|Attention Deficit Hyperactivity Disorders|
a physician trained in child/adolescent psychiatry and pediatrics, I
evaluate and treat many patients with suspected and diagnosed ADHD. I
am a strong believer in holistic approaches to managing problems.
Therefore, I attempt to find the most effective combination of
treatments that suits a patient's sensibilities. In ADHD, this approach
usually involves family, child, school and community. It encompasses
educational work directed toward patient and family, behavioral
treatment when needed, dietary and lifestyle adjustments when
appropriate, psychotherapy, and includes the possibility medication and
other remedies. Psychoeducational evaluation may also be recommended
and utilized to direct treatment.|
|Learning Differences and Disabilities|
part of my training, I spent a year at the Kennedy Krieger Institute.
After completion of training, I spent more than 10 years at Kennedy,
working as psychiatric consultant to the Kennedy School and to the
School problems evaluation team. I am therefore interested in and
familiar with the presentation and evaluation of "school problems,"
which frequently includes learning differences. I enjoy the team
approach to evaluation and treatment. I am also sensitive to emotional
and other difficulties that living with learning differences can
invoke, and enjoy working with people to minimize the impact these
problems have on their lives.|
|Asperger's Disorder Information|
Definition and Description:
Disorder was first described in the 1940's by Hans Asperger who
observed autistic-like behaviors and difficulties with social and
communication skills in boys who had normal intelligence and language
development. Although Asperger's is similar to Autism, and indeed is
"an autistic spectrum disorder," it differs from Autism in severity of
symptoms and absence of language delays. Children with Asperger's may
be only mildly affected and frequently have good language and cognitive
skills. A child with Asperger's may, on the surface, seem like "just a
normal child behaving differently," but this is not the case.
with Asperger's are not aloof as many children with Autism are. They
usually want to fit in and interact with others,they just don't have
the inherent knowledge of how to interact. So they are frequently
socially awkward, often cannot understand conventional social rules,
and seem to lack empathy. This discrepancy between wanting to be social
and being unable to do so successfully often creates sadness and
heartache for the Asperger's child and his family.
Asperger's usually have obsessive interests in particular subjects.
They may like to collect things, such as rocks or baseball cards. They
often are unusually proficient in knowing extensive bits of
information, such as baseball statistics. Although they often have
unusually strong rote memories, they often have difficulty with
abstract concepts, which can perplex parents and teachers of these
children, who seem so bright in many ways. This tendency toward
obsessiveness is also called "perseveration," a symptom present in
other neurologically based disorders as well.
(unlike in Autism) there is no speech delay. Asperger's children often
have quite good language skills, but they may use language in different
ways. Speech patterns may be unusual, lack inflection or have a
rhythmic nature. Or speech may be too formal, too loud or unusually
pitched. In addition, the subtleties of language, such as irony and
humor, may be lacking in children with Asperger's; and these children
often lack the give and take (reciprocity) of conversation, which
clearly impacts social relationships.
Given the above characteristics, children with Asperger's may:
-engage in one-sided long-winded conversations, without noticing if the
listener is listening or trying to change the subject
unusual nonverbal communication, such as lack of eye contact, few
facial expressions, or awkward body postures or gestures
-show an intense obsession with one or two specific narrow subjects
-appear not to understand or empathize with others' feelings
-have a hard time "reading" other people
-speak in a voice that is unusual
-have an odd posture or gait
cognitive ability is preserved in Asperger's, but may be seriously
impaired in Autism. The definition of Asperger's requires normal
intelligence. Some children with Asperger's also have associated
problems including Attention Deficit Hyperactivity Disorder,
Oppositional Defiant Disorder, and one or more specific learning
Children with Asperger's often display motor
difficulties as well; they are usually clumsy or awkward, and may have
specific motor skill delays.
diagnosis of Asperger's Disorder is usually made by a child
psychiatrist or pediatrician, and requires documentation of a symptom
set as described in the DSM or Diagnostic and Statistical Manual of
Mental Disorders. Basically, this requires specific symptoms under two
general categories, including: 1. qualitative impairment in social
interaction, and 2. Restricted repetitive and stereotyped patterns of
behavior, interests and activities.
Further details of diagnostic criteria can be found in the DSM IV Manual.
is a difficult disorder to have and to live with as a parent or
teacher. There are no medications that "cure" Asperger's, although
several types can help control some of the symptoms associated with the
If the child has ADHD, the usual medications for ADHD may help these symptoms.
child who has difficulties with perseveration can be extremely
frustrating and exhausting. Parents often find this symptom one of the
hardest to cope with in their child with Asperger's. No medication has
been shown to effectively "cure" this symptom, but some children have
experienced improvement with the use of an SSRI (selective serotonin
reuptake inhibitor) like Prozac, Zoloft or its relatives.
another group of medications has been approved for use in children with
autism and related disorders. This is the group called "atypical
antipsychotics" and includes risperidone, Zyprexa and Abilify. This
group of medications has some additional side effects, so should be
discussed in detail with your care provider.
than medication are also suggested. Social skills training is a type of
therapy that can be very helpful but is difficult to find in the
community. In addition, it is hard to generalize gains made in the
group to life outside the group. Age-appropriate psychotherapy can
range from play therapy in younger children to supportive and cognitive
behavior therapy in older patients, and can be very helpful, especially
as the child or teenager begins to understand the social difficulties
that emanate from his disorder. Family work can also be very helpful,
and can facilitate understanding and coping strategies.
support and intervention is also important in optimal treatment. Full
psychoeducational evaluation is necessary to clarify the specific
child's strengths and weaknesses, in order to effectively engineer a
unique set of accommodations and remedial strategies. Not all
Asperger's children have the same set of problems, so individualization
is essential educational strategies should include in addition a few
simple interventions: it can help to notify the student ahead of time
about upcoming transitions and changes in routine. Sometimes a child
can benefit from a quiet place to retreat to in case of overstimulation
or excessive frustration. The educational ramifications of executive
dysfunction are wide and serious. This group of symptoms includes the
organization and planning that increases with each step in the school
process. Deficits in this area lead to missed assignments, late
completion of longterm projects, inadequate preparation for tests due
to poor study skills or just not knowing when a test is scheduled.
Executive dysfunctions are extremely handicapping, but can also be
greatly ameliorated by relatively minor, simply interventions. These
can include: routine agenda/planner monitoring, emails between
student/parent and teacher to facilitate knowledge about assignments,
upcoming tests, and projects, the need to complete makeup work, etc.
The goal should be increasing a student's independence in this area.
But parents and teachers need to be sensitive to the fact that these
skills are often very delayed and not under the student's complete
control. So problems in the executive area are not necessarily poor or
oppositional behavior. In fact, many students want to do well but
simply cannot organize themselves adequately to accomplish their work.
disorder is an increasingly diagnosed disorder that is frustrating for
patient, family and community. It is not well understood, but our
knowledge is increasing rapidly. These children are truly impaired and
suffer from their impairments, as to their families. Optimal growth for
a given child requires the coordinated work and support of family,
school, community and medical/psychological professionals.
Sources of Information:
www.ncpamd.com (Asperger's Disorder section of ncpamd written by Carol Watkins, M. D.)
Facts for Families from the American Academy of Child and Adolescent Psychiatry (www.aacap.org)
Diagnostic and Statistical Manual of Mental Disorders fourth Addition, DSM-IV.
I have attempted to paraphrase information from all of the above
sources in order to compile a set of definitions and recommendations
that I think best explains and typifies Asperger?s Disorder. All of the
above sources are public, most are on the web, and available to all
readers for further details.
following is my synopsis of the American Academy of Child and
Adolescent Psychiatry (AACAP) Practice Parameter for the Assessment and
Treatment of Children and Adolescents with Depressive disorders. There
is some solid information about causation, clinical presentation,
comorbidity, differential diagnosis, and treatment, including
medication pros and cons. I have added some personal comments as well.
disorders are some of the most commonly seen problems in child and
adolescent psychiatry, and have the potential to cause severe
dysfunction in the child and the family. Young people with depression
have problems in family, social and academic functioning and run the
risk of suicide, substance abuse and persistent depressive symptoms.
The prevalence of Major Depressive Disorder (MDD) is about 2% in
children and 4-8% in adolescents; male to female ration in childhood is
1:1; in adolescence is 1:2. Another 5-10% of children have some
depressive symptoms but not enough to meet stringent diagnostic
Clinical Presentation It is important to remember that
the symptoms of depression range along a continuous spectrum from very
mild to very severe. Also the symptoms of depression should represent a
change from the child or youth's normal baseline. Depressive symptoms
can include, among others:
*Depressed or irritable mood
*Loss of interest and pleasure
*Wishing to be dead
*Thought of suicide or attempts
*Change in appetite and/or weight
*Change in sleep patterns
*Low self worth
*Exaggerated sense of guilt
*Change in school functioning, drop in grades
and adults are similar but not identical in their presentation of
depression. For example, children can present with irritability and
temper tantrums instead of saying they feel depressed. It is important
to know that depression can masquerade as many other problems, so it is
important to ask for help from a professional if there is any doubt.
Many children with depression have other disorders. As many as 40-90%
have comorbid disorders?that is, coexisting problems. The most frequent
of these are anxiety disorders, disruptive disorders, Attention Deficit
Hyperactivity disorder (ADHD) and substance use.
diagnosis Several medical and psychiatric disorders may mimic
depression and may need to be ruled out before making a diagnosis of
depression. These may include:
*Oppositional defiant disorder
*Pervasive developmental disorder
*premenstrual dysphoric disorder
*chronic fatigue syndrome
Treatment of depression needs to include psychoeducation, support,
family and school involvement at every level of treatment. Treatment is
also divided in acute, continuation and maintenance phases. The acute
phase is geared to achieving symptomatic remission, the continuing
phase is geared toward consolidating the gains made in the acute phase,
and the maintenance phase is geared toward maintaining improvement and
Psychoeducation refers to education of
patient and family about all the aspects of depression and risks
associated with the illness and its treatment. The goal is to make
treatment transparent; hopefully patient, family and doctor will
develop a team approach toward management of this disorder. Supportive
treatment should be individualized, depending on the specific needs of
the patient and family. Supportive treatment may include active
listening, restoration and maintenance of hope, problem solving, coping
skills and strategies for management and planning.
involvement is key since most parents are intimately and anxiously
involved in their child's successes and problems, and the child's
welfare is intimately intertwined with the parents and siblings, who
provide support, motivation for treatment, transportation to therapy,
communication with school and community, and countless other roles in
the child's life. Formal family therapy may or may not be necessary in
a given clinical situation.
School is also a key element in
treating depression, as a child spends the greatest part of his/her
waking hours involved at or with school. It is often hard for school
personnel to understand the difference between depressive symptoms and
difficult behavior since they may look very similar. Understanding
depression strongly colors a school's reaction to a patient.
Appropriate supports and accommodations can mean the difference between
success and failure in school, and are therefore vital to a child's
self image and life success.
There have been many studies and
discussions of what type of treatment works best for depressed children
and youth. Studies seem divided as to whether medication or
psychotherapy or the combination achieves the best remission and
maintenance of remission. Confounding the picture is the wide range of
psychotherapy techniques that have been used in the various studies. My
sense is that the clinician must do as in-depth an evaluation of the
child and family as possible; and make a deliberate effort to recommend
the combination of treatments that seems to best fit the specific child
and family. My sense is that most patients do best with some
combination of psychotherapies, and many require the addition of
antidepressant medication as well.
The question of medication
often comes up when a child is being treated for depression. In mild or
short-lived depression, education, support and management may be
sufficient treatment. In more severe or protracted cases, medication
may become a recommendation. More and more, the medical community turns
quickly to the use of antidepressants?an issue which has sparked great
debate among medical personnel and patients and families
(selective serotonin reuptake inhibitors) are the most commonly
prescribed antidepressants for children and teens. This group includes
Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox
(fluoxetine), Celexa (citalopram) and Lexapro (escitalopram). Other
frequently used medications include Effexor(venlafaxine), Cymbalta
(duloxetine), Wellbutrin(buproprion) and the tricyclic andidepressants,
which have become second line choices because of concern about side
There is a current debate among psychiatric
professionals as to whether there is demonstrable evidence of actual
effectiveness of the SSRI's and other antidepressants in children.
There is a paucity of studies, and their results are divided. It is
reasonable to question the literature in this regard, and families are
advised to raise these questions with their treating professionals. My
feeling, based on experience and not on the data, is that
antidepressants, especially SSRI's, can be an effective and relatively
safe intervention that can help certain children immeasurable.
Judicious dosing and careful follow up are essential to a positive
outcome and avoidance of negative side effects.
One note of
caution: many psychoactive medications have not yet been fully tested
in children and teenagers, and are not formally approved by the DEA for
use in younger people. The standard of care in the field allows and
encourages their use in a disciplined well-monitored manner. This is
the current state of child psychiatry?that the medications we use are
usually tested in adults and approved in older people long before they
are approved in children; and they are already in common use, based on
adult response, before the formal approval is achieved. This is another
point to be discussed in full with your treating professional.
SSRI's have been well-tolerated in children, with a minimum of
bothersome side effects. The can include gastrointestinal symptoms,
sleep changes (insomnia or somnolence, vivid dreams, nightmares),
restlessness, sweating, headaches, appetite changes and sexual
dysfunction. A small percentage of children develop impulsivity,
agitation, irritability, silliness and "activation." The noradrenergic
antidepressants (not the SSRI group, but includes
Cymbalta) have a different set of side effects, and may cause elevation
in BP and heart rate, as well as other side effects. Wellbutrin carries
a caution about possible seizures in doses greater than 400 mg/day.
This is by no means a complete list of side effects of all these
medications. It is intended to discuss some of the more common ones,
and should be a jumping of point for discussion with your doctor.
has been a recent discussion in the press and psychiatric literature
about a possible increase in suicidal thinking that might occur with
SSRI use. This question continues to be investigated. There appears to
be a small but statistically significant elevation in suicidal thoughts
with antidepressant use in children. My feeling is that, because the
increase is real but small, it should not be a deterrent to
antidepressant use, but should be an important point of discussion and
monitoring in all patients, and needs to be discussed as a precaution
in all patients.
Once medication is started and the patient
responds, it is generally recommended to continue the medication course
for about a year. This is also a point of ongoing research, and
recommendations may change as additional data becomes available.
diagnosis and treatment of depression in children is a complex topic,
and the above information is just a beginning in investigating the
topic. The AACAP has released a full discussion of depression in
children entitled : Practice Parameter for the Assessment and Treatment
of Children and Adolescents with Depressive Disorders. It can be
located in the Journal of the American Academy of child and Adolescent
Psychiatry, November 2007 issue. JAACAP 46:11, November, 2007.