Mental Health Facts - Children`s Law Center

Mental Health Facts
CHILDREN & TEENS
Fact: 1 in 5 children ages 13-18 have, or will have a serious mental illness.
20%
11%
20% of youth ages
13-18 live with a mental
health condition
11% of youth have
a mood disorder
10%
8%
10% of youth
have a behavior or
conduct disorder
8% of youth have
an anxiety disorder
Suicide
Impact
50%
10 yrs
50% of all lifetime cases of mental illness
begin by age 14 and 75% by age 24.
2nd
Suicide is the 2nd
leading cause of
death in youth
ages 15 - 24.
The average delay between onset of
symptoms and intervention is 8-10 years.
50%
Approximately 50% of students
age 14 and older with a mental
illness drop out of high school.
70%
70% of youth in state and local
juvenile justice systems have a
mental illness.
90%
90% of those who
died by suicide had
an underlying
mental illness.
Warning Signs
!
Feeling very sad or withdrawn for more than
2 weeks (e.g., crying regularly, feeling
fatigued, feeling unmotivated).
!
Trying to harm or kill oneself or making plans
to do so.
!
Out-of-control, risk-taking behaviors that can
cause harm to self or others.
!
Sudden overwhelming fear for no reason,
sometimes with a racing heart, physical
discomfort or fast breathing.
!
Not eating, throwing up or using laxatives to
lose weight; significant weight loss or gain.
!
Severe mood swings that cause problems
in relationships.
!
Repeated use of drugs or alcohol.
!
Drastic changes in behavior, personality or
sleeping habits (e.g., waking up early and
acting agitated).
!
Extreme difficulty in concentrating or
staying still that can lead to failure in
school.
!
Intense worries or fears that get in the way
of daily activities like hanging out with
friends or going to classes.
4 Things Parents Can Do
Talk with your
pediatrician
Get a referral to a
mental health specialist
Work with
the school
Connect with
other families
This document cites statistics provided by the National Institute of Mental Health. www.nimh.nih.gov
This document cites statistics provided by the Centers for Disease Control and Prevention. www.cdc.gov
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August 2013 No. 86
Psychotherapies for Children and
Adolescents
Psychotherapy is a form of psychiatric treatment that involves therapeutic conversations
and interactions between a therapist and a child or family. It can help children and
families understand and resolve problems, modify behavior, and make positive changes
in their lives. There are several types of psychotherapy that involve different approaches,
techniques and interventions. At times, a combination of different psychotherapy
approaches may be helpful. In some cases a combination of medication with
psychotherapy may be
more effective.
Different types of psychotherapy: (alphabetical order)

Cognitive Behavior Therapy (CBT) helps improve a child's moods, anxiety and
behavior by examining confused or distorted patterns of thinking. CBT therapists
teach children that thoughts cause feelings and moods which can influence
behavior. During CBT, a child learns to identify harmful thought patterns. The
therapist then helps the child replace this thinking with thoughts that result in
more appropriate feelings and behaviors. Research shows that CBT can be
effective in treating a variety of conditions, including depression and anxiety.
Specialized forms of CBT have also been developed to help children coping with
post-traumatic stress disorder. 
Dialectical Behavior Therapy (DBT) can be used to treat older adolescents who
have chronic suicidal feelings/thoughts, engage in intentionally self-harmful
beaviors or have Borderline Personality Disorder. DBT emphasizes taking
responsibility for one's problems and helps the person examine how they deal
with conflict and intense negative emotions. This often involves a combination of
group and individual sessions.

Family Therapy focuses on helping the family function in more positive and
constructive ways by exploring patterns of communication and providing support
and education. Family therapy sessions can include the child or adolescent along
with parents, siblings, and grandparents. Couples therapy is a specific type of
family therapy that focuses on a couple's communication and interactions (e.g.
parents having marital problems).

Group Therapy is a form of psychotherapy where there are multiple patients led
by one or more therapists. It uses the power of group dynamics and peer
Psychotherapies for Children and Adolescents, “Facts for Families,” No. 86 (3/11)
interactions to increase understanding of mental illness and/or improve social
skills. There are many different types of group therapy (e.g. psychodynamic,
social skills, substance abuse, multi-family, parent support, etc.).

Interpersonal Therapy (IPT) is a brief treatment specifically developed and
tested for depression, but also used to treat a variety of other clinical conditions.
IPT therapists focus on how interpersonal events affect an individual's emotional
state. Individual difficulties are framed in interpersonal terms, and then
problematic relationships are addressed

Play Therapy involves the use of toys, blocks, dolls, puppets, drawings and
games to help the child recognize, identify, and verbalize feelings. The
psychotherapist observes how the child uses play materials and identifies themes
or patterns to understand the child's problems. Through a combination of talk and
play the child has an opportunity to better understand and manage their conflicts,
feelings, and behavior.

Psychodynamic Psychotherapy emphasizes understanding the issues that
motivate and influence a child's behavior, thoughts, and feelings. It can help
identify a child's typical behavior patterns, defenses, and responses to inner
conflicts and struggles. Psychoanalysis is a specialized, more intensive form of
psychodynamic psychotherapy which usually involved several sessions per week.
Psychodynamic psychotherapies are based on the assumption that a child's
behavior and feelings will improve once the inner struggles are brought to light.
Psychotherapy is not a quick fix or an easy answer. It is a complex and rich process that,
over time, can reduce symptoms, provide insight, and improve a child or adolescent's
functioning and quality of life.
At times, a combination of different psychotherapy approaches may be helpful. In some
cases a combination of medication with psychotherapy may be more effective. Child and
adolescent psychiatrists are trained in different forms of psychotherapy and, if indicated,
are able to combine these forms of treatment with medications to alleviate the child or
adolescent's emotional and/or behavioral problems.
Click here to find a Child and Adolescent Psychiatrist near you.
For more information see Facts for Families:
#25 Know Where to Seek Help for Your Child
#52 Comprehensive Psychiatric Evaluation
#53 What is Psychotherapy for Children and Adolescents
#21 Psychiatric Medication for Children
#00 Definition of a Child and Adolescent Psychiatrist
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Psychotherapies for Children and Adolescents, “Facts for Families,” No. 86 (3/11)
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school in general (adult) and child and adolescent psychiatry.
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Copyright © 2012 by the American Academy of Child and Adolescent Psychiatry.
Treatment of
Children with
Mental Illness
Frequently asked questions
about the treatment of mental
illness in children
NATIONAL INSTITUTE OF MENTAL HEALTH
U.S. Department of Health
and Human Services
National Institutes of Health
Introduction
R
esearch shows that half of all lifetime cases of mental illness begin by age 14.1 Scientists are discovering that
changes in the body leading to mental illness may start much earlier, before any symptoms appear.
Through greater understanding of when and how fast specific areas
of children’s brains develop, we are learning more about the early
stages of a wide range of mental illnesses that appear later in life.
Helping young children and their parents manage difficulties early in
life may prevent the development of disorders. Once mental illness
develops, it becomes a regular part of your child’s behavior and more
difficult to treat. Even though we know how to treat (though not yet
cure) many disorders, many children with mental illnesses are not
getting treatment.
Q. What should I do if I am
concerned about mental,
behavioral, or emotional
symptoms in my child?
A. Talk to your child’s doctor or health
care provider. Ask questions and learn
everything you can about the behavior
or symptoms that worry you. If your
child is in school ask the teacher if your
child has been showing worrisome
changes in behavior. Share this with
your child’s doctor or health care pro­
vider. Keep in mind that every child is
different. Even normal development,
such as when children develop lan­
guage, motor, and social skills, varies
from child to child. Ask if your child
needs further evaluation by a specialist
with experience in child behavioral
problems. Specialists may include psy­
chiatrists, psychologists, social work­
ers, psychiatric nurses, and behavioral
therapists. Educators may also help
evaluate your child.
If you take your child to a specialist,
ask, “Do you have experience treating
the problems I see in my child?” Don’t
be afraid to interview more than one
specialist to find the right fit. Continue
to learn everything you can about the
problem or diagnosis. The more you
learn, the better you can work with your
child’s doctor and make decisions that
feel right for you, your child, and your
family.
1
This fact sheet addresses common questions about diagnosis and
treatment options for children with mental illnesses. Disorders
affecting children may include anxiety disorders, attention deficit
hyperactivity disorder (ADHD), autism spectrum disorders, bipolar
disorder, depression, eating disorders, and schizophrenia.
Q. How do I know if my child’s
problems are serious?
A. Not every problem is serious. In fact,
many everyday stresses can cause
changes in your child’s behavior. For
example, the birth of a sibling may
cause a child to temporarily act much
younger than he or she is. It is impor­
tant to be able to tell the difference
between typical behavior changes and
those associated with more serious
problems. Pay special attention to
behaviors that include:
Problems across a variety of settings,
such as at school, at home, or with
peers
Changes in appetite or sleep
Social withdrawal, or fearful behavior
toward things your child normally is not
afraid of
Returning to behaviors more common
in younger children, such as bedwetting, for a long time
Signs of being upset, such as sadness
or tearfulness
Signs of self-destructive behavior, such
as head-banging, or a tendency to get
hurt often
Repeated thoughts of death.
Q. Can symptoms be caused by a
death in the family, illness in
a parent, family financial prob­
lems, divorce, or other events?
A. Yes. Every member of a family is
affected by tragedy or extreme stress,
even the youngest child. It’s normal for
stress to cause a child to be upset.
Remember this if you see mental, emo­
tional, or behavioral symptoms in your
child. If it takes more than one month
for your child to get used to a situation,
or if your child has severe reactions,
talk to your child’s doctor.
Check your child’s response to stress.
Take note if he or she gets better with
time or if professional care is needed.
Stressful events are challenging, but
they give you a chance to teach your
child important ways to cope.
Q. How are mental illnesses
diagnosed in young children?
A. Just like adults, children with mental
illness are diagnosed after a doctor or
mental health specialist carefully
observes signs and symptoms. Some
primary care physicians can diagnose
your child themselves, but many will
send you to a specialist who can diag­
nose and treat children.
Before diagnosing a mental illness, the
doctor or specialist tries to rule out
other possible causes for your child’s
behavior. The doctor will:
Take a history of any important medical
problems
Take a history of the problem – how
long you have seen the problem – as
well as a history of your child’s
development
Take a family history of mental disorders
Ask if the child has experienced physi­
cal or psychological traumas, such as a
natural disaster, or situations that may
cause stress, such as a death in the
family
Consider reports from parents and
other caretakers or teachers.
Very young children often cannot
express their thoughts and feelings, so
making a diagnosis can be challenging.
The signs of a mental illness in a young
child may be quite different from those
in an older child or adult.
As parents and caregivers know, chil­
dren are constantly changing and grow­
ing. Diagnosis and treatment must be
viewed with these changes in mind.
While some problems are short-lived
and don’t need treatment, others are
ongoing and may be very serious. In
either case, more information will help
you understand treatment choices and
manage the disorder or problem most
effectively.
While diagnosing mental health prob­
lems in young children can be challeng­
ing, it is important. A diagnosis can be
used to guide treatment and link your
child’s care to research on children with
similar problems.
Q. Are there treatment options
for children?
A. Yes. Once a diagnosis is made, your
child’s specialist will recommend a spe­
cific treatment. It is important to under­
stand the various treatment choices,
which often include psychotherapy or
medication. Talk about the options with
a health care professional who has
experience treating the illness observed
in your child. Some treatment choices
have been studied experimentally, and
other treatments are a part of health
care practice. In addition, not every
community has every type of service or
program.
Q. What are psychotropic
medications?
A. Psychotropic medications are sub­
stances that affect brain chemicals
related to mood and behavior. In recent
years, research has been conducted to
understand the benefits and risks of
using psychotropics in children. Still,
more needs to be learned about the
effects of psychotropics, especially in
children under six years of age. While
researchers are trying to clarify how
early treatment affects a growing body,
families and doctors should weigh the
benefits and risks of medication. Each
child has individual needs, and each
child needs to be monitored closely
while taking medications.
Q. Are there treatments other than
medications?
A. Yes. Psychosocial therapies can be very
A. Some children get better with time. But
effective alone and in combination with
medications. Psychosocial therapies
are also called “talk therapies” or
“behavioral therapy,” and they help
people with mental illness change
behavior. Therapies that teach parents
and children coping strategies can also
be effective.2
2
Cognitive behavioral therapy (CBT) is a
type of psychotherapy that can be used
with children. It has been widely stud­
ied and is an effective treatment for a
number of conditions, such as depres­
sion, obsessive-compulsive disorder,
and social anxiety. A person in CBT
learns to change distorted thinking pat­
terns and unhealthy behavior. Children
can receive CBT with or without their
parents, as well as in a group setting.
Q. Will my child get better with
time?
other children need ongoing profes­
sional help. Talk to your child’s doctor
or specialist about problems that are
severe, continuous, and affect daily
activities. Also, don’t delay seeking
help. Treatment may produce better
results if started early.
CBT can be adapted to fit the needs of
each child. It is especially useful when
treating anxiety disorders.3
Additionally, therapies for ADHD are
numerous and include behavioral par­
ent training and behavioral classroom
management. Visit the NIMH Web site
for more information about therapies
for ADHD.
Some children benefit from a combina­
tion of different psychosocial approaches.
An example is behavioral parent man­
agement training in combination with
CBT for the child. In other cases, a
combination of medication and psycho­
social therapies may be most effective.
Psychosocial therapies often take time,
effort, and patience. However, some­
times children learn new skills that may
have positive long-term benefits.
More information about treatment
choices can be found in the psycho­
therapies and medications sections of
the NIMH Web site.
Q. When is it a good idea to use
psychotropic medications in
young children?
A. When the benefits of treatment out­
weigh the risks, psychotropic medica­
tions may be prescribed. Some children
need medication to manage severe and
difficult problems. Without treatment,
these children would suffer serious or
dangerous consequences. In addition,
psychosocial treatments may not
always be effective by themselves. In
some instances, however, they can be
quite effective when combined with
medication.
Ask your doctor questions about the
risks of starting and continuing your
child on these medications. Learn
everything you can about the medica­
tions prescribed for your child. Learn
about possible side effects, some of
which may be harmful. Know what a
particular treatment is supposed to do.
For example, will it change a specific
behavior? If you do not see these
changes while your child is taking the
medication, talk to his or her doctor.
Also, discuss the risks of stopping your
child’s medication with your doctor.
Q. Does medication affect young
children differently than older
children or adults?
Q. What medications are used
for which kinds of childhood
mental disorders?
A. Yes. Young children handle medications A. Psychotropic medications include stim­
differently than older children and
adults. The brains of young children
change and develop rapidly. Studies
have found that developing brains can
be very sensitive to medications. There
are also developmental differences in
how children metabolize – how their
bodies process – medications. There­
fore, doctors should carefully consider
the dosage or how much medication to
give each child. Much more research is
needed to determine the effects and
benefits of medications in children of
all ages. But keep in mind that serious
untreated mental disorders themselves
can harm brain development.
Also, it is important to avoid drug inter­
actions. If your child takes medicine for
asthma or cold symptoms, talk to your
doctor or pharmacist. Drug interactions
could cause medications to not work as
intended or lead to serious side effects.
Q. How should medication be
included in an overall treatment
plan?
A. Medication should be used with other
treatments. It should not be the only
treatment. Consider other services,
such as family therapy, family support
services, educational classes, and
behavior management techniques. If
your child’s doctor prescribes medica­
tion, he or she should evaluate your
child regularly to make sure the medi­
cation is working. Children need treat­
ment plans tailored to their individual
problems and needs.
ulants, antidepressants, anti-anxiety
medications, antipsychotics, and mood
stabilizers. Dosages approved by the
U.S. Food and Drug Administration
(FDA) for use in children depend on
body weight and age. NIMH’s medica­
tions booklet describes the types of
psychotropic medications and includes
a chart that lists the ages for which
each medication is FDA-approved. See
the FDA Web site for the latest informa­
tion on medication approvals, warn­
ings, and patient information guides
at www.fda.gov.
Q. What does it mean if a
medication is specifically
approved for use in children?
A. When the FDA approves a medication,
it means the drug manufacturer pro­
vided the agency with information
showing the medication is safe and
effective in a particular group of people.
Based on this information, the drug’s
label lists proper dosage, potential side
effects, and approved age. Medications
approved for children follow these
guidelines.
Many psychotropic medications have
not been studied in children, which
means they have not been approved by
the FDA for use in children. But doctors
may prescribe medications as they feel
appropriate, even if those uses are not
included on the label. This is called
“off-label” use. Research shows that
off-label use of some medications
works well in some children. Other
medications need more study in chil­
dren. In particular, the use of most psy­
chotropic medications has not been
adequately studied in preschoolers.
More studies in children are needed
before we can fully know the appropri­
ate dosages, how a medication works
in children, and what effects a medica­
tion might have on learning and
development.
3
Q. Why haven’t many medications
been tested in children?
A. In the past, medications were seldom
studied in children because mental ill­
ness was not recognized in childhood.
Also, there were ethical concerns about
involving children in research. This led
to a lack of knowledge about the best
treatments for children. In clinical set­
tings today, children with mental or
behavioral disorders are being pre­
scribed medications at increasingly
early ages. The FDA has been urging
that medications be appropriately stud­
ied in children, and Congress passed
legislation in 1997 offering incentives
to drug manufacturers to carry out
such testing. These activities have
helped increase research on the effects
of medications in children.
There still are ethical concerns about
testing medications in children. How­
ever, strict rules protect participants in
research studies. Each study must go
through many types of review before,
and after it begins.
Q. How do I work with my child’s
school?
A. If your child is having problems in
school, or if a teacher raises concerns,
you can work with the school to find a
solution. You may ask the school to
conduct an evaluation to determine
whether your child qualifies for special
education services. However, not all
children diagnosed with a mental
illness qualify for these services.
Start by speaking with your child’s
teacher, school counselor, school
nurse, or the school’s parent organiza­
tion. These professionals can help you
get an evaluation started. Also, each
state has a Parent Training and Infor­
mation Center and a Protection and
Advocacy Agency that can help you
request the evaluation. The evaluation
must be conducted by a team of pro­
fessionals who assess all areas related
to the suspected disability using a
variety of tools and measures.
Q. What resources are available
from the school?
A. Once your child has been evaluated,
there are several options for him or her,
depending on the specific needs. If spe­
cial education services are needed, and
if your child is eligible under the Indi­
viduals with Disabilities Education Act
(IDEA), the school district must develop
an “individualized education program”
specifically for your child within
30 days.
If your child is not eligible for special
education services, he or she is still
entitled to “free appropriate public edu­
cation,” available to all public school
children with disabilities under Section
504 of the Rehabilitation Act of 1973.
Your child is entitled to this regardless
of the nature or severity of his or her
disability.
The U.S. Department of Education’s
Office for Civil Rights enforces Section
504 in programs and activities that
receive Federal education funds. For
more information about Section 504,
please see http://www.ed.gov/about/
offices/list/ocr/504faq.html.
More information about programs for
children with disabilities is available at
http://www.ed.gov/parents/needs/
speced/edpicks.jhtml?src=ln.
Q. What special challenges can
school present?
A. Each school year brings a new teacher
and new schoolwork. This change can
be difficult for some children. Inform
the teachers that your child has a men­
tal illness when he or she starts school
or moves to a new class. Additional
support will help your child adjust to
the change.
Q. What else can I do to help my
child?
A. Children with mental illness need guid­
ance and understanding from their par­
ents and teachers. This support can
help your child achieve his or her full
potential and succeed in school. Before
4
a child is diagnosed, frustration, blame,
and anger may have built up within a
family. Parents and children may need
special help to undo these unhealthy
interaction patterns. Mental health pro­
fessionals can counsel the child and
family to help everyone develop new
skills, attitudes, and ways of relating to
each other.
Parents can also help by taking part
in parenting skills training. This helps
parents learn how to handle difficult
situations and behaviors. Training
encourages parents to share a pleasant
or relaxing activity with their child, to
notice and point out what their child
does well, and to praise their child’s
strengths and abilities. Parents may
also learn to arrange family situations
in more positive ways. Also, parents
may benefit from learning stressmanagement techniques to help them
deal with frustration and respond
calmly to their child’s behavior.
Sometimes, the whole family may need
counseling. Therapists can help family
members find better ways to handle
disruptive behaviors and encourage
behavior changes. Finally, support
groups help parents and families con­
nect with others who have similar prob­
lems and concerns. Groups often meet
regularly to share frustrations and suc­
cesses, to exchange information about
recommended specialists and strate­
gies, and to talk with experts.
Q. How can families of children
with mental illness get support?
A. Like other serious illnesses, taking care
of a child with mental illness is hard on
the parents, family, and other caregiv­
ers. Caregivers often must tend to the
medical needs of their loved ones, and
also deal with how it affects their own
health. The stress that caregivers are
under may lead to missed work or lost
free time. It can strain relationships
with people who may not understand
the situation and lead to physical and
mental exhaustion.
Stress from caregiving can make it hard
to cope with your child’s symptoms.
One study shows that if a caregiver
is under enormous stress, his or her
loved one has more difficulty sticking to
the treatment plan.4 It is important to
look after your own physical and mental
health. You may also find it helpful to
join a local support group.
Q. Where can I go for help?
A. If you are unsure where to go for help,
ask your family doctor. Others who can
help are listed below.
Mental health specialists, such as psy­
chiatrists, psychologists, social work­
ers, or mental health counselors
Health maintenance organizations
Community mental health centers
Hospital psychiatry departments and
outpatient clinics
Mental health programs at universities
or medical schools
State hospital outpatient clinics
Family services, social agencies,
or clergy
Peer support groups
Private clinics and facilities
Employee assistance programs
Local medical and/or psychiatric
societies.
You can also check the phone book
under “mental health,” “health,” “social
services,” “hotlines,” or “physicians”
for phone numbers and addresses. An
emergency room doctor can also pro­
vide temporary help and can tell you
where and how to get further help.
More information on mental health is at
the NIMH Web site at www.nimh.nih.gov.
For the latest information on medica­
tions, see the U.S. Food and Drug
Administration Web site at www.fda.gov.
Citations
1. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE.
Prevalence, severity, and comorbidity of 12-month DSM-IV
disorders in the National Comorbidity Survey Replication.
Arch Gen Psychiatry. 2005 Jun;62(6):617–27.
For more information about children
and mental health
2. Silverman WK, Hinshaw SP. The Second Special Issue on
Evidence-Based Psychosocial Treatments for Children and
Adolescents: A Ten-Year Update. J Clin Child Adolesc Psychol.
2008 Jan–Mar;37(1).
En Español, http://medlineplus.gov/spanish
3. Silverman WK, Hinshaw SP. The Second Special Issue on
Evidence-Based Psychosocial Treatments for Children and
Adolescents: A Ten-Year Update. J Clin Child Adolesc Psychol.
2008 Jan–Mar;37(1).
4. Perlick DA, Rosenheck RA, Clarkin JF, Maciejewski PK, Sirey J,
Struening E, Link BG. Impact of family burden and affective
response on clinical outcome among patients with bipolar
disorder. Psychiatr Serv. 2004 Sep;55(9):1029–35.
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U.S. Department of Health
and Human Services
National Institutes of Health
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
National Institute of Mental Health
NIH Publication No. 09-4702
Revised 2009
The Child Advocate’s Guide to
Psychiatric Diagnoses & Psychotropic Medications
Ca rtoon from Google Images, courtesy of http://contemplative-activist.blogspot.com/
Created for the Children’s Law Center by
Jessica Yeatermeyer, MD, MSc
Purpose and Disclaimer
The overarching aim of this guide is to better equip advocates of children to nurture the mental
health needs of their clients. The guide is organized in chapters by mental health condition.
Each chapter offers a brief description of the condition (as laid out in the current Diagnostic and
Statistical Manual of Mental Disorders, DSM-5) and the most common treatments for the
condition. Each chapter contains a section on commonly asked questions and important things
to know about the conditions and treatments. Each chapter concludes with a section entitled
“Reputable Resources Regarding,” which provides URL links to websites that can be trusted as
reliable sources for information. At the end of the guide are two appendices, one which lists
each medication (alphabetically by brand name and by generic name) and directs the reader to
the chapter in which information can be found about that medication, and one which lists
common medical abbreviations that an advocate might encounter when reviewing medical
records or files. Throughout the guide, important points are highlighted with various colors so
that the guide may be scanned quickly for take-home points, but all highlights are transparent
enough that if the guide is printed in black-and-white ink, the highlighted text will still be
readable. In order to keep limit the length of the guide, only the most commonly encountered
mental health conditions and medications have been included. Conditions not covered include:
conduct disorder, oppositional defiant disorder, learning disorders, reactive attachment disorder,
gender dysphoria, and eating disorders. These conditions, while important and prevalent in the
communities with which child advocates work, are often treated with non-medication
interventions and may be covered in other educational series available to child advocates. This
guide primarily aims to increase knowledge and awareness about medication interventions
(through pertinent psychotherapies are mentioned). Additionally, pediatric schizophrenia is not
covered for the sake of space, and because this condition is more rare than those that have
been included.
This guide is intended to serve as a reference for professionals working in the field of child
advocacy. It is meant to provide a general overview of common mental health conditions and
treatments, and to help advocates form questions to ask mental health providers on behalf of
their clients. It is not intended to offer medical advice or to be used in place of seeking
professional medical care. All questions pertinent to a particular client or situation should be
directed to the medical provider who is caring for the patient. Additionally, any personal opinion
contained within this guide represents that of the author, and not of the general psychiatry
community or of Children’s National Medical Center in particular.
With gratitude for all who tend to children,
Jessica Yeatermeyer, MD, MSc
Child & Adolescent Psychiatry Fellow
Children’s National Medical Center
Washington, DC
2
Table of Contents
Who Is Treating my Client?
4
The FDA and Psychotropic Meds for Kids
5
Chapter I: Attention Deficit Hyperactivity Disorder (ADHD)
7
Chapter II: Anxiety and Depression
11
Chapter III: Autism Spectrum Disorder (ASD)
16
Chapter IV: Mood Disorder NOS, Bipolar Disorder, and
Disruptive Mood Dysregulation Disorder (DMDD)
19
Chapter V: Post-Traumatic Stress Disorder
25
Appendix I: Medications Index
Alphabetical by Brand Drug Name
27
Appendix I: Medications Index
Alphabetical by Generic Drug Name
28
Appendix II: Common Medical Abbreviations
29
3
Who Is Treating My Client?
Psychiatrists (MDs or DOs) Hierarchy
Attending Child & Adolescent Psychiatrist
(academic setting, e.g., Children’s
National Medical Center, Georgetown)
Child & Adolescent Psychiatry Fellow
Academic centers only
Completing 2 years subspecialty training
Already completed general psychiatry residency
Non-Academic Child & Adolescent Psychiatrist
Private or community practice or hospital
(e.g., CSAs, PIW, solo practice)
General Adult Psychiatrist
Private, community or academic practice
License allows Dr. to see kids, but may have only 2
months psychiatric experience with kids in residency
General Adult Psychiatry Resident
Academic centers only
Completing 3-4 years training post-med school,
usually includes 2-4 months psychiatry with kids
Other Prescribers
Nurse Practitioner (NP/APRN)
Often practices independently
of physicians. Experience with
children (and with psychiatry
in general) varies.
Physician Assistant (PA)
Generally practicing under
supervision of a physician.
Experience with children &
psychiatry varies.
Pediatrician (MD, DO)
Can prescribe any med, but often
uncomfortable with complicated psych
meds. Usually has had no specific
psychiatric training after med school
Providers of Psychotherapy
Psychologist
(PhD, PsyD)
Psychiatrist
(MD, DO)
Social Worker
(LCSW, MSW)
Counselor
(LPC, LMHC)
Family Therapist
(DMFT, LMFT)
In general, it is best for children and adolescents to be seen by prescribers who have specialized
psychiatric training in the pediatric age group (orange or green boxes above), especially for an initial
evaluation. It is important to note, however, that many child & adolescent psychiatric practices (including
Children’s National Medical Center) cannot treat children after they turn 18, even though other pediatric
departments will often see patients through age 24 years. Thus, it is important to anticipate the child’s
18th birthday in order to ensure smooth transitioning to an adult practitioner (blue box). Additionally,
because there is such a shortage of child-trained psychiatrists, it is helpful for children with uncomplicated
conditions (such as well-controlled ADHD or simple depression improving on a stable dose of medication)
to be managed by their pediatricians, who can then consult with child a psychiatrist as needed.
4
The FDA and Psychotropic Meds for Kids
Advocates often raise concerns about whether or not medications prescribed to their clients are
approved by the FDA for use in children. In truth, this is probably not the right question to ask.
The FDA “approves” medications for use in specific populations with specific conditions (e.g.,
adults over 65 with chest pain; pregnant women with diabetes; children with cystic fibrosis; etc.).
When a drug company submits a new medication to the FDA for approval, it must provide data
from research studies demonstrating that the medication is safe and effective for use. Drug
companies can’t study all possible uses in all age groups—the trials would be prohibitively large
and expensive and drugs would rarely be approved for anything or anyone. Thus, assuming that
the data is compelling enough, the FDA will approve the medication for only the certain conditions
and populations studied in the drug trials that have been submitted. This doesn’t mean, however,
that doctors can’t prescribe the medication to—or that it wouldn’t be beneficial for—other
“unapproved” patient groups.
When a medication is prescribed to a type of patient or for a reason that is not specified in the
original FDA approval, it is being used in an “off-label” manner. This term is often misconstrued
to mean “inappropriate.” In reality, when a doctor prescribes off-label, he or she is making the
decision to do so based on clinical knowledge and experience, and on data from other ongoing
trials (not necessarily being conducted by the drug company itself) that have been published in
peer-reviewed (scientifically reputable) medical journals. This sort of practice is referred to as
evidence-based medicine (EBM). There are many off-label uses that most doctors and
researchers agree are safe and beneficial, based on study data; some of these uses, however,
never become approved by the FDA. One reason for this is that once a medication has been
approved for one purpose, there is little incentive for the manufacturing pharmaceutical company
to put in the time and expense to get it approved again.
To illustrate, several medications used to treat depression in adults are not approved by the FDA
to treat depression in children, even though they may be approved to treat other conditions in that
age group (Zoloft, for example, is approved for obsessive compulsive disorder in children but not
depression). These meds are regularly prescribed off-label for depression with positive effect.
Another (perhaps surprising) example is ADHD. Because this condition is traditionally identified
and treated in childhood, many of the medications used for ADHD have not been FDA-approved
for use in adults. Because ADHD affects some people into adulthood, providers often prescribe
these meds off-label.
Fortunately for prescribers (and for patients), there are national organizations of medical
specialists who come together to decide what is the best evidence-based practice in a given field.
The American Academy of Child and Adolescent Psychiatry (AACAP) releases practice
parameters for providers to reference when they are making clinical decisions. These are only
guidelines; each individual provider must offer treatment according to his/her own judgment
regarding the unique patient sitting before him/her. A better question, then, for parents and
Is the med being prescribed based on scientific
evidence and the consensus of the specialty?
advocates of children is this:
5
Reputable Resources Regarding the FDA and Prescribing
National Institute of Mental Health section on mental health medications:
http://www.nimh.nih.gov/health/publications/mental-health-medications/index.shtml
FDA section on drug research in children:
http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143565.htm
National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health and Human
Development section on the Best Pharmaceuticals for Children Act (BPCA):
http://bpca.nichd.nih.gov/about/Pages/Index.aspx
American Academy of Child & Adolescent Psychiatry section on Practice Parameters:
http://www.aacap.org/AACAP/Resources_for_Primary_Care/Practice_Parameters_and_Resource_Cent
ers/Practice_Parameters1.aspx
6
Chapter I: Attention Deficit Hyperactivity Disorder (ADHD)
Three types:



Predominantly inattentive type
Predominantly hyperactive/impulsive type
Combined type (inattentive and hyperactive/impulsive) – most common
Common symptoms:
 Trouble staying focused, difficulty paying attention to details, easily distracted
 Fidgety, wanders classroom, calls out in class, talks constantly, intrusive
 Poorly organized, forgets homework, loses things easily
Important criteria for making the diagnosis:
 Symptoms must appear before age 12 years & last at least 6 months
 Symptoms must occur in at least two settings (home, school, sports, church, etc.)
 Symptoms must cause distress/impairment - poor performance in school; negatively
affected social relationships; kicked off sports teams; problems at work
Treatment:

Large study conducted by the National Institute of Mental Health (NIMH), the Multimodal Treatment Study of Children with ADHD (the MTA), found that medication is
more effective than behavioral therapy alone for the treatment of ADHD.
 Combining medication with behavioral treatment helps parents, children, and teachers
modify problematic behaviors. In the MTA study, some children receiving behavioral
therapies were able to take lower doses of medication with good outcomes.
 There are two major categories of medications for ADHD: Stimulants & Non-Stimulants
Stimulant Medications: Generally the first-line choice for treatment, very effective
 Methylphenidate Derivatives:
o Short-acting (immediate release): Ritalin, Focalin, Methylin (chewable and
solution forms). These meds are sometimes dosed more than once daily.
o Long-acting (extended release): Ritalin LA, Concerta, Focalin XR, Metadate CD,
Metadate ER, Daytrana (patch), Quilivant (liquid). Meds usually given once daily.
 Amphetamine Derivatives:
o Short-acting (immediate release): Adderall, ProCentra (liquid). Meds are
sometimes dosed more than once daily.
o Long-acting (extended release): Adderall XR, Vyvanse, Dexedrine Spansule.
Meds are usually dosed once daily.
Non-Stimulant Medications: Generally second-line, if stimulants are ineffective or contraindicated




Atomoxetine (Strattera): Takes longer to see effect (2-4 weeks), lower efficacy than
stimulants. Positive: not a controlled substance—low abuse potential/little street value.
Guanfacine: Short-acting (Tenex) and long-acting (Intuniv) forms. Sometimes given in
combination with stimulants. Not controlled, low abuse potential.
Clonidine: Short-acting and long-acting (Kapvay) forms. Sometimes given in combination
with stimulants. Not controlled, low abuse potential.
Bupropion (Wellbutrin): Antidepressant, takes weeks for effect.
7
Common Questions & Important Things to Know About ADHD

What are possible side effects of medications for ADHD?
o Stimulants:
 More common: decreased appetite, trouble falling asleep, headache, nausea
 More rare: irritability, tics, hallucinations, heart racing, dullness/”Zombie”-ism
o Atomoxetine (Strattera):
 Nausea, stomach pain, mood swings. Carries Black Box Warning for suicidal
thoughts (see section on Black Box Warning for details)
o Guanfacine & Clonidine:
 Most important: low blood pressure, dizziness, fainting
 Sedation, daytime sleepiness

What if my client suddenly stops his medication?
The prescriber should always be consulted before stopping medication, as some medications
need to be slowly tapered down to prevent adverse effects. If your client misses his medication,
especially for multiple days, it is important to contact the provider. In general, for ADHD meds:
 Stimulants: Usually no/mild adverse effects from sudden stoppage. May get headache,
irritability, or fatigue. Some parents don’t give stimulants over weekends & holidays to
“give the child a break.” Most doctors advise against this practice; if the medication is
needed for daily function, then it should be given daily.
 Atomoxetine (Strattera): Usually no serious withdrawal upon sudden stoppage, but
depends on dose and duration of treatment. May have dizziness, headache, anxiety.
 Guanfacine & Clonidine: DANGEROUS TO STOP SUDDENLY! May have serious and rapid
elevations in blood pressure. Less serious but bothersome: agitation, tremor, anxiety .

Do children become addicted to stimulants? Does taking stimulants lead to other illicit drug use?
According to the National Institute on Drug Abuse (NIDA), research suggests that people
diagnosed with ADHD have a higher risk of abusing drugs/alcohol than people without ADHD.
Retrospective studies of adult substance users indicate that a high percentage of users had ADHD
that was undiagnosed & untreated in childhood. In fact, NIDA found that children who were
medicated for ADHD were less likely to become substance abusers than un-medicated children
with ADHD. Additionally, treatment with medication delays the age of onset of substance use.
Though it is uncommon for children with ADHD to abuse their own meds, they are at risk for
sharing or selling their meds, or for parents to divert them. Also of note, teenage drivers with
ADHD are more likely to have traffic accidents, more likely to have traffic injuries, and more likely
to be at fault in traffic issues than teens without ADHD. Studies suggest that stimulants improve
performance and safety on the road. References at end of chapter.

Why does my client have to see the doctor every month for a prescription?
Stimulants are classified as Schedule II Controlled Substances by the DEA. This means that doctors
can only write prescriptions for a one-month supply and cannot write for refills. Additionally,
faxed and phoned-in prescriptions are not allowed.
8

What should schools be doing for my clients who have ADHD?
The MTA study demonstrated that medications are superior to behavioral intervention alone in
treating ADHD, but concluded that medication plus behavioral intervention is ideal. Children with
ADHD should be given support in school to help with organization skills, behavior modification,
social interaction, and academic performance. Most children be nefit from having a 504 plan, if
not a full individualized education plan (IEP), to ensure that they receive appropriate
accommodations at school. Doctors should check in with teachers and school counselors, whether
by telephone or through scales and written feedback, to provide a well-rounded picture of how
the child is doing (i.e., prescribing and increasing medication without understanding how the child
is doing in school, where he spends most of his waking hours, is not best practice). Reciprocally,
schools should follow recommendations of providers when diagnoses are made or special
accommodations are needed (e.g., a child needs to take his medication at school or needs to be
allowed an afternoon snack because of decreased lunchtime appetite due to medi cation).

What about special diets to treat ADHD?
The best advice is for families to consult with their doctor about diet and herbal/alternative
treatments for ADHD. In general, most dietary treatments lack supporting evidence for effect, and
some can be dangerous if implemented incorrectly. Like every child, kids with ADHD should eat a
balanced diet and engage in regular exercise.

Why does it seem like every child is diagnosed with ADHD?
ADHD and the medicating of children is a hot topic and parents and child advocates often wonder
how it is possible that “so many kids” have ADHD. The DSM-5 (Diagnostic and Statistical Manual
of Mental Disorders, updated in 2013) indicates that ADHD occurs in ~5% of children—one child
in a classroom of twenty. The CDC notes that community studies yield higher rates than this, and
that rates vary significantly by state. The NIMH indicates that ADHD affects ~9% of children
between the ages of 13 and 18 years, and that boys are 4 times at risk compared to girls. (Of note,
girls are more likely to have the inattentive type, and are sometimes missed until they are much
older because they are not acting out with behavior problems.) Studies show that the number of
children being diagnosed with ADHD is increasing, but it is as yet unclear why—are we diagnosing
it better and picking up kids who in the past have been missed? Are we over-diagnosing? Is there
a true increase in prevalence? It’s hard to say. An important take-home point is that not every
child who is inattentive or hyperactive has ADHD—many other conditions can cause these
symptoms (anxiety, depression, stressful circumstances, etc.). Providers must do their best to take
an all-encompassing picture of the child (through child interview, parent interview, family history,
rating scales, teacher feedback, etc.) to come to a diagnosis. Similarly, it is important for families
and child advocates to understand that sometimes providers get it wrong, and sometimes
diagnoses change over time (in fact, many people “grow out” of ADHD symptoms as they age,
especially hyperactive symptoms). In the absence of a crystal ball, providers and families must
work together to come to the best diagnosis and treatment plan possible for a child, to ensure
that vital time is not lost for academic progress, participation in formative activities, and the
development of peer relationships and social skills. Undertreating is problematic, too, and can
lead to long-lasting drops in self-esteem and happiness.
9
Reputable Resources Regarding ADHD
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). Includes reference regarding
ADHD and teenage driving: http://www.chadd.org/
National Institute of Mental Health section on ADHD:
http://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorderadhd/index.shtml#part4
Center for Disease Control and Prevention section on ADHD:
http://www.cdc.gov/ncbddd/adhd/index.html
National Institute on Drug Abuse article on substance abuse in ADHD:
http://archives.drugabuse.gov/NIDA_Notes/NNVol14N4/ADHD.html
American Academy of Child & Adolescent Psychiatry: Parents Medication Guide for ADHD
http://parentsmedguide.org/parentguide_english.pdf
10
Chapter II: Anxiety and Depression
Anxiety Disorders:
There are many different kinds of anxiety disorders, but in general, they share a few common
features: patients suffer from excessive fear or worry about imminent threats, future threats, or perceived
threats; patients often engage in avoidance behaviors (refusing to go to school, for example); patients
often hold negative cognitions about themselves that can seem like paranoia (e.g., “everyone is always
talking about me”); and patients are debilitated by their worry. In children, it is important to distinguish
anxiety disorders from developmentally normative fear or anxiety and transient fears or anxieties (often
related to stressful situations). Anxiety disorders are persistent. Many anxiety disorders of adulthood first
develop in childhood and early intervention can be instrumental.
 Types of anxiety disorders: Separation Anxiety Disorder; Generalized Anxiety Disorder;
Selective Mutism; Specific Phobia; Social Anxiety Disorder; Panic Disorder; Agoraphobia
 Obsessive Compulsive Disorder (OCD) used to be grouped with anxiety. In the DSM-5 it
has its own section, “Obsessive-Compulsive and Related Disorders,” which includes
other conditions like Body Dysmorphic Disorder, Hoarding, and Trichoti llomania (Hairpulling). Treatment for OCD is similar to anxiety, so it is included here.
Depressive Disorders:
Many people are familiar with the classic condition called Major Depressive Disorder (MDD),
which can be a single episode of clear changes in mood, cognition, sleep, appetite, energy and feelings of
self-worth, or can be a recurrence of episodes separated by remissions of feeling good or “normal.”
Children and adolescents can be deeply affected by their own depression or that of their caretakers.
Identifying and treating depression in children and teens is crucial because depression can lead to
checking out from school work and afterschool activities, turning to substances to alleviate low mood,
and feeling so down as to want to engage in self-harming behaviors or even commit suicide.
 Types of depressive disorders: Major Depressive Disorder (MDD); Persistent Depressive
Disorder (Dysthymia); Premenstrual Dysphoric Disorder; Substance-Induced Depression
 New in the DSM-5: Disruptive Mood Dysregulation Disorder (DMDD). This will be
discussed in its own chapter later in this guide.
 Depression accompanies Bipolar Disorder (also discussed later in this guide), and in fact
people with bipolar disorder generally spend more time feeling depressed than manic. It
is important to screen for accompanying mania when diagnosing depression.
Symptoms and Presentation:
 In kids, anxiety and depression often look different than they do in adults. Irritability and
anger can be seen more often than sad mood.
 Anhedonia is especially common in teens (lack of interest/ability to find pleasure in activities
that used to be pleasurable—quits clubs, sports teams, sits in room all day
 Academic decline is very common – sudden problems completing assignments in 10th grade
is likely not new-onset ADHD at 15…should be concerned about depression!
11
Symptoms and Presentation, continued:
 Somatic symptoms or complaints are very common—especially stomach aches and
headaches without a physical explanation. Missing school for physical symptoms is a red flag
for anxiety or depression
 Bullying is a huge culprit as a precipitating and/or perpetuating factor, and the online nature
of children’s social lives makes it easy to anonymously bully in a public venue
Treatment:
In general, severe depression is treated with a two-pronged attack: medication plus
psychotherapy. The Treatment of Adolescents with Depression Study (termed TADS and published in
JAMA in 2004- see resources page) found that teens improved more quickly and with better lasting effect
when they were given a medication and participated in cognitive behavioral therapy. It’s important to
note that teens on medication for depression will likely not be on medication forever; it is normal practice
to pull children off medication once they have had a substantial period of remission from symptoms.
Additionally, most forms of anxiety are treated with the same first-line medications as depression, though
the doses needed to adequately treat the varying conditions may differ.
 First-line Medications: Selective serotonin reuptake inhibitors (SSRIs)
Fluoxetine (Prozac), Sertraline (Zoloft), Citalopram (Celexa), Escitalopram (Lexapro)
These medications take 4-6 weeks to take effect, so a “true trial” requires sticking
with the medication before declaring it ineffective.
These medications need to be taken every day, and not an as-needed basis
If a true trial of one medication is ineffective (or if side effects necessity early
discontinuation), the general practice is to try another medication in this class. If
that fails, generally providers will try a third medication in this class
 Second-line Medications (for depression) :
- Switch to: Venlafaxine (Effexor), Duloxetine (Cymbalta), Bupropion (Wellbutrin)
- Give SSRI plus adjuvant med: low-dose lithium; aripiprazole (Abilify); T3 (synthetic
thyroid hormone)
 Second-line or Adjuvant Medications (for anxiety):
- Benzodiazepines: usually added to antidepressants, rarely given alone
 Long-acting: Clonazepam (Klonopin)
 Short-acting “rescue”: Lorazepam (Ativan), often used in inpatient
setting for severe agitation or panic attack
 Very short-acting: Alprazolam (Xanax), ALMOST NEVER USED IN
KIDS/TEENS!! Can be very habit-forming & has street value
- Other forms: usually added to antidepressants rather than given alone
 Gabapentin (Neurontin), Buspirone (Buspar), Clonidine, Propranolol
(beta-blocker); Fluvoxamine (Luvox) is an SSRI used for OCD, given alone
 Psychotherapy: Very helpful and important for almost anyone with anxiety/depression
- Cognitive Behavioral Therapy (CBT) with an individual therapist weekly
- Family therapy, especially when social/economic stressors are a significant problem
12
Common Questions & Important Things to Know About Anxiety & Depression

What are possible side effects of Selective Serotonin Reuptake Inhibitors (SSRIs)?
In general, SSRIs are well tolerated by most people. While it can take up to 6 weeks to see positive
effects on mood, adverse effects (side effects) usually appear soon after initiating the medication and
many of them resolve after the first week. Patients may experience upset stomach, nausea, diarrhea,
headache, sleep changes, weight gain, night sweats, decreased libido, decreased ability to have or sustain
erection. For teenagers especially, the sexual side effects may cause them to stop taking the medication
without telling their parents why. If side effects occur, it is very important to talk with the provider who
prescribed the medication.

What is the deal with the Black Box Warning about suicidal thoughts?
In 2004 the FDA reviewed the available literature and issued a public warning about increased suicidal
thinking in children and adolescents taking SSRIs to treat depression. In 2006 the FDA expanded the black
box warning to include persons up to age 25. As summarized on the NIMH website: “In the FDA review,
no completed suicides occurred among nearly 2,200 children treated with SSRI medications. However,
about 4 percent of those taking SSRI medications experienced suicidal thinking or behavior, including
actual suicide attempts—twice the rate of those taking placebo, or sugar pills.” There are many theories
about why there was an apparent increase in reported suicidal thinking, and it is best for families who
have questions about the black box warning to talk about this with their providers. The NIMH website
also notes that there was a subsequent comprehensive review of pediatric trials, published in JAMA in
2007 (see resources page), which found that the benefits of antidepressant medications outweigh the risk.
It should be remembered that depression itself seriously increases the risk of suicidal thoughts and that
untreated depression seriously increases the risk of suicide attempts. The take-home point for all of this
for providers has been that children and teens should be closely monitored for suicidal thinking upon
initiating antidepressant treatment.

Is it dangerous to take too much of an SSRI?
YES! Overdosing on SSRIs can be very dangerous. Additionally, taking an SSRI with other medications
that cause increases in serotonin levels can be very dangerous. Other medications that increase serotonin
levels include: antidepressants in other classes [TCAs (amitriptyline), SNRIs like venlafaxine (Effexor) or
duloxetine (Cymbalta), MAOIs ]; some anti-migraine medications, like triptans (e.g., Imitrex, Imigran,
Maxalt); and herbal medications like St. John’s Wart. In general (as in most cases), be sure that your client
talks with the provider before adding new medications, and be sure that all providers know about all
medications being taken. In the event of overdose, call the provider right away and/or go to the ED. Build
up of too much serotonin in the body can lead to Serotonin Syndrome, which is marked by anxiety,
sweating, significantly increased heart rate, high blood pressure, overactive reflexes, and hallucinations.
This is an emergency and should be treated in an ED/hospital setting.
13

What if my client suddenly stops taking his SSRI?
The prescriber should always be consulted before stopping medication, as some medicatio ns need to
be slowly tapered down to prevent adverse effects. If your client misses his medication, especially for
multiple days, it is important to contact the provider. In general, for SSRIs, there may be a discontinuation
or withdrawal syndrome, marked by a “flu-like reaction” (headache, nausea, vomiting, dizziness, blurred
vision, dizziness). Usually this is not serious or life-threatening. In general, the higher the dose at the time
of the sudden stop, the greater the chance of experiencing a withdrawal reaction. Additionally, shortacting (and short-lived) medications pose a greater risk for withdrawal—fluoxetine (Prozac) has a long
half-life and generally “self-tapers” upon cessation, making withdrawal less likely but requiring much more
time for the medication to fully leave the system; paroxetine (Paxil), on the other hand, has a very short
half-life and may be more likely to produce withdrawal symptoms if it is stopped abruptly. Withdrawal
symptoms are treated with supportive care (i.e., no specif ic medication needed, as with alcohol
withdrawal). Always consult the provider before stopping medications, or after it is discovered that your
client has stopped his medication.

Is there any special monitoring that is needed for people who are taking SSRIs?
SSRIs do not require monitoring of blood levels or of specific physical exam findings. Given the black
box warning, however, when starting children or teens on SSRIs, there should be frequent contact with
the provider to assess for safety.
14
Reputable Resources Regarding Anxiety & Depression
National Institute on Mental Health section on depression in children & adolescents:
http://www.nimh.nih.gov/health/topics/depression/depression-in-children-and-adolescents.shtml
National Institute on Mental Health section on anxiety in children & adolescents:
http://www.nimh.nih.gov/health/publications/anxiety-disorders-in-children-andadolescents/index.shtml
Treatment for Adolescents with Depression Study (TADS). Available for free:
http://jama.jamanetwork.com/article.aspx?articleid=199274
Article in the Journal of American Medical Association (JAMA, 2007) regarding suicide risk and
antidepressants, as mentioned in the text of this chapter. Available for free:
http://jama.jamanetwork.com/article.aspx?articleid=206656
15
Chapter III: Autism Spectrum Disorder (ASD)
Features:
 Persistent deficits in social communication & social interaction across multiple contexts
o Poor back-and-forth conversation, reduced sharing of interests, difficulty with
nonverbal cues, trouble understanding relationships, poor eye contact
o Must occur in more than just one setting (school, home, community, etc.)
 Restricted, repetitive patterns of behavior or interests
o Stereotyped movements, lining up toys, echolalia (repeating what is heard),
insistence on sameness, fixed interests abnormal in intensity (e.g., cannot stop
talking about trains and memorizes train routes and schedules), hypo- or hyperreactivity to sensory input
 Symptoms must be present in early development
 Symptoms must cause significant impairment
 Can have autism with or without intellectual impairment
 Can have autism with or without language impairment
Treatment:
Early intervention with supports for the child and family is key. Treatment depends on level of
functioning (or level of impairment).
 Therapy:
o Applied Behavioral Analysis therapy (ABA) – shapes and reinforces new behaviors and
reduces undesirable ones. Interventions are focused on functional and socially
appropriate goals. Based on the principle of positive reinforcement.
o School services are imperative – IEP, sometimes specialized schools
o Occupational therapy, especially for patients with sensory issues (some specialized
schools have “sensory rooms” that can be very helpful)
o In-home services for therapy and/or nursing assistance for family
o Support groups and networks for family and patient (see resources page).
 Medication:
o There are no medications to treat the primary symptoms of autism
o FDA has approved aripiprazole (Abilify) and risperidone (Risperdal) for treatment of
aggression, self-harming acts, dangerous outbursts in this population
o DSM-5 indicates that ~70% of individuals with autism have another mental disorder, and
40% may have two or more. It is important to treat these conditions (especially anxiety,
depression, ADHD—with the institution of DSM-5, patients may now be diagnosed with
both ASD and ADHD if they meet criteria for both, whereas under DSM-IV the diagnosis
of autism excluded ADHD).
16
Common Questions & Important Things to Know About ASD

What if I suspect that my client has autism but he hasn’t been diagnosed?
Any doctor can diagnose autism, but often the symptoms aren’t straight-forward and the
diagnosis is not clear-cut. In such instances, more formalized evaluation can be helpful. Child
psychiatrists and psychologists are the best trained to make the diagnosis; more specifically,
specialized autism centers offer the most in-depth option for evaluation. In this area, Children's
National Medical Center has the Center for Autism Spectrum Disorders (CASD) in Rockville, MD.
Unfortunately, DC Medicaid does not pay for evaluation at that site. The Kennedy Krieger Institute
(KKI) at Johns Hopkins in Baltimore also has a full diagnostic center. There is no blood test or single
scale to assess for autism. The Autism Diagnostic Interview (ADI) and the Autism Diagnostic
Observation Schedule (ADOS) are helpful and spe cific assessment tools, but they must be
administered by an evaluator who receives specialized certification to give them. Other important
assessments to pursue are neuropsychological testing (done by a PhD in psychology —this is
sometimes confused with a neurology assessment by an MD, which is not generally a needed
piece in an autism evaluation unless there are specific concerning neurological complaints),
speech and language evaluation (by a speech pathologist), and occupational therapy assessment
(OT). At the very least, referral to a child psychiatrist, who can then orchestrate all these other
pieces, should be pursued when autism is suspected (but not confirmed) by the family, child
advocate or pediatrician.

If my client already has an IEP but has now been diagnosed with autism, is it necessary to add the
autism diagnosis to the IEP?
The answer to this is a resounding YES. Children with the autism diagnosis are entitled to
resources and accommodations that are sometimes hard to get without the diagnosis.
Additionally, there are certain specific interventions and curricula that are specific for children
with autism. Even if the child’s particular school is not implementing these interventions for other
students, they may be compelled to do so if the advocacy team of a child with autism pushes for
them. If the school is not equipped, it is important that the autism diagnosis be formalized in the
IEP so that the child can be transferred to a school that might better fit his needs.
17
Reputable Resources Regarding ASD
CNMC Autism Family Resources PDF:
http://childrensnational.org/~/media/cnhssite/files/departments/casd/casdbook_june27_final.ashx?la=en
Children's National Medical Center – Center for Autism Spectrum Disorders
http://childrensnational.org/departments/center-for-autism-spectrum-disorderscasd?sc_lang=en
Autism Speaks:
https://www.autismspeaks.org/
National Institute of Mental Health section on autism:
http://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/index.shtml
18
Chapter IV: Mood Disorder NOS, Bipolar Disorder, and Disruptive Mood
Dysregulation Disorder (DMDD)
All children and teenagers have mood swings and emotional outbursts—this is part of normal
development. For some youth, however, regulating mood and emotion can be overwhelming and
incapacitating, and in some cases out of their volitional control. In the DSM-IV, Mood Disorders (also called
affective disorders) were classified into two main categories: Depressive Disorders and Bipolar Disorder.
Depressive Disorders have been covered in another chapter (but to refresh, include Major Depressive
Disorder, Persistent Depressive Disorder or Dysthymia, and Substance-Induced Depression, among
others). Bipolar Disorder will be covered in more detail in this chapter, but in general is a condition of
cycling mood, consisting of discrete periods of expansive and abnormally elevated mood (mania) and
longer periods of low mood (depression). For people with debilitating impairments in mood that do not
quite meet the specific criteria for a depressive or bipolar disorder diagnosis, the diagnosis of Mood
Disorder Not Otherwise Specified (NOS) has historically been given. Advocates for children often see this
diagnosis and feel confused about what exactly it means—to be frank, this is how many providers feel
when they see this diagnosis as well. To further muddle the waters, the diagnosis of Bipolar Disorder in
pediatric populations has been contentious at best within the psychiatric community and in the realm of
mass media. In the DSM-5, Mood Disorder NOS does not specifically exist. There is a new diagnosis called
Disruptive Mood Dysregulation Disorder (DMDD), which appears in the “Depressive Disorders” section of
the DSM-5, which may help to capture some of the mood/affective problems seen in children. There is a
section called “Bipolar and Related Disorders” that includes the classical Bipolar I and Bipolar II disorders,
and also “Unspecified Bipolar and Related Disorder.” Advocates for children may see these diagnoses with
increasing frequency in the future. This chapter will discuss DMDD and Bipolar Disorder and the
treatments children might receive.

Disruptive Mood Dysregulation Disorder (DMDD)
 Created in part to address concerns about the over-diagnosis of bipolar diagnosis in children
and adolescents.
o Characterized by severe recurrent temper outbursts (verbal or physical) that are out of
proportion to the intensity of the situations provoking them, occurring 3+ times/week
o Mood between temper outbursts is persistently irritable or angry most of the day,
nearly every day
o These symptoms have been present for 12 months, with no more than 3 consecutive
months without symptoms
o Must be at least 6yrs old to be diagnosed, with symptoms having begun by age 10
 Estimated prevalence of 2-5%
 Research has demonstrated that children with DMDD usually do not go on to have bipolar
disorder in adulthood. They are more likely to develop problems with depression or anxiety.
 IMPORTANT FOR TREATMENT DECISIONS: Classified in DSM-5 as a Depressive Disorder
o Specific treatments may vary by provider and by the individual patient, but it may not
be unusual to see this diagnosis treated with antidepressants, or with mood stabilizers
(covered in this chapter). Recommend talking with the provider for clarification of how
the particular child’s condition has been conceptualized in creating the treatment plan.
19

Bipolar Disorder
 Severe, non-episodic irritability has been considered as characteristic of bipolar disorder in
children, but DSM-IV and DSM-5 require that both children and adults have distinct episodes of
mania or hypomania to qualify for the diagnosis (thus, DMDD was created)
o Manic episode: distinct period of persistently elevated, expansive or irritable mood and
increased energy or goal-directed activity lasting at least 1 week and present most of
the day
o Common symptoms: grandiosity, decreased need for sleep (sometimes staying awake
for days at a time without fatigue), pressured speech, flight of ideas/racing thoughts
o The mood disturbance is severe enough to cause impairment in social functioning or to
warrant hospitalization to prevent harm to self or others
o Hypomania is similar to mania but must last only 4 consecutive days and persist most of
the day, nearly every day, and is not severe enough to cause marked impairment in
functioning or to necessitate hospitalization
o The manic episode may be preceded and/or followed by hypomanic episodes or
depressive episodes
 Cyclothymic Disorder (classified in the DSM-5 under the “Bipolar and Related Disorders”
chapter) is given to children who have had at least one full year (2 yrs for adults) of both
hypomanic and depressive periods without having fulfilled the criteria for a single episode of
mania, hypomania or major depression
 DSM-5 estimates that the prevalence ranges from 0.0 – 0.6% worldwide
 Family history is one of the strongest risk factors for the condition, with risk increasing by about
10-fold for people with a first-degree relative with the condition
 Suicide risk is very high in Bipolar Disorder. DSM-5 estimates that the risk of suicide is 15 times
that of the general population, and that bipolar disorder may account for 25% of all completed
suicides. This makes screening of adolescents, and provision of appropriate treatment,
exceedingly important for children and teens with this diagnosis.

Common Treatments
 Mood Stabilizers:
o Lithium:
 Classic medication that works well.
 Need to monitor kidney function regularly via blood draw
 Need to check thyroid function before starting and periodically thereafter
(blood test to measure TSH)
 Must monitor levels of drug in the blood
 Can cause significant weight gain, so measure cholesterol and blood sugar
before starting and periodically thereafter
 Should taper off—don’t discontinue rapidly.
o Valproic Acid (Depakote, Depakene):
 Originally an anti-seizure medication & still used regularly for that purpose, but
shows positive effects for mood stabilization
 Need to check liver function (blood test) before starting and periodically
thereafter
20


Can cause significant weight gain, good idea to monitor blood sugar and
cholesterol
 Can cause pancreatitis (generally requires hospitalization) and changes to
platelet counts
 Must monitor levels of drug in the blood
 Teratogenic (girls should be on birth control)
 Should taper off—don’t discontinue rapidly.
o Lamotrigine (Lamictal):
 Can be very helpful for mood, and generally has less weight gain than lithium
and valproic acid, and antipsychotics
 LIFE-THREATENING SIDE EFFECT: Stevens Johnson Syndrome (SJS)
 Begins as rash. ANY sign of rash should be reported to the doctor
IMMEDIATELY and the medication should be stopped
 Generally occurs in response to high doses started too precipitously—
providers should start low and go slow with dosing (increased every
two weeks in small increments)
 There is no withdrawal/sudden discontinuation syndrome
 If a few doses are missed, notify the provider because the patient will
likely need to go back to a lower dose to restart it
o Other Mood Stabilizers: Sometimes these are used in mood disorders; they are also all
used to treat patients with seizure disorders, and sometimes for migraines
 Carbemazepine (Tegretol), Oxcarbazepine (Trileptal), Topiramate (Topamax)
Antipsychotics:
o True schizophrenia and other psychotic disorders (marked by hallucinations, delusions,
and paranoia) are unusual in children. Sometimes, however, psychotic symptoms
accompany mood disorders (as in depression with psychotic features or mania with
psychosis).
o When antipsychotic medications are prescribed in kids, it is often for mood
stabilization, aggression/self-harm (as discussed in the autism chapter), or as adjuvants
to antidepressants (as in Abilify + SSRI, discussed in the depression chapter), rather than
to treat psychotic symptoms.
o Significant controversy exists about the use of antipsychotics in children, particularly
children in the foster care system (where they have been shown to be prescribed with
greater frequency), and there is little known about long-term effects of these
medications in children.
o Antipsychotics are generally classified into first and second generation meds:
 First Generation (AKA Typical) Antipsychotics:
 Haloperidol (Haldol), Chlorpromazine (Thorazine), Perphenazine
(Trilafon), and Fluphenazine (Prolixin)
 These are not used often in children, except for Haldol, which is
sometimes used for acute management on inpatient units or on an
outpatient basis for children who have not responded to other meds
 Adverse effects: Extrapyramidal Symptoms (EPS): muscle spasms,
restlessness, rigid muscles, Parkinsonism (tremor, slowed movements);
21

Tardive Dyskinesia: long-term effect, jerky movements, often seen in
tongue/mouth
 Second Generation (AKA Atypical) Antipsychotics:
 Aripiprazole (Abilify), Olanzapine (Zyprexa), Quetiapine (Seroquel),
Risperidone (Risperdal), Ziprasidone (Geodon), Clozapine (Clozaril)
 Preferred over first generation because the risk of EPS is lower
 Adverse effects: Weight gain (esp with Zyprexa, Seroquel, Risperidone),
diabetes/metabolic problems; Gynecomastia, or enlarged breast tissue,
even in boys (especially with Risperdal)
 Very rare but serious side effect of antipsychotics: Acute Dystonia
 Sudden & severe rigidity, twisting, sustained contractions of limbs, face,
or whole body
 This is an emergency and requires hospital-level intervention
 More likely with first generation (typical) antipsychotics
 If the antipsychotic medication works very well to stabilize mood or control
aggression but there are some unwanted (but not severe) side effects,
providers sometimes use additional medication to ameliorate the side effect:
 Benztropine (Cogentin)
 Diphenhydramine (Benadryl)
Combination Treatment:
o Sometimes, and especially in the midst of an acute manic episode, providers use a
mood stabilizer plus an antipsychotic.
o It is unusual, however, to have a child on more than one antipsychotic, except in the
case of cross-tapering from one to another (at the end of which the child will be on only
one antipsychotic)
22
Common Questions & Important Things to Know About Mood Stabilizers &
Antipsychotics for Mood Disorders

What sort of monitoring needs to be done if my client is on one of these medications?
For any of the medications that can cause weight gain or metabolic problems (lithium, valproic acid,
atypical antipsychotics), the patient should have blood sugar, electrolytes and a lipid panel
(cholesterol) drawn prior to initiating the therapy. Continued monitoring depends on the particular
medication. It is important to note that blood sugar and lipid panels should be drawn after the patient
has fasted (at least 6 hrs), so it is best to schedule this firs thing in the morning. Lithium requires
monitoring of thyroid hormone levels and kidney function (via cre atinine). Valproic acid requires
monitoring of liver function tests and blood cells (especially platelets). Lithium and Valproic acid also
require that the level of drug in the blood be monitored periodically. In general, blood drug levels
should be drawn just before the AM dose is given; a blood level taken shortly after the patient has
received the medication is less helpful. Clozapine (Clozaril) is not used very often, despite the fact that
it works very well for treating psychosis, because it carries a risk of agranulocytosis (dangerously low
levels of a particular kind of white blood cell), which leaves the patient at risk for serious infection.
Patients on clozapine must have a complete blood count (CBC) drawn regularly and they must be
listed on a national registry if they are taking this medication.

What sort of medication should kids with DMDD be prescribed?
Because DMDD is a relatively new diagnosis, it is unclear as of yet what will be the most common
treatments for the disorder. Because the diagnosis was conceived of partly in order to keep children
with chronic irritability from being labeled as having bipolar disorder, it may be that providers will still
reach for mood stabilizers to help to level off the irritable/labile mood. This may be exactly the right
approach for some children. On the other hand, because studies have shown that children who meet
criteria for DMDD are more likely to go on to develop depressive disorders than bipolar disorder, it
may make more sense to treat with antidepressants to address irritability and emotional lability (as
these symptoms may be stemming from underlying dysphoria or depression). This may be exactly the
right approach for some children. Complicating matters further is the well-established fact that using
antidepressants, particularly SSRIs, in people with underlying bipolar disorder can precipitate a switch
into mania, which can be dangerous (and children are reportedly especially vulnerable to a “manic
switch” from SSRIs). Taken together, the best advice is to talk with the provider about the diagnosis,
and about why the particular treatment plan is being chosen for that particular child—there may be
other factors, like family history, co-morbid conditions, or past medication trials that are playing a role
in the treatment planning.

What is the deal with the use of antipsychotics and the foster care system?
This question is the subject of entire books and is too large for a guide like this one. The American
Academy of Child & Adolescent Psychiatry (AACAP) has written a Practice Parameters document
about the use of antipsychotics in children and it addresses this issue. It can be accessed for free
here:http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic
_Medications_Web.pdf . AACAP is in the process of creating another Practice Parameters document
that is solely dedicated to the mental health of children in foster care.
23
Reputable Resources Regarding Mood Disorders, Mood Stabilizers &
Antipsychotics
National Institute of Mental Health (NIMH) section on Bipolar Disorder in Children & Adolescents:
http://www.nimh.nih.gov/health/publications/bipolar-disorder-in-children-and-adolescents/index.shtml
NIMH section: Most Children with Rapidly Shifting Moods Don’t Have Bipolar Disorder:
http://www.nimh.nih.gov/news/science-news/2010/most-children-with-rapidly-shifting-moods-donthave-bipolar-disorder.shtml
American Academy of Child & Adolescent Psychiatry:
http://www.aacap.org
24
Chapter V: Post-Traumatic Stress Disorder
 Description:
 For adults, teens, and children > 6yrs old:
o Exposure to actual or threatened death, serious injury, or sexual violence by direct
experiencing, witnessing, or learning that event happened to close family member
o Presence of intrusive symptoms associated with event – memories, flashbacks,
nightmares
o Persistent avoidance of stimuli associated with traumatic event
o Hyper-reactivity/hyper-arousal associated with triggers
 For children < 6yrs:
o Sexually violent events may include developmentally inappropriate sexual experiences
without violence/injury

Treatment:
 Therapy:
o Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
 Should be given by an experienced therapist
 Continuity of therapist is very important! If the child will be inconsistent with
therapy or may not be able to complete and will have to start over, or if the
therapist will be leaving the agency, consider postponing the therapy until the
child can work with one therapist consistently through completion of therapy
 Medication:
o Some studies indicate that SSRIs can be helpful
o Clonidine (quiets the fight-or-flight system) can be helpful
o Prazosin (similar to clonidine) is used on the west coast and in military vets to treat
nightmares associated with PTSD; not wide usage in children, especially on east coast

Is it PTSD?
 Not every child who experiences trauma will develop PTSD:
o There is growing literature on resiliency in children – who suffers through trauma but
does not go on to develop PTSD, and why not?
o Some studies show that over-therapizing or forcing therapy directly after a traumatic
event can actually make coping worse (fine line)
 Look for co-morbid conditions:
o Children with PTSD can still have anxiety and depression, and often do
o Sometimes children with symptoms of PTSD are mis-diagnosed as having ADHD; it is
important to inform providers of known trauma. It should be noted, however, that
children with PTSD can also have ADHD. Sometimes treating symptoms in the service of
daily functioning can be more helpful than focusing on diagnosis
25
Reputable Resources Regarding PTSD
National Child Traumatic Stress Network:
http://www.nctsn.org
National Institute of Mental Health section on PTSD:
http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml
U.S. Department of Veterans Affairs National Center for PTSD, section on Children & Adolescents:
http://www.ptsd.va.gov/professional/treatment/children/ptsd_in_children_and_adolescents_overview
_for_professionals.asp
26
Appendix I: Medications Index
Alphabetical by Brand Name (alphabetical by generic name on next page)
Medication
Abilify (aripiprazole)
Adderall (mixed amphetamine salts)
Ativan (lorazepam)
Buspar (buspirone)
Celexa (citalopram)
Clonidine (clonidine)
Clozaril (clozapine)
Concerta (methylphenidate ER)
Cymbalta (duloxetine)
Daytrana (methylphenidate patch)
Depakote, Depakene (valproic acid)
Effexor (venlafaxine)
Focalin (dexmethylphenidate)
Geodon (ziprasidone)
Haldol (haloperidol)
Inderal (propranolol)
Intuniv (guanfacine ER)
Kapvay (clonidine ER)
Klonopin (clonazepam)
Lamictal (lamotrigine)
Lexapro (escitalopram)
Lithium
Luvox (fluvoxamine)
Metadate (methylphenidate CD)
Neurontin (gabapentin)
Prolixin (fluphenazine)
Prozac (fluoxetine)
Quillivant (methylphenidate liquid)
Risperdal (risperidone)
Ritalin (methylphenidate)
Seroquel (quetiapine)
Strattera (atomoxetine)
Tegretol (carbamazepine)
Tenex (guanfacine)
Topamax (topiramate)
Trilafon (perphenazine)
Trileptal (oxcarbazepine)
Vyvanse (lisdexafetamine)
Wellbutrin (bupropion)
Xanax (alprazolam)
Zoloft (sertraline)
Zyprexa (olanzapine)
Usual Uses
Mood stabilization, adjuvant for depression, psychosis, aggression
ADHD
Anxiety, acute agitation
Anxiety
Depression, anxiety
ADHD
Mood stabilization, psychosis
ADHD
Depression
ADHD
Mood stabilization, seizure control
Depression
ADHD
Mood stabilization, psychosis
Mood stabilization, psychosis, acute agitation
Performance anxiety, panic, restless leg
ADHD
ADHD
Anxiety
Mood stabilization
Depression, anxiety
Mood stabilization, seizure control, adjuvant for depression
Depression, anxiety, OCD
ADHD
Anxiety, neuropathic pain
Mood stabilization, psychosis
Depression, anxiety, bulimia
ADHD
Mood stabilization, psychosis, aggression
ADHD
Mood stabilization, psychosis, sometimes sleep
ADHD, depression
Mood stabilization, seizure control
ADHD
Mood stabilization, seizure control, migraines
Mood stabilization, psychosis
Mood stabilization, seizure control
ADHD
Depression, sometimes ADHD
Panic attacks
Depression, anxiety, OCD
Mood stabilization, psychosis
Chapter
IV, III
I
II
II
II
I
IV
I
II
I
IV
II
I
IV
IV
II
I
I
II
IV
II
IV
II
I
II
IV
II
I
IV, III
I
IV
I
IV
I
IV
IV
IV
I
II
II
II
IV
27
Appendix I: Medications Index
Alphabetical by Generic Name
Medication+C6A45:C76
Alprazolam (Xanax)
Aripiprazole (Abilify)
Atomoxetine (Strattera)
Bupropion (Wellbutrin)
Buspirone (Buspar)
Carbamazepine (Tegretol)
Citalopram (Celexa)
Clonazepam (Klonopin)
Clonidine (clonidine)
Clonidine ER (Kapvay)
Clozapine (clozaril)
Dexmethylphenidate (Focalin)
Duloxetine (Cymbalta)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Fluphenazine (Prolixin)
Fluvoxamine (Luvox)
Gabapentin (Neurontin)
Guanfacine (Tenex)
Guanfacine ER (Intuniv)
Haloperidol (Haldol)
Lamotrigine (Lamictal)
Lisdexafetamine (Vyvanse)
Lithium
Lorazepam (Ativan)
Methylphenidate (Ritalin)
Methylphenidate CD (Metadate)
Methylphenidate ER (Concerta)
Methylphenidate liquid (Quillivant)
Methylphenidate patch (Daytrana)
Mixed amphetamine salts (Adderall)
Olanzapine (Zyprexa)
Oxcarbazepine (Trileptal)
Perphenazine (Trilafon)
Propranolol (Inderal)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Sertraline (Zoloft)
Topiramate (Topamax)
Valproic acid (Depakote, Depakene)
Venlafaxine (Effexor)
Ziprasidone (Geodon)
Usual Uses
Panic attacks
Mood stabilization, adjuvant for depression, psychosis, aggression
ADHD, depression
Depression, sometimes ADHD
Anxiety
Mood stabilization, seizure control
Depression, anxiety
Anxiety
ADHD
ADHD
Mood stabilization, psychosis
ADHD
Depression
Depression, anxiety
Depression, anxiety, bulimia
Mood stabilization, psychosis
Depression, anxiety, OCD
Anxiety, neuropathic pain
ADHD
ADHD
Mood stabilization, psychosis, acute agitation
Mood stabilization
ADHD
Mood stabilization, seizure control, adjuvant for depression
Anxiety, acute agitation
ADHD
ADHD
ADHD
ADHD
ADHD
ADHD
Mood stabilization, psychosis
Mood stabilization, seizure control
Mood stabilization, psychosis
Performance anxiety, panic, restless leg
Mood stabilization, psychosis, sometimes sleep
Mood stabilization, psychosis, aggression
Depression, anxiety, OCD
Mood stabilization, seizure control, migraines
Mood stabilization, seizure control
Depression
Mood stabilization, psychosis
Chapter
II
IV, III
I
II
II
IV
II
II
I
I
IV
I
II
II
II
IV
II
II
I
I
IV
IV
I
IV
II
I
I
I
I
I
I
IV
IV
IV
II
IV
IV, III
II
IV
IV
II
IV
28
Appendix II: Common Medical Abbreviations
A&O/AAO
alert and oriented
ADE/ADR
adverse drug effect/reaction
ADHD
attention deficit hyperactivity disorder
AED
anti-epileptic drug
AMS
altered mental state
ASD
autism spectrum disorder
AVH
auditory and visual hallucinations
BAL
blood alcohol level
BID
twice daily
BMP
basic metabolic panel
BPD
borderline personality disorder OR bipolar disorder (ambiguous)
c
*with straight line over top* "with"
CBC
complete blood count
CC
chief complaint
CICU
cardiac intensive care unit
CMP
complete metabolic panel
CNII-XII
cranial nerves II-XII
CNS
central nervous system
CPK
creatine phosphokinase (measure of muscle breakdown)
CSF
cerebrospinal fluid
CT
computerized tomography or chlamydia trachomatis (STI)
CTA
clear to auscultation
CVA
cardiovascular accident (stroke)
Cx
culture (for urine, blood, sputum, etc.)
CXR
chest x-ray
D/C
discharge or discontinue
DDx
differential diagnosis (list of conditions that might fit the symptoms)
DKA
diabetic ketoacidosis (life-threatening result of very high blood sugars)
DM
diabetes mellitus, specify type I (insulin resistant) and type II
DMDD
disruptive mood dysregulation disorder
DTR
deep tendon reflexes
DVT
deep vein thrombosis
Dx
diagnosis
ECT
electroconvulsive therapy
EDNOS
eating disorder not otherwise specified
EEG
electroenecephalopgram
EKG/ECG
electrocardiogram
EOM
extraocular muscles
EtOH
ethanol (used short-hand to indicate alcohol on breath, for example)
29
F/U
follow up
FMH
family pedical history
FTT
failure to thrive
Fx
fracture
GAD
generalized anxiety disorder
GC
gonorrhea
GI
gastrointestinal or gastroenterology
GID
gender identity disorder
GSW
gunshot wound
gt/gtt
drops
GU
genitourinary
H/H
hemoglobin and hematocrit (often reported together)
HCG
human chorionic gonadotropin (measure of pregnancy & some tumors)
HCT
hematocrit (measure of anemia)
HEENT
head, eyes, ears, nose and throat
HgA1c
hemoglobin A1c (measure of long-term blood sugar control)
Hgb
hemoglobin (measure of anemia)
HI
homicidal ideation
HIV
human immunodeficiency virus
HPI
history of present illness
HPV
human papillomavirus
HSM
hepatosplenomegaly (enlarged liver or spleen)
HSV
herpes simplex virus
HTN
hypertension
Hx
history
I&O
input and output (fluid in and fluid out)
I/P
inpatient
ICU
intensive care unit
ID
infectious disease (department)
IED
intermittent explosive disorder
IM
intramuscular
IOP
intensive outpatient program
IT
intrathecal (delivered into the cerebrospinal fluid, usually chemotherapy)
IV
intravenous
JODM
juvenile onset diabetes mellitus
KUB
x-ray of kidneys, ureters, bladder
LFTs
liver function tests
LMP
last menstrual period
LOC
loss of consciousness or level of consciousness
LP
lumbar puncture (spinal tap, commonly)
LUQ/LLQ
left upper/lower quadrant (of abdomen)
M/R/G
murmurs, rubs or gallups
MDD
major depressive disorder
30
MMR
measles, mumps, rubella vaccine
MRA
magnetic resonance angiogram
MRI
magnetic resonance imaging
MRSA
methicillin-resistant staph aureus
MSE
mental status exam
MVA/MVC
motor vehicle accident/crash
NAD
no acute distress
NC
nasal cannula (as in oxygen delivered to nose)
NCAT
normo-cephalic, atraumatic (normal head, no injuries)
NES
non-epileptic seizure
NG
nasogastric (as in a feeding tube through the nose)
NICU
neonatal intensive care unit
NKDA
no known drug allergies
NOS
not otherwise specified
NPO
nothing by mouth (as in before surgery)
NSR
normal sinus rhythm (refers to cardiac exam)
O/P
outpatient
OCD
obsessive compulsive disorder
OCP
oral contraceptive pill
ODD
oppositional defiant disorder
OT
occupational therapy
PDDNOS
pervasive developmenttal disorder not otherwise specified
PE
physical exam or pulmonary embolism
PFTs
pulmonary function tests
PHP
partial hospitalization program
PICU
pediatric intensive care unit
PKU
phenylketonuria
PMH
past medial history
PNA
pneumonia
PO
by mouth
PPD
purified protein derivative (tuberculosis skin test)
PR
per rectum
PRN
as needed
Pt
patient
PT
physical therapy
q
every (q4h = every 4 hours)
QID
four times daily
QOD
every other day
QTc
corrected QT interval (EKG finding pertinent to some meds)
R/O
rule out
RIS
responding to internal stimuli
ROM
range of motion
ROS
review of symptoms
31
RPR
rapid plasma reagin (syphillis test)
RRR
regular rate and rhythm
RTC
residential treatment center OR return to clinic
RUQ/RLQ
right upper/lower quadrant (of abdomen)
Rx
prescription
s
*with straight line over top* "without"
S/NT/ND
soft, non-tender, non-distended
S/S
signs and symptoms
SAD
seasonal affective disorder OR schizoaffective disorder (ambiguous)
SGA
second-generation antipsychotic (atypical antipsychotic)
SI
suicidal ideation
SIB
self-injurious behavior
SL
sublingual (under the tongue)
SNRI
serotonin and norepinephrine reuptake inhibitor
SOB
shortness of breath
SQ
subcutaneous
SSRI
selective serotonin reuptake inhibitor
STD/STI
sexually transmitted disease/infection
SUD
substance use disorder
Sx
symptoms
TCA
tricyclcic antidepressant
TFTs
thyroid function tests
THC
tetrahydrocannabinol (marijuana)
TIA
transient ischemic attack
TID
three times daily
TSH
thyroid stimulating hormone
Tx
treatment or therapy
U/S
ultrasound (also US)
UA
urinalysis
UDS
urine drug screen
UPT
urine pregnancy test
URI
upper respiratory infection
UTI
urinary tract infection
VDRL
Venereal Disease Research Laboratory (syphillis test)
VPA
valproic acid (Depakote/Depakene)
VRE
vancomycin-resistent enterococcus
W/U
workup
WBC
white blood cells
WNL
within normal limits
WWP
warm and well-perfused
32
Resource Brief for Juvenile Defenders
What Juvenile Defenders Should
Know about the DSM-5
This resource brief is intended to support juvenile defense
advocacy by providing an overview of some of the latest
Diagnostic and Statistical Manual of Mental Disorders (DSM)
revisions, as well as recommendations and implications for
juvenile defense practice. The DSM is a classification manual
for mental health professionals with itemized criteria for diagnosing disorders. Juvenile defenders who are knowledgeable
about the DSM are better prepared to advocate for and
against diagnoses of their youth clients. Defenders further
enhance their advocacy when they insist that evaluators specifically identify the symptoms behind youth behaviors as
well as the services and supports necessary to address those
symptoms in school, at home, and in the community.
The DSM has always been relevant to juvenile defenders to
the extent that DSM diagnoses drive decisions in juvenile
court. Yet juvenile defenders may be unfamiliar with the latest revisions to diagnoses and diagnostic criteria and how to
manage the ways they are used in the juvenile court context.
TABLE OF CONTENTS
I. Neurodevelopmental
Disorders............................................ 2
Language Disorder............................... 2
Attention-Deficit/
Hyperactivity Disorder......................... 3
Intellectual Disability........................... 4
Autism Spectrum Disorder................... 4
Social (Pragmatic) Communication
Disorder . ............................................ 5
II. Trauma- and Stressor-Related
Disorders............................................ 7
Posttraumatic Stress Disorder............. 7
Acute Stress Disorder.......................... 8
III. Disruptive, Impulse-Control, and
Oppositional Defiant
Disorder (ODD)..................................... 8
Intermittent Explosive
Disorder (IED)....................................... 9
Conduct Disorder............................... 10
The DSM-5, a revised and updated manual, was released in
2013. The changes in the DSM-5 reflect continuing research
and learning about psychiatric disorders by medical and mental health professionals. Juvenile defenders should be aware
of the current disorders and diagnostic criteria, as well as
how they have changed from the DSM-IV, to ensure that when
Disruptive Mood Dysregulation
Disorder.............................................. 11
IV. Substance-Related and
Addictive Disorders........................ 12
Appendix................................................ 13
their clients’ diagnoses are discussed in court – especially by non-psychologists – it is being done accurately. Diagnoses under older criteria may
no longer be valid and may lead to inappropriate intervention or services.
Diagnoses continue to be double-edged swords as they relate to juvenile defense. Some diagnoses are used to justify unnecessary confinement
or invasive court-ordered services, and yet defenders might use them to mitigate client conduct. As with most aspects of juvenile defense, how
one approaches a diagnosis is a client-centered decision made after weighing all of the potential implications. This is especially true when
considering diagnoses becoming part of court records that will follow youth clients, for good or bad, for a long time, despite the fact that scientific
research underscores the transient nature of youth physical, mental, emotional, and moral development.
For juvenile defenders, it is essential to keep in mind that immature thinking, identity issues, and moral reasoning, typical of adolescence, are
often linked to illegal behavior, and must be distinguished from symptoms of psychiatric disorders. Failure to recognize and account for this
developmental interplay can lead to misdiagnosis and/or punitive consequences with mismatched services for adolescents. Evaluators assessing youth in the juvenile court context must, therefore, have specific expertise in child and adolescent development, juvenile delinquency, and
the elements of effective interventions for youth in the delinquency system. When seeking an evaluation, juvenile defenders should request a
developmental evaluation with specific identification of the symptoms behind any diagnosis, recommendations for addressing those symptoms,
and a clear articulation of the role immaturity and other developmental factors play in understanding the youth’s behavior.
SUMMARY OF DSM-5 REVISIONS
I. NEURODEVELOPMENTAL DISORDERS
This category of disorders is typified by an onset of personal, social, academic, and job-related functioning impairments in the “developmental
period,” a timeframe which the DSM editors kept intentionally vague to account for varying timelines of youth and adolescent development from
childhood through adolescence.
Language Disorder
What’s This About?
• Client has persistent difficulties in language learning, retention, and use (in all forms—written, spoken, etc.) due to deficits such as
°° Reduced vocabulary;
°° Limited ability to form correct sentence structure; and
°° Difficulty carrying on a typical conversation.
• Language abilities are significantly below those expected at that age and the limited abilities result in functional limitations in
communication and achievement at work and school.
What’s Changed?
Language Disorder was previously termed “Expressive Language Disorder or Mixed Receptive-Expressive Language
Disorder” in the DSM-IV.
Implications for Defender Practice
• Language disorders may impair a client’s ability to connect with the defender; may have affected a client’s understanding of and communication during an offense and subsequent police questioning; may limit a client’s ability to understand and waive rights; and may impact
representation at all stages of a case, on probation, in placement, and in regards to educational and other services.
2
Resource Brief for Juvenile Defenders
• Language impairments also severely affect a client’s ability to comprehend Miranda warnings adequately. Juvenile defenders should consider this in moving to suppress statements made by a client with a language disorder.
• Linguistic issues may limit a client’s ability to provide vital background information “and factual information about the allegations,
recall details, or to even tell a story. This in turn may interfere with the attorney’s constitutional obligation to assess potential defenses and
mitigating factors, investigate, and mount a defense.”1
• Where defenders are not aware of and are unable to help alleviate language deficits, such deficits can negatively influence all aspects of the
interview, preparation, and courtroom process, leaving the client feeling confused and misunderstood.
• Court forms, orders, or waivers of rights will likely be challenging for youth with language disorders. A client’s difficulties with language may
be used to mitigate actions against them for “failure to comply.”
• Consider counseling clients with language impairments against testifying, as clients with language impairments are particularly susceptible
to coercive and underhanded interrogation and cross-examination techniques.
• At disposition, defenders can raise the fact that “research and experience have demonstrated that the lack of language skills associated with
undesirable behavior can be treated successfully, and that doing so can substantially alter the behavior as well.” In this way, defenders can
argue for services to help rehabilitate their clients, and effectively fight against the possibility of incarceration.2
• When developing a theory of the defense, juvenile defenders should work with clients to consider whether an undiagnosed language disorder
played a role in the charged offense and then consider requesting a speech-language evaluation.
• To protect clients’ due process rights, defenders should confirm the client has an Individualized Education Program (IEP) that addresses not
just speech but the specific symptoms of his/her language disorder.
Attention-Deficit/Hyperactivity Disorder (ADHD)
What’s This About?
• ADHD is understood as a “persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.”
• There are 18 symptoms of ADHD (see the appendix for full symptoms list) which are divided between two “domains”: inattention and
hyperactivity-impulsivity.
• Diagnoses may be appropriate only where the client exhibits at least six symptoms in one domain (persisting for at least six months) (five
symptoms for individuals 17 and older).
What’s Changed?
°° In the DSM-IV, ADHD was grouped in the now-eliminated chapter of “Disorders Usually First Diagnosed in
Infancy, Childhood, or Adolescence.”
°° In DSM-5, the age prior to which symptoms of ADHD must appear was raised to 12 (from 7 in DSM-IV).
°° This change expands the ability of professionals to diagnose ADHD in adolescents and teenagers.
Implications for Defender Practice
• Keep in mind the dichotomy between the two domains of ADHD. Youth clients may present as inattentive, hyperactive/impulsive, or a combination of both.
• Become familiar with experts who can evaluate clients for ADHD. These evaluators may also be able to testify in court as to the linkages
between the child’s undesirable behavior(s) and their ADHD.
1. Michelle LaVigne, Breakdown in the Language Zone: the Prevalence of Language Impairments Among Juvenile and Adult Offenders and Why it Matters,
15 U.C. Davis J. Juv. L. & Pol’y 37, 69 (2011).
2. Id. at 111.
What Juvenile Defenders Should Know about the DSM-5
3
• When considering the theory of the case, if a youth client describes battling regularly with inattention or impulsivity, the defender and client
should consider requesting an evaluation to consider ADHD diagnosis and treatment. Evaluators should consider the symptoms underlying
the youth’s behavior, especially the behavior leading to court involvement, and where appropriate recommend specific services to manage
the symptoms.
• NJDC’s Juvenile Court Training Curriculum3 has information and advice on selecting an appropriate and effective evaluator.
• Because manifestations of the disorder must be present in multiple settings, defenders should be aware that an evaluator should not diagnose ADHD unless questionnaires regarding behavior (these are typically standardized) have been completed by parents (or other caretakers)
and teachers.
• The classification of ADHD as a “neurodevelopmental disorder” may give it greater scientific and developmental credibility than it previously
received, giving it more potency as a mitigating factor defenders can raise at disposition.
Intellectual Disability (Intellectual Developmental Disorder)
What’s This About?
• The diagnosis reflects deficits in intellectual functions (such as reasoning, problem solving, etc.), and deficits in adaptive functioning that
result in failure to meet developmental and socio-cultural standards for personal independence and social responsibility.
What’s Changed?
°° In the DSM-IV, this was called Mental Retardation. Federal law, research journals, and medical, educational, and
other professionals have replaced “mental retardation” with “intellectual disability.”
°° Previously, the four levels of Mental Retardation (Mild, Moderate, Severe, and Profound) had been based on IQ
testing. In the DSM-5 these severity levels are instead based on level of adaptive behavior (e.g., academic skills,
social and communication ability, and self-care skills).
Implications for Defender Practice
• When developing a juvenile client’s case, defenders should take note of specific client challenges in academic, social, and communication
skills as these can be indicators of a potential intellectual disability.
• Defenders should be aware that for this diagnosis to be made appropriately, there must be a systematic assessment of the client’s adaptive
behaviors and not just reliance on IQ tests.
• The appropriate use of this diagnosis is especially important in competence determinations or when defenders challenge the validity of a
youth’s waiver of his or her rights.
• Defenders should consider pursuing evaluations for intellectual disabilities when this diagnosis furthers the theory of defense.
Autism Spectrum Disorder (ASD)
What’s This About?
• This disorder is demonstrated by markedly impaired development in social interaction and communication across multiple contexts, and a
restricted repertoire of interests, behavior, or activities.
• See the appendix for full list of symptoms.
3. N
ational Juvenile Defender Center & Juvenile Law Ctr., Toward Developmentally Appropriate Practice: A Juvenile Court Training Curriculum, Screening, Assessing,
and Evaluating Youth (2d ed. 2009).
4
Resource Brief for Juvenile Defenders
What’s Changed?
°° Autism Spectrum Disorder (ASD) encompasses what were Autistic Disorder, Asperger’s Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder not otherwise specified in the DSM-IV.
°° These diagnoses are now captured in three severity levels (described in detail in the appendix), based on how much
communication is impaired and the extent to which the individual exhibits restricted, repetitive patterns of behavior:
• Level 3: “Requiring Very Substantial Support”
• Level 2: “Requiring Substantial Support”
• Level 1: “Requiring Support”
Implications for Defender Practice
• ASD impacts a client’s responses to other people and therefore has an impact before, during, and after a charged offense. ASD can
be significant in terms of a client’s actions during an alleged offense, their competence to proceed, their ability to waive rights, and their
disposition.
• Defenders should be aware that clients who appear to have normal intelligence, but who describe themselves as isolated, do not pick up on
social cues normally, do not understand what makes them different from their peers, and have an intense interest in one or two areas (for
example, they may make complicated Lego® constructions for hours even as teenagers) may have ASD.
• If ASD is suspected, and diagnosis would advance the theory of defense, an evaluation is necessary to ascertain how communication and
social deficits may have affected the youth’s conduct during the offense as well as their competence to proceed and ability to waive rights.
In particular, crimes with specific intent, like stalking, can be challenged if an ASD diagnosis is warranted.
• In disposition planning for clients with ASD, the severity levels can be crucial because they literally dictate the “support” needed—something defenders can refer to when arguing against incarceration.
Social (Pragmatic) Communication Disorder
What’s This About?
• Social Communication Disorder may be diagnosed where all of the following occur:
°° Deficits in using communication socially, such as greeting and sharing information, in a manner appropriate for the context;
°° Impairment of ability to change communication to match needs of listener;
°° Difficulties following rules for conversation and storytelling, such as taking turns and rephrasing; and
°° Difficulty understanding ambiguous meaning in language.
• The disorder exists only where the symptoms are not better explained by another disorder.
What’s Changed?
This is an entirely new diagnosis in the DSM, to “more accurately recognize individuals who have significant
problems using verbal and nonverbal communication for social purposes, leading to impairments in their ability to
effectively communicate, participate socially, maintain social relationships, or otherwise perform academically or
occupationally.”4
Implications for Defender Practice
• Clients who have difficulty communicating effectively, and whose inability to communicate may negatively impact others’ perceptions of
them, may have Social Communication Disorder. Defenders should consider requesting that a psychologist or speech-language pathologist
assess specific communication difficulties and make recommendations for services, provided the defense theory calls for such evaluations
and/or interventions.
4. DSM5.org, Social (Pragmatic) Communication Disorder Fact Sheet, http://www.dsm5.org/Documents/Social%20Communication%20Disorder%20Fact%20Sheet.pdf
(last visited June 4, 2014).
What Juvenile Defenders Should Know about the DSM-5
5
• Because this type of disorder may be difficult to diagnose via standard testing, judges and even defenders may attribute the inappropriate
behavior of respondent-clients to deliberate non-compliance or bad attitude, even where symptoms are explained by a diagnosis of Social
Communication Disorder. Defenders should think not only about how this may impact the judge’s perceptions of the client, but their own.
• Defenders should be aware that this is a new diagnosis, and that as such, previous inaccurate diagnoses may have led to inconsistent treatment and services.
Other Implications for Practice Regarding Neurodevelopmental Disorders
Little attention has been paid to the specific, significant effects of neurodevelopmental disorders on the behavior of juveniles prior to, during, and
after their offenses. Neurodevelopmental disorders have typically been dismissed as “special education issues,” which fails to recognize that
youth with these disabilities often function younger than their chronological age and have comprehension, communication, or social difficulties
that may affect them at home, in the community, and in school. For example, a client who does not meet the criteria for Intellectual Development
Disorder may have academic skills substantially below those expected for his/her chronological age that are the result of impaired reading, writing and/or mathematics due to a Specific Learning Disorder (SLD) (SLD has not changed in the DSM-5).
If the defense theory would be supported by an evaluation for a possible neurodevelopmental disorder, the defender must ask evaluators to
assess the effects of deficits in cognitive processes such as: organization (including task initiation and follow-through); working memory (holding things in memory while using them, which is essential for carrying out multistep activities and following complex instructions); planning
(including setting goals and goal-directed persistence); sustained attention; performance monitoring (including time management); emotional
regulation; and impulse regulation. These deficits, properly understood and described, may play a role in understanding clients’ behavior at the
time of the offense and in disposition planning.
Fetal Alcohol Spectrum Disorder (FASD) (which includes other fetal substance exposure) and Traumatic Brain Injury (TBI) (seen in juveniles who
lost consciousness from child abuse and/or being hit by cars, e.g.) are usually not considered in court evaluations but may have a significant
impact on adolescent behavior. FASD is not a DSM-5 diagnosis, but the diagnosis “Other Specified Neurodevelopmental Disorders” is vaguely
described as being characterized by a range of developmental disabilities, and the DSM-5 example given is “Neurodevelopmental disorder
associated with prenatal alcohol exposure.” TBI is included in a different section of the DSM-5: major and mild neurocognitive disorder due to
traumatic brain injury. Therefore, while symptoms may present as neurodevelopmental, it is possible that an injury to the brain may actually be
the cause. Provided the defense theory calls for such intervention, defenders must ask evaluators to specifically consider FASD and TBI when
explaining a youth’s behavior because they require substantially different interventions in school, at home, and in the community than other
neurodevelopmental disorders.
In general, neurodevelopmental disorders may require services through an IEP. A client may not have an IEP and the defender may want
to discuss initiating a special education eligibility determination with the client. The client may have an IEP focused on behavior problems
without services for a language disorder, ADHD, ASD, or a communication disorder. Defenders can request an IEP meeting, attend it, and
advocate for specialized services.
Neurodevelopmental disorders also affect youth where they live. Services to assist a youth’s caretakers and to support youth in working with the
defender can also be arranged. Juvenile defenders must caution probation officers and other providers that they cannot communicate with or
expect the same comprehension by a youth with a neurodevelopmental disorder as they would with other young people.
6
Resource Brief for Juvenile Defenders
II. TRAUMA- AND STRESSOR-RELATED DISORDERS
These are disorders in which exposure to a traumatic or stressful event is explicitly listed as a diagnostic criterion. The ways in which individuals
react to these events can be quite disparate, ranging from extreme anger to fear to anxiety, among others. Because of the variability in psychological distress that may follow a traumatic event, these disorders have been given their own chapter in the DSM-5, though they may be or
appear to be related to anxiety, dissociative, and other disorders.
Posttraumatic Stress Disorder (PTSD)
What’s This About?
• The trigger for PTSD is “exposure to actual or threatened death, serious injury or sexual violation.” The exposure must result from one or
more of the following scenarios:
°° directly experiencing the traumatic event;
°° witnessing the traumatic event in person;
°° learning that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either
violent or accidental); or
°° experiencing first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television
or movies unless work-related).
• Additionally, a PTSD diagnosis requires that the “disturbance, regardless of its trigger, causes clinically significant distress or impairment in
the individual’s social interactions, capacity to work or other important areas of functioning.”5
• There are higher rates of PTSD among racial/ethnic minorities in the U.S., and it is more prevalent among females than males.
What’s Changed?
This is a new chapter in the DSM. Posttraumatic Stress Disorder was previously listed as an Anxiety Disorder in the
DSM-IV. The requirement for someone to respond to the traumatic event with intense fear, helplessness or horror
has been deleted because that criterion proved to have no utility in predicting the onset of PTSD.
Implications for Defender Practice
• Defenders should be aware that individuals with PTSD may be quick-tempered and engage in violent behavior with little to no provocation.
They may have exaggerated negative expectations regarding important aspects of life applied to themselves or others, including a lack of
trust in themselves or in people in positions of authority. Therefore, it may take additional time and effort to establish a relationship of trust
with a client suffering from PTSD.
• One of the symptoms of PTSD is avoidance, and it may be hard or impossible to learn from the client about past trauma he or she has experienced. Defenders may have to learn about it from a third party, such as a parent/guardian, teacher, or case file.
• Defenders should keep in mind that the DSM-5 made changes to the “marked alterations symptom cluster” by including irritable or aggressive behavior and reckless or self-destructive behavior. Defenders may want to address these issues in court, particularly for clients charged
with crimes of violence against people and property, as a way of mitigating the charges.
• Avoidant behavior in adolescents associated with PTSD includes reluctance to participate in developmental opportunities, e.g., dating and
driving. Clients may judge themselves as cowardly, may believe that they don’t fit in and will never fit in, and may lose aspirations for the
future. Aggressive behavior impacting peers and school may increase. Engaging in risky behaviors is a characteristic of immaturity typical of
adolescents, but clients with trauma exposure may be involved in greater self-harm or risk-taking.
• The DSM-5 notes risk factors for developing PTSD that are commonly found in youth involved with the court system, including lower socioeconomic status, education, and childhood adversity, among others.
5. DSM5.org, PTSD Fact Sheet, http://www.dsm5.org/Documents/PTSD Fact Sheet.pdf (last visited July 2, 2014).
What Juvenile Defenders Should Know about the DSM-5
7
Acute Stress Disorder
This disorder is similar to PTSD, but is distinguished from it in that its duration is limited to a month after the traumatic event.
Implications for Defender Practice
• When clients have experienced, witnessed, or learned about traumatic events to someone close to them, defenders should be aware of the
symptoms of Acute Stress Disorder and PTSD.
• These symptoms may be especially relevant when communicating with the client, and in arguing mitigating factors at disposition, as well
as generally throughout the trial process.
Other Implications for Practice Regarding Trauma- and Stressor-Related Disorders
Little attention has been paid to the specific, significant effects of trauma on the behavior of juveniles prior to, during, and after their offenses.
Typically, past abuse or exposure to violence may be listed in the client’s history, but is rarely connected to their sadness, anxiety, over-reacting,
and substance use (and clients often do not talk about past trauma or endorse trauma symptoms when questioned). Although DSM-5 refined
PTSD to make it more applicable to children and adolescents, the definition of “traumatic event” remains narrow for the juvenile population.
For example, juvenile offenders experience higher than average rates of close family member deaths (which the DSM only considers to be a
potential PTSD trigger if the circumstances of the death itself were traumatic) and of disrupted caregiving (due to foster care as well as parent
incarceration). Children’s trauma researchers consider both of these types of events as traumatic, affecting emotional regulation and reactivity to
perceived threat. Evaluators may give little attention to the effects of loss and disrupted caregiving, despite the other criteria of PTSD being met,
but as part of the defense theory, juvenile defenders may want them to highlight these effects, where appropriate.
Another area impacted by trauma and stressor-related disorders is substance use. The DSM-5 has dropped all references to substance “abuse,”
instead using only the phrase “substance use.” Many juveniles use marijuana, alcohol, or other substances to numb their sadness and anger
about past maltreatment, loss, and their anxiety, but the evaluator may not make this connection. A substance use disorder diagnosis may give
the impression that a juvenile will be difficult to rehabilitate because use began at a young age and/or is daily, rather than contextualizing the
issue as one of self-medication and the necessity for trauma treatment (which may not be part of substance use treatment). Defenders should
remember—especially if their clients have high anxiety, sadness, reactivity, emotional regulation difficulties, and/or use substances—to ask
evaluators to complete a thorough history that includes a broad definition of trauma and its specific effects on behavior, regardless of whether
the criteria for PTSD or Acute Stress Disorder are met.
III. DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDERS
Oppositional Defiant Disorder (ODD)
What’s This About?
• An ODD diagnosis requires (1) a pattern of behavior from one of the following three categories for at least six months, that is (2) evidenced
by at least four symptoms from any of the categories,
°° Angry/Irritable Mood: Often loses temper; often touchy/easily annoyed; often angry and resentful;
°° Argumentative/Defiant Behavior: Often argues with authority figures (adults where the individual is a child/adolescent); often actively
defies/refuses to comply with requests from authority figures/rules; often deliberately annoys others; often blames others for his or her
mistakes/misbehavior;
°° Vindictiveness: has been spiteful or vindictive at least twice within the past six months.
• Additionally, an ODD diagnosis requires that these behaviors occur in non-sibling interactions, where the disturbance is associated with
distress in the immediate social context or negatively impacts important areas of functioning. Additionally, the behaviors cannot occur “exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder.”
• For an ODD diagnosis, for children under 5 years, behavior should occur on most days for the six-month period; for older children, at least
once a week for that same period.
8
Resource Brief for Juvenile Defenders
• ODD can be distinguished from ADHD because unlike in ADHD, an ODD individual’s failure to conform to requests of others is not limited
solely to situations that demand sustained effort/attention/that the individual sit still.
What’s Changed?
°° All disorders in this new chapter of the DSM are characterized by problems in emotional and behavioral control.
(These disorders had previously been spread across various DSM-IV chapters).
°° The DSM-5 groups ODD into the three categories described above, in recognition that an ODD diagnosis reflects
both emotional and behavioral symptoms.
°° Because behaviors associated with ODD symptoms occur commonly in youth showing normal development,
the criteria now provide guidance on the frequency of these symptoms needed for a behavior to be considered
an ODD symptom.
°° The DSM-5 adds a severity rating to the ODD criteria as a specifier, dictating the number of settings in which
the ODD symptoms must be present. Mild means one setting, severe means three or more settings, and
moderate two.
Implications for Defender Practice
• ODD may be diagnosed in youth clients and used against them in court. Defenders, therefore, should be prepared to challenge the
accuracy of the diagnosis and/or the severity level assigned by calling a defense expert or mitigation witness, or cross-examining
the court evaluator.
°° Given the changes in how ODD is diagnosed under the DSM-5, it is critical that older diagnoses be re-examined or challenged
(depending on the defense strategy), as the diagnosis may no longer be valid.
• For mitigation purposes, be aware that risk factors for ODD include harsh, inconsistent, or neglectful child-rearing practices.
• ODD is frequently co-morbid with and, may be mistaken for, ADHD. Make sure evaluators are competent and can distinguish between
the two.
Intermittent Explosive Disorder (IED)
What’s This About?
• The core feature of an IED diagnosis is the failure to control impulsive aggressive behavior in response to provocation that would typically
not result in such an aggressive outburst.
• An IED diagnosis can be made in addition to ADHD, Conduct Disorder, ODD, or Autism Spectrum Disorder diagnoses where the aggressive
outbursts are in excess of those that would accompany those disorders and warrant independent clinical attention.
• The two major ways in which IED behavior manifests are:
°° Verbal aggression/physical aggression occurring twice weekly on average, for a three-month period, and which does not result in damage/destruction to people or property; or
°° Three behavioral outbursts in a 12-month period that cause harm.
What’s Changed?
°° Whereas physical aggression was required for a diagnosis of IED in the DSM-IV, the DSM-5 criteria for IED
include verbal aggression and non-destructive/non-injurious physical aggression.
°° The DSM-5 outlines the frequency with which aggressive outbursts must occur to meet the criteria for IED.
DSM-5 also specifies that the aggressive outbursts are impulsive and/or anger-based in nature, and must
cause marked distress, impairment in job/inter-personal functioning, or be associated with negative financial
or legal consequences. The minimum age for an IED diagnosis is now 6 years (as opposed to no minimum
under the DSM-IV).
What Juvenile Defenders Should Know about the DSM-5
9
Implications for Defender Practice
• Clients with a history of physical or emotional trauma are at increased risk for IED.
• If a client has had impulsive aggressive behaviors triggered by minor provocation AND if a finding of IED will enhance the defense theory, the
defender may consider requesting an evaluation to see if these behaviors meet the criteria for IED.
• For purposes of disposition planning and argument, defenders should discuss available treatment options with their client, such as cognitive
restructuring, coping skills training, and relaxation training.
Conduct Disorder (CD)
What’s This About?
• Conduct Disorder may be diagnosed where there is a repeated and persistent pattern of behavior that violates the basic rights of others or
breaks major age-appropriate social norms or rules. A diagnosis requires three or more of the following behaviors in the past 12 months, with
at least one in the last six months:
°° Aggression to people or animals (bullying, threatening, or intimidating others; initiating physical fights; or engaging in physical cruelty to
people or animals).
°° Destruction of property (engaging in fire-setting causing serious damage; deliberately destroying property).
°° Deceitfulness or theft (stealing items of non-trivial value; lying to obtain goods or favors or to avoid obligations).
°° Serious violations of rules (running away from home overnight; truancy).
• There are two major sub-types of CD: Childhood-onset and Adolescent-onset.
°° Those with Childhood-onset CD are more likely to have problems early and to have problems in adulthood.
°° Those with Adolescent-onset CD (usually typified by being more rebellious than is normal for one’s age group) are less likely to have
problems that continue into adulthood.
• There are three severity specifiers:
1. Mild – consisting of few if any conduct problems in excess of those required to make the diagnosis AND where conduct problems cause
only minor harm to others;
2. Moderate – consisting of a number of conduct problems and effect on others is at intermediate level, and;
3. Severe – consisting of many conduct problems in excess of those required to make the diagnosis OR conduct problems cause significant
harm to others.
What’s Changed?
There is a new specifier of “Limited Pro-Social Emotions” that has been added in the DSM-5. It is found in a minority
of individuals with Conduct Disorder. This specifier exists if a child meets the full criteria for Conduct Disorder and
has at least two or more of the following criteria that are displayed persistently for at least 12 months and in multiple
relationships and settings:
°° lack of remorse or guilt,
°° callousness/lack of empathy,
°° lack of concern about performance, or
°° shallow or deficient affect (inability to express feelings or show emotions to others, except in ways that seem
shallow, insincere, superficial, or for gain).
These characteristics reflect the individual’s typical pattern of interpersonal and emotional functioning over this
period and not just occasional occurrences in some situations. In addition to self-reporting, reports from others who
have known the youth for an extended period are required to assess these criteria.
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Resource Brief for Juvenile Defenders
Implications for Defender Practice
• It is important for defenders to recognize the limitations of what a Conduct Disorder diagnosis says about the client. Conduct Disorder can
be attributed to a first-grader who lies and gets into fights or to a 17-year old arrested for murder. An accurate diagnosis indicates that the
young person has persistent behavior problems, but not what caused the behavior problems. There are usually several different contributors
to behavior problems for a youth.
• Defenders should challenge a callous and unemotional diagnosis based only on an interview in a justice setting or mental health
setting. Soon after an offense, it is extremely difficult to determine a young person’s remorse, especially if they believe their actions
were unintentional. Anyone rendering this opinion should be asked to specify the basis of their conclusion; it is not sufficient to indicate that
the young person did not respond when asked their feelings about the harm of the offense. Many teens who do not have CD are also reluctant
to share their emotions with adults, including showing concern about school or others’ feelings. This kind of behavior is not dispositive of
a disorder.
• Most youth with CD do not show callous/unemotional traits. CD does not imply psychopathy or the lack of a conscience, and defenders
should challenge indication of callous/unemotional traits whenever possible.
• CD youth without callous traits tend to be highly emotionally reactive and to have cognitive difficulties.
• A diagnosis of CD does not mean a young person cannot be rehabilitated.
Disruptive Mood Dysregulation Disorder
What’s This About?
• This disorder is defined by severe recurrent temper outbursts that occur at least three times a week and where the mood between these
outbursts is persistently irritable and angry most of the day.
• This is a chronic mood disorder, whereas a youth with Bipolar Disorder has periods of mania and depression that are clearly different from
their typical mood.
• This diagnosis cannot be made before age 6 and symptoms must have started before age 10.
What’s Changed?
This diagnosis is new to the DSM-5, and was included largely because of the overuse of the diagnosis of Bipolar
Disorder in children and adolescents.
Implications for Defender Practice
• Defenders should be aware that chronic, severe irritability and low frustration tolerance that characterize Disruptive Mood Dysregulation
Disorder interfere with family and peer relationships and school, and that this may be connected to the youth’s behavior before, during, and
after the offense.
• Like Intermittent Explosive Disorder, this diagnosis might be relevant for clients who have severe angry and aggressive outbursts. A description of the underlying behaviors leading to this diagnosis can help with obtaining appropriate services and can assist the judge in understanding a possible connection between the crime alleged and the youth’s disorder.
• Defenders should be aware that this is a new disorder, so the field is still setting standards of practice.
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11
IV. SUBSTANCE-RELATED AND ADDICTIVE DISORDERS
What’s Changed?
°° The DSM-5 does not dichotomize, as the DSM-IV did, between substance abuse and dependence.
°° The DSM-5 provides criteria for substance use disorder, as well as criteria for intoxication, withdrawal,
substance/medication-induced disorders, and unspecified substance-induced disorders, for each type of drug
(alcohol, opiates, cannabis, hallucinogens, etc.), as appropriate.
°° The DSM-5 added a new criterion: craving/strong desire/urge to use a substance.
°° In the DSM-IV, one criterion for substance abuse had been recurrent substance-related legal problems.
The DSM-5 removed this criterion. (see Implications for Defender Practice, below).
°° Cannabis and caffeine withdrawal are both new to DSM-5.
°° Severity of substance use disorders is based on number of criteria present—2-3 (mild disorder); 4-5 (moderate); and 6+ (severe).
Implications for Defender Practice
• Changes in the substance use disorder criteria may be particularly relevant for clients who had been previously diagnosed with a substance use disorder because they had legal problems caused by marijuana use. Because the existence of legal problems associated
with substance use was deleted as a diagnostic criterion, and since two or more criteria are necessary to meet the diagnosis, clients
may no longer meet the criteria for a substance use disorder.
• Substance use can often be a peer-influenced activity that is typical of immaturity in teens.
• Substance use by youth clients may be an indicator of past trauma or disabilities and may be a means of self-medication to calm and/or numb
feelings and memories.
• Defenders should incorporate developmental research as mitigation where substance use was a factor in the offense charged.
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Resource Brief for Juvenile Defenders
APPENDIX
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) SYMPTOMS:
People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning
or development:
1. Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and
adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
°° Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
°° Often has trouble holding attention on tasks or play activities.
°° Often does not seem to listen when spoken to directly.
°° Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses
focus, side-tracked).
°° Often has trouble organizing tasks and activities.
°° Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or
homework).
°° Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork,
eyeglasses, mobile telephones).
°° Is often easily distracted
°° Is often forgetful in daily activities.
2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for
adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent
that is disruptive and inappropriate for the person’s developmental level:
°° Often fidgets with or taps hands or feet, or squirms in seat.
°° Often leaves seat in situations when remaining seated is expected.
°° Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
°° Often unable to play or take part in leisure activities quietly.
°° Is often “on the go” acting as if “driven by a motor”.
°° Often talks excessively.
°° Often blurts out an answer before a question has been completed.
°° Often has trouble waiting his/her turn.
°° Often interrupts or intrudes on others (e.g., butts into conversations or games)
Source: Centers for Disease Control and Prevention, Attention-Deficit / Hyperactivity Disorder (ADHD): Symptoms and Diagnosis,
http://www.cdc.gov/ncbddd/adhd/diagnosis.html (last visited 3/13/2014).
AUTISM SPECTRUM DISORDER DIAGNOSTIC CRITERIA
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following,
currently or by history (examples are illustrative, not exhaustive):
1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-andforth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
What Juvenile Defenders Should Know about the DSM-5
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2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated
verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use
of gestures; to a total lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting
behavior to suit various social contexts; to difficulties in sharing imaginative paly or in making friends; to absence of
interest in peers.
[Specify current severity]
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or
by history (examples are illustrative, not exhaustive; see text):
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or
flipping objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme
distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route
or eat food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with
unusual objects, excessively circumscribed or perseverative interest).
4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent
indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of
objects, visual fascination with lights or movement).
[Specify current severity]
C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).
D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global
developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for
general developmental level.
Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental
disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits
in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated
for social (pragmatic) communication disorder.
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Resource Brief for Juvenile Defenders
AUTISM SPECTRUM ORDER SEVERITY LEVELS
Severity Level for ASD
Social Communication
Restricted Interests & Repetitive Behaviors
Level 3
‘Requiring very substantial support’
Severe deficits in verbal and nonverbal social communication skills cause severe impairments in
functioning; very limited initiation of social interactions and minimal response to social overtures
from others.
Inflexibility of behavior, extreme difficulty coping
with change, or other restricted/repetitive behaviors markedly interfere with functioning in all
spheres. Great distress/difficulty changing focus
or action.
Level 2
‘Requiring substantial support’
Marked deficits in verbal and nonverbal social
communication skills; social impairments apparent even with supports in place; limited initiation
of social interactions and reduced or abnormal response to social overtures from others.
Inflexibility of behavior, difficulty coping with
change, or other restricted/repetitive behaviors
appear frequently enough to be obvious to the
casual observer and interfere with functioning
in a variety of contexts. Distress and/or difficulty
changing focus or action.
Level 1
‘Requiring support’
Without supports in place, deficits in social communication cause noticeable impairments. Has
difficulty initiating social interactions and demonstrates clear examples of atypical or unsuccessful responses to social overtures of others.
May appear to have decreased interest in social
interactions.
Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities.
Problems of organization and planning hamper independence.
Source: Autism Speaks, DSM-5 Diagnostic Criteria, http://www.autismspeaks.org/what-autism/diagnosis/dsm-5-diagnosticcriteria (last visited 3/13/2014).
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National Juvenile Defender Center
1350 Connecticut Avenue NW, suite 304
Washington, DC 20036
202.452.0010 (phone)
202.452.1205 (fax)
www.njdc.info
The National Juvenile Defender Center (NJDC) is a non-profit organization that is dedicated to promoting justice for all children
by ensuring excellence in juvenile defense. NJDC provides support to public defenders, appointed counsel, law school clinical
programs, and non-profit law centers to ensure quality representation in urban, suburban, rural, and tribal areas. NJDC also offers
a wide range of integrated services to juvenile defenders, including training, technical assistance, advocacy, networking, collaboration, capacity building, and coordination. To learn more about NJDC, please visit www.njdc.info.
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