumstances (i.e., tell an adult if a stranger approaches them or touches them)

* Say "no" and mean it (i.e., firmly shouting "no, don't touch me").

Implementing survival skills requires knowing right and wrong. Children must know or be able to recognize:

* Appropriate vs. inappropriate touching (i.e., shoulder vs. genitals).

* Appropriate vs. inappropriate information sharing (i.e., who is at home at what times).

* Presence of appropriate vs. inappropriate people (i.e., the teacher on playground duty vs. a prowling stranger).

SKILLS TO MITIGATE PTSD

While there is no predictability in who will develop PTSD, it is possible to take steps to prepare children ahead of time and by doing so, lessen the PTSD potential. Children need to be taught lessons about trauma. Learning about people who have experienced trauma and gone on to live healthy lives gives children role models and hope for their own future.

During a traumatic experience, children will survive better if they have a structure to follow and can maintain some sense of control. Learning the survival skills will aid in maintaining this control. Children need accurate and specific information about their immediate safety, about what has happened and about what will happen to them next (James, 1989). Knowledge helps them control their thoughts and feelings.

Following a trauma, debriefing is critical. Children will vary concerning their willingness and readiness to talk about their experiences. Some will play out the event, while others may be more comfortable writing or drawing about the event. What is important is the opportunity to communicate. There are different avenues for the child to communicate, including online discussion forums for children (Sleek, 1998).

A child's initial debriefing should be child-centered and nonjudgmental. The adult should recognize that each child did his or her best, no matter what the outcome, and refrain from offering advice. Adults should recognize that no two children will have the same thoughts, feelings, or opinions. All expressions about the trauma are acceptable.

Following a trauma, it is also important to help a child reestablish control. Reviewing survival skills and drills and planning for "next time" reestablishes strength. Allowing a child to make choices reestablishes their governance over their own lives.

IDENTIFYING PTSD

Everyone reacts to trauma. What differentiates normal reaction from PTSD is the timing of the reaction, its intensity, and the duration of the reaction. Trauma includes emotional as well as physical experiences and injury. Even second-hand exposure to violence can be traumatic. For this reason, all children and adolescents exposed to violence or disaster, even if only through graphic media reports, should be watched for signs of emotional distress (National Institute of Mental Health, 2000).

Symptoms lasting more than one month post trauma may indicate a problem. Specific symptoms to look for include:

* Re-experiencing the event (flashbacks),

* Avoidance of reminders of the event,

* Increased sleep disturbances, and

* Continual thought pattern interruptions focusing on the event.

In children, symptoms may vary with age. Separation anxiety, clinging behavior, or reluctance to return to school may be evident, as may behavior disturbances or problems with concentration. Children may have self doubts, evidenced by comments about body confusion, self-worth, and a desire for withdrawal. As there is no clear demarcation between adolescence and adulthood, adult PTSD symptoms may also evidence themselves in adolescents. These may include recurrent distressing thoughts, sleep disturbances, flashbacks, restricted range of affect, detachment, psychogenic amnesia, increased arousal and hypersensitivity, and increased irritability and outbursts or rage.

HELPING THE CHILD

Making the diagnosis of PTSD requires evaluation by a trained mental health professional. However, regular classroom teachers have a major role in the identification and referral process. Children often express themselves through play. Because the teacher sees the child for many hours of the day including play time, the teacher may be the first to suspect all is not well. Where the traumatic event is known, caregivers can watch for PTSD symptoms. However, traumatic events can involve secrets. Sexual abuse, for example, may take place privately. Sensitive teachers should monitor all children for changes in behavior that may signal a traumatic experience or a flashback to a prior traumatic experience.

Teachers can help a child suspected of post traumatic stress disorder by: * Gently discouraging reliance on avoidance; letting the child know it is all right to discuss the incident;

* Talking understandingly with the child about their feelings;

* Understanding that children react differently according to age - young children tend to cling, adolescents withdraw;

* Encouraging a return to normal activities;

* Helping restore the child's sense of control of his or her life; and

* Seeking professional help.

Professional assistance is most important since PTSD can have a lifelong impact on a child. Symptoms can lie dormant for decades and resurface many years later during exposure to a similar circumstance. It is only by recognition and treatment of PTSD that trauma victims can hope to move past the impact of the trauma and lead healthy lives. Thus, referral to trained mental health professionals is critical. The school psychologist is a vital resource, and guidance counselors can be an important link in the mental health resource chain.

Although professional assistance is ultimately essential in cases of PTSD, classroom teachers must deal with the immediate daily impact. Becoming an informed teacher isthe first step in helping traumatized children avoid the life long consequences of PTSD.

REFERENCES

American Psychiatric Association. (1996). Diagnostic and statistical manual of mental disorders IV. Washington, DC. American Psychiatric Association.

James, B. (1989). Treating traumatized children: new insights and creative interventions. Lexington, MA: D.C. Heath.

National Institute of Mental Health (2000). Helping children and adolescents cope with violence and disasters. Washington, DC: NIMH. Available online at http://www.nimh.nih.gov/publicat/violence.cfm

Sleek, S. (1998). After the storm, children play out fears. APA Monitor, 29(6). Available online at http://www.apa.org/monitor/jun98/child.html.

RESOURCES AVAILABLE FROM ERIC

These resources have been abstracted and are in the ERIC database. Journal articles (EJ) should be available at most research libraries; most documents (ED) are available in microfiche collections at more than 900 locations. Documents can also be ordered through the ERIC Document Reproduction Service (800-443-ERIC).

Demaree, M.A. (1995). Creating safe environments for children with post-traumatic stress disorder. Dimensions of Early Childhood, 23(3), 31-33, 40. EJ 501 997.

Demaree, M.A. (1994). Responding to violence in their lives: Creating nurturing environments for children with post-traumatic stress disorder (conference paper). ED 378 708.

Dennis, B.L. (1994). Chronic violence: A silent actor in the classroom. ED 376 386.

Karcher, D.R. (1994). Post-traumatic stress disorder in children as a result of violence: A review of current literature (doctoral research paper). ED 379 822.

Motta, R.W. (1994). Identification of characteristics and causes of childhood posttraumatic stress disorder. Psychology in the Schools, 31(1), 49-56. EJ 480 780.

Richards, T., & Bates, C. (1997). Recognizing posttraumatic stress in children. Journal of School Health, 67(10), 441-443. EJ 561 961.

OTHER RESOURCES

American Academy of Child and Adolescent Psychiatry, 3615 Wisconsin Avenue, NW, Washington, DC, 20016-3007, 202-966-7300, http://www.aacap.org

American Psychiatric Association, 1400 K Street, NW, Washington, DC 20005, 202-682-6000; http://www.psych.org

American Psychological Association, 750 First Street, NE, Washington, DC 20002, 202-336-5500, http://www.apa.org

Anxiety Disorders Association of America (ADAA), 11900 Parklawn Drive, Suite 100, Rockville, MD 20852, 301-231-9350; http://www.adaa.org

Disaster Stuff for Kids, http://www.jmu.edu/psychologydept/4kids.htm

Federal Emergency Management Agency http://www.fema.gov/kids

International Society for Traumatic Stress Studies (ISTSS), 60 Revere Drive, Suite 500, Northbrook, IL 60062, http://www.istss.org

National Center for Kids Overcoming Crisis, (includes Healing Magazine online) 1-800-8KID-123, http://www.kidspeace.org/facts

National Center for PTSD, 215 N. Main Street, White River Junction, VT 05009; 802-296-5132; http://www.ncptsd.or

National Center for Post-Traumatic Stress Disorder of the Department of Veterans Affairs http://www.ncptsd.org/

National Institute for Mental Health (NIMH) 6001 Executive Boulevard, Rm 8184, MSC 9663, Bethesda, MD 20892-9663; 301-4513, Hotline 1-88-88-ANXIETY, http://www.nimh.nih.gov