School Psychiatry Resources

This page is a joint project of the Massachusetts General Hospital School Psychiatry Program and the Mood & Anxiety Disorders Institute Resource Center. We are committed to enhancing the education and mental health of every student in every school.

This site contains a curriculum for teaching emotional self-regulation tools, as well as information about common mental health conditions that affect young people.

See the curriculum     Explore mental health conditions

The site’s collaborators include:

• Child & Adolescent Psychiatrists - Lisa Price, MD, Jefferson Prince, MD, Jeff Bostic, MD, EdD and Mona Patel Potter, MD
• Education Professionals - Julie DeLuca, EdM, Judy Derr, EdM, Denise Oldham, EdM, Joe Ristuccia, EdM, Perri Wexler, EdM, and many others
• Parents - Karen Blumenfeld and Jessica Solodar

Thank you to the individual and foundation donors who helped make this project possible.

Teaching Emotional Self-Regulation Skills

This section was created for high school teachers and mental health professionals. It provides materials that build aspects of emotional and behavioral competence into the high school English/language arts curriculum.

Preparation

Literature in the English/language arts curriculum provides an excellent starting point for classroom discussions about managing thoughts, feelings and behavior. Using literary characters as examples, you can start students thinking about how the skillful management of feelings, thoughts and behavior can lead to more positive outcomes in daily life.

A natural next step after examining how the characters in literature manage thoughts, feelings, and behavior is to encourage students to reflect on their own experiences. These lessons offer strategies for students to more effectively manage their own thoughts and feelings, consider others’ perspectives, resolve conflicts and make good choices even when feelings run high.

These lesson plans are designed for a team-teaching approach in collaboration with adjustment counselors, guidance counselors, school psychologists and other mental health clinicians.

How to Use These Materials

You can use the lesson plans to:

• Help students develop skills to recognize and overcome counterproductive thinking and behavior patterns in themselves and others
• Incorporate strategies for self-reflection, self-calming, and conflict resolution into the classroom, thereby promoting emotional well-being
• Proactively provide effective methods or easing emotional stress at home and at school

The lesson plans can be used to analyze virtually any piece of literature depicting characters facing emotional situations and interpersonal conflict. We encourage you to tailor the lesson plans for use with any literature of your choosing. You can use the four lessons either as a unit or individually.

Lessons

Student Manual: Assigned readings are drawn from this manual, and each lesson is paired with a corresponding thematic unit in the manual.

Brain Driver's Education: Operator's Guide to Using Your Brain to Get Where You Want to Go

Lesson on Emotional Regulation: "How hot or cold does your emotional 'engine' run?"

• Lesson Plan
• Student Activity
• Student Reading

Lesson on Self-Calming Methods: "Downshift to a lower gear, with help from your body"

• Lesson Plan
• Student Activity
• Student Reading

Lesson on Reframing Feelings: "Slow down and look around you"

• Lesson Plan
• Student Activity 1
• Student Activity 2
• Student Reading

Lesson on Conflict Resolution: "Find the best route to your destination"

• Lesson Plan
• Student Activity 1
• Student Activity 2
• Student Reading

Download all lessons

The Evidence Base

These lessons and readings, which were developed by a team of child and adolescent psychiatrists, educators, and parents, draw from widely accepted, evidence-based therapies and approaches for achieving mind/body wellness and healthy interpersonal relationships, including the following sources:

Cognitive Behavioral Therapy

• Beck, Judith S. and Beck, Aaron T. Cognitive Therapy: Basics and Beyond. New York: The Guilford Press, 1995.
• Beck, Aaron T., Rush, A. John, Shaw, Brian F., and Emery, Gary. Cognitive Therapy of Depression. New York: The Guilford Press, 1979.

Dialectical Behavioral Therapy

• Linehan, Marsha M. Skills Training for Treating Borderline Personality Disorder. New York: The Guilford Press, 1993.

Collaborative Problem Solving

• Greene, Ross W. Lost at School: Why Our Kids with Behavioral Challenges are Falling Through the Cracks and How We Can Help Them. New York: Scribner, 2009.
• Greene, Ross W. The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children. New York: Harper Paperbacks, Revised and Updated 2010.

Nature, Nurture, and the Brain

• Siegel, Daniel J. The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. New York: The Guilford Press, 2001.

Mind/Body Techniques

• Benson, Herbert and Klipper, Miriam Z. The Relaxation Response. New York: Harper Paperbacks, Revised and Updated 2000.

This site contains descriptions of mental health conditions and disorders commonly seen in children and adolescents. The information about each disorder provides answers to these questions:

• What is the disorder?
• What does the disorder look like in children and adolescents at home, at school and at the doctor's office?

The mental health conditions described are:

• Anxiety (generalized anxiety disorder)
• Separation anxiety disorder
• Social phobia (social anxiety disorder)
• Panic disorder
• Obsessive-compulsive disorder
• Depression
• Bipolar disorder (manic depression)
• Attention deficit/hyperactivity disorder (ADHD)
• Autism spectrum disorders

To contact us, please email moodandanxiety@partners.org.

We are unable to provide clinical advice or to recommend or endorse programs for a specific child. For assistance with a specific child, we encourage you to contact your local school's special education department, your state education agency or your local mental health providers. For urgent or emergency communications, please contact your local mental health provider or your local emergency room.

For information about how to receive clinical care in the Mass General Department of Psychiatry, please call:

For Children and Adolescents: 617-726-2725

For Adults: 617-724-7792

Participation in Clinical Trials

To learn more about clinical research studies at Mass General, please visit the Research at the Department of Psychiatry page.

Generalized Anxiety Disorder

What is generalized anxiety disorder?

Anxiety disorders are one of the most common mental health conditions in children and adolescents. While everyone may have occasional moments of feeling anxious or worried, an anxiety disorder is a medical condition that causes people to feel persistently, uncontrollably worried over an extended period of time. The disorder may result in significant distress in a number of settings, such as school, peer relationships, and home life, and it may dramatically affect people's lives by limiting their ability to engage in a variety of activities.

Anxiety that occurs in multiple settings, involving excessive apprehension about a number of situations on most days, is known as a generalized anxiety disorder. Generalized anxiety disorder (GAD) affects approximately three to four percent of children. Other anxiety disorders, which are triggered by more specific situations, include:

• Social phobia or social anxiety - fear of meeting new people or of embarrassing oneself in social situations
• Specific phobia - fear of a particular object (for example, a spider) or situation (for example, airplane travel)
• Separation anxiety disorder - fear of separating from home or primary caregiver
• Panic disorder - unpredictable and repeated panic attacks unrelated to surrounding circumstances
• Obsessive-compulsive disorder - uncontrollable, repetitive thoughts and fears, often accompanied by repetitive behaviors intended to prevent the fears from being realized
• Selective mutism - persistent failure to speak in specific social situations (despite the physical ability to speak in other situations), most likely due to severe social anxiety

The tendency to develop any anxiety disorder involves complex genetic and environmental factors, and it is possible for one person to have more than one anxiety disorder. 

What does generalized anxiety disorder look like in children and adolescents?

Children with generalized anxiety disorder are often preoccupied with worries about their success in activities and their ability to obtain the approval of others. These children may have persistent thoughts of self-doubt that they are unable to control, and they constantly criticize themselves. Children may be preoccupied with being on time to events and insist on doing a task "perfectly." In contrast to the ordinary, occasional worries or fears experienced in childhood, generalized anxiety disorder persists for at least six months and affects children throughout the day (at home, at school, and with friends).

Children may appear inflexible or excessively worried about conforming to rules, or they may not be able to enjoy hobbies or other recreational activities. Some children may appear shy when, in fact, they are preoccupied with significant worries. Even if children are aware that their worries are more intense than is warranted by a situation, they may not be able to stop the worry. A trained clinician (such as a child psychiatrist, child psychologist or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis. 

Separation Anxiety Disorder

What is separation anxiety disorder?

Separation anxiety disorder is a medical condition that is characterized by significant distress when a person is away from parents, another caregiver or home. Unlike the occasional, mild worries that children may feel at times of separation, separation anxiety disorder can dramatically affect a person's life by limiting the ability to engage in ordinary activities. Children with the disorder become extremely upset whenever they separate from their primary caregiver, whether that person is a parent, relative, nanny or other caregiver. Unlike children who are simply shy, children with separation anxiety disorder may become severely anxious and agitated even when just anticipating being away from their home or primary caregiver.

Separation anxiety disorder affects approximately two to five percent of children. These children, who often have additional anxiety disorders, frequently have other family members with anxiety disorders. The tendency to develop separation anxiety disorder involves complex genetic and environmental factors.

What does separation anxiety disorder look like in children and adolescents?

A certain level of separation anxiety is an expected and healthy part of normal development that occurs in all children to varying degrees between infancy and age six. Healthy separation anxiety is typically first seen around 8-10 months of age, when an infant becomes anxious when meeting strangers (this is called stranger anxiety). Children also may become mildly anxious around 18-24 months of age, when they are increasingly exploring their world but wanting to return to their caregiver frequently for security.

In contrast, children with separation anxiety disorder have separation worries that are excessive and much greater than their peers. These worries can overwhelm a child, even when they involve brief separations, such as leaving to go to school, going to sleep, or staying behind at home when a parent runs an errand. The child's fears may appear to be irrational, such as the fear that the parent may suddenly die or become ill. Young people with separation anxiety disorder often go to great extremes to avoid being apart from their home or caregivers. They may protest against leaving a parent's side, refuse to play with friends or complain about physical illness at the time of separating. Frequently, a child tolerates separation from one parent more easily than separation from the other parent.

Diagnosing separation anxiety disorder can be challenging because children with separation anxiety disorder may have more than one anxiety disorder. Children with separation anxiety disorder frequently have physical complaints, which also may need to be medically evaluated. A trained clinician (such as a child psychiatrist, child psychologist or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis.

What is social phobia?

Social phobia (also known as social anxiety disorder) is a medical condition characterized by extreme and consistent fear of meeting new people or embarrassing oneself in social situations. Social phobia is different than the occasional nervousness or shyness a person may feel before a big social event, and it may dramatically limit a person's ability to engage in ordinary social activities.

Social phobia, one of the most common anxiety disorders in adults, is thought to affect about one percent of children. It is possible that the incidence is higher than one percent because children's symptoms may incorrectly be attributed to a shy personality rather than a treatable condition. The tendency to develop social phobia involves both genetic and environmental factors.

What does social phobia look like in children and adolescents?

Young people with social phobia are frequently preoccupied with negative views of themselves. These children are afraid they will speak or act foolishly, be rejected by peers, or publicly fail when performing school tasks. Children with social phobia may in fact be less adept in social interactions. When social phobia develops in childhood, the symptoms generally last at least six months, which distinguishes it from the temporary social awkwardness that many children briefly experience in new environments. Peer relationships, school functioning and attendance, and family functioning may all suffer as a result of a child's social phobia.

Social phobia may look different in young people than in adults. While adults recognize the excessiveness of their discomfort in social situations, children may not have that understanding. Younger children with social phobia may protest when forced to leave a parent's side, have a tantrum when facing a social encounter, refuse to play with friends, or complain about physical illness at the time of a social event. In contrast, adolescents may simply avoid group gatherings or express little interest in friendships. Childhood social phobia is often identified around age 12, at a time when children are expected to increase their social activities with peers and in school.

Diagnosing social phobia can be challenging, and children with social phobia may have more than one anxiety disorder. A trained clinician (such as a child psychiatrist, child psychologist or pediatric neurologist) should integrate information from home, school and the clinical visit to make a diagnosis.

What is panic disorder?

Panic disorder is a medical condition that causes a person to experience recurrent panic attacks and persistent concerns about having future attacks. A panic attack is a brief period of intense fear or discomfort accompanied by distinct symptoms. An attack usually comes to an end gradually on its own and rarely lasts beyond 10 minutes. Symptoms may include heart palpitations, chest discomfort, sweating, trembling, nausea, numbness or tingling, hot/cold flashes, feeling short of breath, feeling dizzy, feeling disconnected from one's self, fear of losing control or fear of dying. These symptoms, which feel very real to the person, likely reflect the body’s intense response to a strong “fight or flight” signal that is beyond the person’s conscious control.

Unlike the occasional, mild worries that children often experience, panic disorder may dramatically affect a child's life by interrupting his or her normal activities when an episode occurs or when the child becomes preoccupied with worry about possible future panic attacks. Some individuals with panic disorder avoid places where they think panic attacks might occur, or worry about being trapped in places where help might be unavailable if an attack occurred. This behavior of worrying about certain places or avoiding them is called agoraphobia. Young people who have panic disorder with agoraphobia most often avoid places with large numbers of unfamiliar people, such as school auditoriums, large parties, and restaurants.

Many children and adolescents have an isolated panic attack, which does not require intervention because it does not recur. A smaller number of children and adolescents develop panic disorder. The tendency to develop panic disorder involves complex genetic and environmental factors. Panic disorder affects as many as 5%  of adolescents, and is less common in younger children.

What does panic disorder look like in children and adolescents?

Panic disorder often looks different in young people than in adults, because children tend to report the physical symptoms accompanying panic attacks rather than the psychological symptoms. Children having a panic attack may appear to be suddenly frightened or upset with no easily identified explanation. This behavior is often confusing to others.

Sometimes children having a panic attack incorrectly explain their symptoms as a response to an external trigger (for example, "It started when I saw that dog"). These children, particularly if they are very young, may not be able to articulate the intense fears they experience during a panic attack. Adolescents are generally better able to describe what they experience, particularly after a panic attack has ended.

Panic disorder is distinguished by the unpredictability of the panic attacks. If a child is predictably frightened by a particular situation (such as meeting a new person) or predictably panics when seeing something he or she finds upsetting (such as a spider), the child may have a phobia rather than panic disorder. Phobias are intense fears predictably triggered by particular situations or objects. Phobias include social phobia (associated with intense fear when exposed to new people) and specific phobia (associated with intense fear when exposed to a particular situation or object).

If left untreated, panic disorder can lead to considerable worry or limitations in other areas of the child's life. Peer relationships, school functioning, and family functioning may suffer, or depression may develop. In some situations, in response to extreme anxiety, social isolation, or limited activities, a child may develop thoughts of self-harm or not wanting to be alive. A trained clinician (such as a child psychiatrist, child psychologist or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis.

Obsessive-Compulsive Disorder

What is obsessive-compulsive disorder?

Obsessive-compulsive disorder (OCD) is a medical disorder that causes repetitive, unpleasant thoughts (obsessions) or behaviors (compulsions) that are difficult to control. Unlike ordinary worries or habits, these obsessions and compulsions may consume significant amounts of time (more than an hour per day), may interfere with a person's daily schedule, and may cause significant distress. OCD affects approximately 1% of children and adolescents. The tendency to develop this disorder involves complex genetic and environmental factors.

Examples of obsessions include recurrent concern about germ contamination, persistent worry that a family member may become sick, or excessive preoccupation with perfection or tidiness. Compulsions, also known as rituals, include repetitive behaviors (such as washing hands, checking locks) and repetitive thoughts (such as silently counting, praying, or repeating words) that the person feels must be completed. A person who has compulsions believes that performing these rituals will prevent a frightening event (for example, "If I count to three every time I talk to my mother, then she won't die").

People with obsessive-compulsive disorder may try to ignore these thoughts or avoid the behaviors but are generally unable able to do so. Whereas adults with OCD may recognize that their obsessions or compulsions are not rational, a child or adolescent may not have that awareness.

What does obsessive-compulsive disorder look like in children and adolescents?

The thoughts and behaviors associated with obsessive-compulsive disorder are often perplexing to parents, teachers and peers. Recognizing the symptoms of obsessive-compulsive disorder may be challenging, as the symptoms can easily be misinterpreted as willful disregard, oppositionality or meaningless worry. In addition, children and adolescents may try to hide their symptoms or may not know how to express their underlying worries. Often, a parent or teacher only sees the end result of the symptom (hours in the bathroom, extended time alone in the bedroom, or tantrums when the child cannot do something his or her way).

Symptoms may vary over time and may change in the way they appear, which can further complicate diagnosis. Children may be able to resist the obsessions and compulsions at school but not at home. The symptoms may fluctuate, with more symptoms at stressful periods and fewer symptoms at other times. Other medical conditions can mimic the disorder, and other conditions may co-occur with the disorder.

If left untreated, the condition may lead to considerable worry or limitations in other areas of the child's life. Peer relationships, school functioning, and family functioning all may suffer. Depression may develop. In some situations, in response to the extreme anxiety, social isolation, and limited activities, a child may develop thoughts of self-harm or not wanting to be alive. A trained clinician (such as a child psychiatrist, child psychologist or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis.

What is depression?

Depression is a medical disorder that causes a person to feel persistently sad, low, or disinterested in daily activities. While everyone may have occasional moments of feeling sad or "blue," or a temporary period of sadness in response to a major loss, a depressive disorder causes those feelings to continue for an extended period. The tendency to develop depression involves complex genetic and environmental factors.

Depression in a child or adolescent is usually in the form of a major depressive disorder, in which multiple, significant symptoms of depression persist nearly every day for at least two weeks. Major depressive disorder affects about two percent of children and about five percent of adolescents. It can develop in response to a stressful situation or it may develop on its own.

Many children have symptoms of a milder depression, known as dysthymic disorder, that last for at least one year and impair their functioning at home and at school. Another type of depressive disorder is seasonal affective disorder or seasonal depression, which is diagnosed when the depression is triggered each year by the change of seasons (most often, during fall or winter). Symptoms or episodes of depression can also be seen in children or adolescents with bipolar disorder.

What does depression look like in children and adolescents?

Depression in young people often looks different than it does in adults. In some cases, children or adolescents with depression may look sad or tearful more frequently than they had previously. In other cases, they may be constantly irritable, or they may be tired, listless, or uninterested in favorite activities. In general, depression is an episodic condition in which a child has symptoms for several weeks or months, which may then gradually resolve. A child or adolescent may have recurring depression or a single episode.

Treatment for depression usually speeds the process of decreasing symptoms, reduces recurrence, and diminishes the time the child may be at risk for suicide or other consequences of the depressive episodes (such as school failure, loss of friends, or family conflict). Variations in the course and presentation of depressive episodes can make diagnosing depression a challenge. A trained clinician (such as a child psychiatrist, child psychologist, or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis.

What is bipolar disorder?

Bipolar disorder, also known as manic depression, is a medical disorder that impairs the brain's ability to sustain a calm, steady mood. People with bipolar disorder experience a variety of intense emotional states, including elation and grandiosity, explosiveness and irritability, and periods of extreme sadness and low energy that they cannot easily control. Moods may shift abruptly many times per day, or they may persist for weeks, months or even years and may seem inappropriate responses to actual circumstances and stresses.

Bipolar disorder is distinguished from depressive disorders by the presence of manic episodes (mania) in addition to depressive episodes (depression). Symptoms of mania and depression can also occur simultaneously, and these periods are called mixed episodes. In some individuals, particularly children and adolescents, the disorder produces chronic irritability or explosiveness with no discernible pattern and few periods of wellness. During mild manic episodes (known as hypomania), many individuals experience periods of tremendous productivity and creativity.

Bipolar disorder is a complex illness that tends to worsen over time if left untreated or if improperly treated. Without effective treatment, young people with bipolar disorder are at risk for substance abuse, school failure, accidents, incarceration and suicide. Although there is no cure, the symptoms can be managed with proper treatment, understanding, and lifestyle and environmental modifications. For reasons that are not understood, bipolar disorder is occurring with growing frequency at younger ages in children and adolescents. About one percent of the total population is affected by bipolar disorder. The tendency to develop bipolar disorder involves complex genetic and environmental factors.

What does bipolar disorder look like in children and adolescents?

Bipolar disorder may look different in young people than it does in adults. Children with bipolar disorder often have mood swings that shift rapidly over hours or even minutes, while adults' mood swings typically shift over days to weeks. Whereas adults with bipolar disorder generally have discrete periods of depression and discrete periods of mania, children with bipolar disorder are more likely to have moods that are not distinct. Children who develop the disorder very young are particularly likely to experience irritability and frequent mood shifts rather than discrete periods of mania and depression.

The first episode of bipolar disorder that a child or adolescent experiences may be in the form of depression, mania, or a combination of both. It may be difficult to identify a child's "first episode" of bipolar disorder if mania and depression occur at the same time, or if these moods occur chronically rather than during discrete periods of time.

During a depressive episode, children or adolescents may look frequently sad or tearful; they may be constantly irritable; or they may be tired, listless, or uninterested in favorite activities. Children or adolescents having an episode of mania often have more prominent irritability, aggression, and inconsolability than adults having an episode of mania. In a manic or mixed state they may be excessively giddy, happy, or silly; they may be intensely irritable, aggressive or inconsolable; and there may be changes in their sleep patterns. They may be restless, persistently active, and more talkative than usual; they may display behavior that is risky or hypersexual beyond what is age-appropriate; and they may have grandiose thoughts, such as the belief that they are more powerful than others; they may also hear voices. Explosive outbursts may involve physical aggression or extended, rage-filled tantrums.

Children with bipolar disorder have moods that often seem to occur unexpectedly and appear unresponsive to normally effective parenting efforts. Parents often become discouraged and exhausted by their child's difficult and erratic behaviors. They may try almost anything to avoid or stop the severe tantrums that can last for hours, and often end up feeling helpless to alleviate their child's suffering. They may feel guilty when neither "tough love" nor consoling the child works. Worst of all, children with bipolar disorder are frightened and confused by their own moods and often feel remorseful for the hurt they cause others when "under the influence" of a powerful mood.

A child or adolescent who first experiences symptoms of depression may in fact turn out to have bipolar disorder. Studies of children with depression show that 20% or more will go on to develop bipolar disorder, depending on the characteristics of the study population and the length of time they were followed. Since it is uncertain whether a child with a first episode of depression will later develop symptoms of mania, children with depression must be carefully monitored for the emergence of mania symptoms.

Because doctors only recently began to identify bipolar disorder in children, researchers have little data with which to predict the long-term course of the illness. It is not known if early-onset bipolar disorder with rapidly shifting moods, if untreated, evolves over time  into the more classic, episodic form of the disorder as the child reaches adulthood, or if this outcome can be prevented by early intervention and treatment. Puberty is a time of high risk for the disorder to develop in individuals with genetic vulnerability.

If bipolar disorder is left untreated, all major realms of the child’s life (including peer relationships, school functioning, and family functioning) are likely to suffer. Early treatment with proper medication and other interventions generally improves the long-term course of the illness. A trained clinician (such as a child psychiatrist, child psychologist, or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis of bipolar disorder.

Attention deficit/hyperactivity disorder

What is attention deficit/hyperactivity disorder?

Attention Deficit/Hyperactivity Disorder, or ADHD, is a medical condition that makes it hard for people to regulate their attention, organize themselves, and control their impulses. For some people with the hyperactivity component of ADHD, keeping quiet, staying seated, or stopping all body movements is nearly impossible. While everyone may have occasional moments of daydreaming, fidgeting, or forgetfulness, someone with ADHD experiences these difficulties often, in multiple settings, such as home and school, over a period of at least six months.

The symptoms of ADHD are clustered into three main types of the disorder:

• inattentive type – characterized by forgetfulness, distractibility, and difficulty focusing and maintaining attention
• hyperactive/impulsive type – characterized by a tendency to act or speak before considering consequences, by restlessness, and by difficulty staying seated, keeping hands to self, or resisting the need to constantly move
• combined type – characterized by significant difficulties with both regulating attention and controlling hyperactivity/impulsivity

ADHD may significantly affect a child’s life by impairing academic activities, peer relationships, and home life. Estimates of the prevalence of ADHD among children range from 3 to 12 percent. The tendency to develop ADHD involves complex genetic and environmental factors. Although the disorder occurs more frequently in boys than in girls, its prevalence in girls is greater than previously thought.

What does attention deficit/hyperactivity disorder look like in children and adolescents?

During the toddler and pre-school years, difficulties with paying attention, staying still, and controlling impulses are expected in children. For example, children ages two to three are expected to be curious about their environment and to shift their attention from one toy to another. Similarly, young children are expected to move frequently as they explore their world. As children progress through childhood, however, most of them develop the ability to regulate their behavior and sustain concentration on tasks as needed. Children with ADHD, in contrast, do not attain age-appropriate levels of self-control, organization, and concentration. ADHD symptoms generally appear before age seven, although for a variety of reasons, some children are not diagnosed until later.

Children with the inattentive type of ADHD are often not identified until a pattern of concentration problems leads to lower academic performance. These children face a variety of challenges, including frequent forgetfulness and boredom, trouble remembering instructions and responsibilities, problems with focusing and an aversion to mentally challenging tasks. The same child with significant difficulties sustaining attention, organizing tasks, and completing homework, however, may be able to focus attention for long periods of time on pleasurable activities that require focused attention, such as videogames or artistic pursuits.

Children with inattentive symptoms may be described as “daydreamers” or “spaced out.” Often, these children are more socially withdrawn and have more frequent problems with mild anxiety than children with the hyperactive/impulsive type of ADHD. Symptoms of inattentiveness may be difficult for others to detect, and many children–especially girls–with the inattentive type of ADHD are diagnosed much later or are never identified. Girls are more likely to have the inattentive type of ADHD, and for a variety of reasons girls are less likely to be diagnosed with ADHD or treated for their symptoms.

Children with hyperactive/impulsive symptoms of ADHD have difficulty controlling their actions. Their impulsive tendencies are often misunderstood as rudeness, disregard for others, or willful disobedience. These children tend to explore new settings with enthusiasm and touch objects without asking for permission. Their unrestrained behavior may lead to careless accidents (broken possessions or physical injury), the disapproval and irritation of others (due to difficulties waiting one’s turn or respecting others’ rules), and potentially dangerous situations (for example, darting across the street before looking both ways). Because this behavior is often disruptive to others, ADHD with hyperactivity and impulsivity is typically identified more easily than the inattentive type. The hyperactive type of ADHD appears to be more prevalent in boys than in girls.

All children with ADHD may struggle with low frustration tolerance and trouble following rules. Often they are “poor sports” in games, and they may seem intrusive or bossy in their play. As a result, children with ADHD face social challenges because their peers may perceive them as immature and annoying. They may be taunted by peers or tricked into getting into trouble with adults. Whereas older adolescents are able to describe their difficulties due to ADHD, children frequently have trouble identifying their underlying difficulties. Instead, children with ADHD are often only aware that they get into trouble more often than their peers, leading to self-doubt and low self-esteem.

Generally, as a person with ADHD goes through adolescence into adulthood, symptoms of hyperactivity and impulsivity decrease. Until recently it was therefore assumed that ADHD is outgrown in childhood, but it is now known that many children with ADHD continue to experience impairing symptoms into adulthood. When children are diagnosed with the disorder, it is not uncommon for parents to discover their own symptoms of ADHD that were never previously recognized or identified.

Early identification of the underlying disorder and a comprehensive treatment plan can help avert many difficulties. A trained clinician (such as a child psychiatrist, child psychologist or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis.

What is an autism spectrum disorder?

An autism spectrum disorder (ASD), also called a pervasive developmental disorder (PDD), is a biological brain disorder that significantly affects an individual’s ability to understand people, interpret events, communicate, and interact with others. These disorders are described as occurring on a spectrum because of the wide variability of impact they may have on everyday functioning. The scope, variety, and severity of symptoms differ in each individual, but in general, autism spectrum disorders are characterized by the following:

• Difficulty with communication
• Impairments in social skills and understanding of how to engage and interact with others
• Unusual behaviors and interests (such as attachments to unusual objects or speaking in movie scripts)

Symptoms of autism spectrum disorders are usually identified by age three, and researchers are now identifying ways to detect early signs during the first year. Early detection and intervention can significantly lessen a child’s symptoms. The tendency to develop autism spectrum disorders involves complex genetic and biological factors that are still being determined. ASD occurs in boys four times more often than in girls. In the past, about 75% of children with autism were presumed to have mental retardation because of their low performance on standard IQ tests. It is now understood that because of the communication and perception deficits associated with ASD, these tests may not be able to provide an accurate measure of intelligence in an individual with ASD. As children with ASD become more verbal, they sometimes perform better on these tests.

It is widely believed that there has been a marked rise in the occurrence of ASD worldwide. Estimates of the incidence of autism spectrum disorders have increased over past decades from 1 in 2,000 children to current estimates of 1 in 250. This steep increase is due not only to the higher incidence, but also to a growing understanding of the disorder, such that:

• Criteria have become broader and include a wider spectrum of children
• Diagnosis of mental retardation has diminished as diagnosis of ASD has increased, reflecting more sophisticated methods of distinguishing these conditions

Certain rare medical conditions can be associated with autism spectrum disorders. Families should talk with their child’s clinician about medical conditions such as Fragile X (a chromosomal abnormality) or tuberous sclerosis (a condition that causes benign tumors), particularly if other family members have had unusual medical conditions or symptoms of ASD.

Five subcategories of ASD have been identified:

• Autistic disorder (commonly called autism)
• Asperger’s disorder
• Pervasive developmental disorder - not otherwise specified (PDD-NOS)
• Rett’s disorder
• Childhood disintegrative disorder

The most prevalent conditions (autistic disorder, Asperger’s disorder and PDD-NOS) are discussed here. Rett’s disorder and childhood disintegrative disorder occur very rarely, but families should ask their clinician about them if a diagnosis of ASD is being considered.

Autistic Disorder

A diagnosis of autistic disorder, commonly known as autism, is made when a child displays six or more of 12 symptoms of impairment across all three major areas affected by ASD by age three:

• Communication
• Social interaction
• Interests and behavior

Individuals with autistic disorder often appear aloof and uninterested in interacting with others, and they experience delays in speech development. They also often have severely impaired abilities to communicate, participate in social interchanges and attend to things identified or pointed out by others.

Asperger’s Disorder

Asperger’s disorder is a condition with social and behavioral problems similar to autistic disorder, but with minimal or no apparent speech delay during the first three years of life. Communication skills are also less affected. Some children with Asperger’s disorder have narrow and intense interests (such as fascination with weather conditions, train schedules or historical dates) that lead them to develop extensive knowledge of a particular subject

. In addition, these children may be less interested in the breadth of activities typical of their peers, which further contributes to their social challenges. Asperger’s disorder is less impairing than autistic disorder and it may go undetected until middle school, when the preoccupations and social difficulties become more impairing.

Some people with Asperger’s disorder have a neuropsychological profile known as Nonverbal Learning Disability (NVLD). NVLD has also been called “Right Hemispheric Insufficiency” since the affected skills are thought to be predominantly associated with the right side of the brain. Individuals with NVLD often have difficulties with a variety information-processing skills, including the following:

• Organization
• Adapting to change
• Math calculations
• Visual-spatial perception (affecting balance, sense of direction, and the ability to understand information presented in pictures and graphs rather than in words)
• Motor skills (affecting activities such as sports and handwriting)
• Inferential reasoning (arriving at information that is implied but not directly stated)
• The subtleties of social relationships (for example, understanding when to let others speak, accurately “reading” nonverbal cues such as facial expressions to assess feelings)

People with NVLD are usually quite articulate speakers, but often have trouble putting their thoughts in writing. Students with these discrepancies in their abilities may experience frustration in both academic and social situations, especially as the complexities in both domains increase sharply in middle school. As a result of their perceptual and related difficulties, people with NVLD sometimes have difficulty in sports, may feel socially isolated and may be accused of stubbornness and laziness when seemingly manageable work overwhelms them. NVLD sometimes leads to depression and anxiety disorders.

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

The diagnosis of PDD-NOS is given to children who meet some, but not all, criteria for a specific autism spectrum disorder. Since this diagnosis hinges on a child not meeting “full” criteria for an ASD, it usually reflects a less severe disorder. This diagnostic category is used when there is significant impairment in the development of reciprocal social interaction or communication skills, or when stereotyped behavior, interests and activities are present. As with all of the autism spectrum disorders, the symptoms vary considerably from one person to another.

Clinicians and researchers continue to refine the criteria for these disorders. In the interim, families, clinicians and researchers must contend with variation in the way diagnostic terms are used for ASD. Talking with a clinician about symptoms and clarifying diagnostic terms is often helpful for families.