ADHD in the DSM-5 Era

Friday, May 24th, 2013

The new diagnostic criteria for ADHD in DSM-5 flag issues that deserve attention if you are a parent. These include:

1) Age doesn’t matter as much. In prior versions of the DSM, ADHD was represented as a disorder which starts in childhood – an onset prior to age 7 had to be established to make a diagnosis. This has changed – the age of onset has been extended to before 12 years of age. So parents should be aware that ADHD symptoms may now  be detected later in childhood. And parents too may be more likely to be diagnosed themselves, as the new criteria make it easier to recognize ADHD in adults.

2) Age does matter though. While it is legitimate to say that children, teens, and adults all can show symptoms of ADHD, applying the criteria to the different age groups requires much clinical skill. Keep in mind that the proper use of DSM-5 requires this. For example, a clinician must apply the same criteria to a 5-year-old, a 10-year-old, and a 15-year old. The symptoms of ADHD reflect behaviors that can be shown by any child – it’s typically the frequency of these behaviors (they occur much more often as compared to what’s expected developmentally), the pervasiveness of the behaviors (you see them at home and in school), and the consequences of the behaviors (e.g., a kid is having difficulties keeping up with school work, is getting in trouble in school). A clinician needs to have a reference point for each age in their head in order to properly apply the DSM-5 criteria. This means that they should have very solid training in developmental science as part of their overall expertise. This is particularly true given the controversies about diagnosing and treating ADHD in preschoolers.

3) Be careful who applies the criteria. The DSM series (we are now on the 5th edition) is a guidebook for clinicians. It represents current thinking on the most telling signs of a disorder. It does not say anything about how the information should be collected to come to a clinical decision. So, you need to beware of anyone who doesn’t do a full, comprehensive evaluation that includes observations of the child, interviews with the child, much discussion with parents, acquiring lots of information from parents via questionnaires, collecting information from teachers and school personnel, and ideally a range of tests (including neuropsychological exams) that can consider alternative issues (like underlying learning disorders). This kind of evaluation is required to prevent overdiagnosis of ADHD, which may be rampant these days.

4) DSM-5 does not dictate what treatment will work best. DSM-5 is designed to facilitate the diagnostic process. It does not dictate the treatment strategy. A diagnosis of ADHD does not mean that a child necessarily needs Ritalin or other similar medications to control the symptoms. That’s a whole different discussion with a clinician who is trained to consider a range of treatment strategies. It is always wise to consider first behavioral treatments for ADHD and determine, after a sufficient amount of time, how much improvement can be gained by them before thinking about medication. Do not believe a practitioner who only endorses medication after a diagnosis is made.

The bottom line is the the DSM-5 is not intended to be used in a simplistic way to quickly diagnose ADHD and immediately promote medication. It is a tool that helps clinicians come to a determination of where a child is at developmentally with respect to ADHD. This is a complex process that requires lots of clinical insight. Having DSM-5 in hand doesn’t change that.

ADHD via Shutterstock.com

Saluting Our Nation’s Littlest Heroes, and Letting Them Know the USO and Sesame Street Are Always By Their Side

Thursday, May 23rd, 2013

Sesame Street and the USO have now partnered for five years to support military families around the world. As they celebrate this milestone, Rachel Tischler (Vice President of USO Entertainment) and Lynn Chwatsky (Vice President of Sesame Street’s Outreach Initiatives and Partners) offer this guest blog post to announce the new world tour of The Sesame Street/US Experience for Military Families. 

The children of US service members scream and wave at the start of the USO/Sesame Street Experience for Military Families at USAG Humphreys in South Korea February 9, 2010. (USO Photo by Fred Greaves)

Imagine you are five years old and you haven’t seen your mommy or daddy’s face, touched their hand or received their hug in six months because they’re deployed overseas. Now, imagine two years have passed and your mommy or daddy is back home, you have lots of friends at school, and you’re told the family is moving to a new base far away for the third time.  How do you feel?  And as a parent, what do you do?

These are just two of the many unique and challenging issues our nation’s military families face everyday.  It’s also THE reason Sesame Street and the USO partnered and are celebrating five years of working together to take The Sesame Street/USO Experience for Military Families around the world.  Over the past five years our two organizations have brought the messages from Sesame Street’s military families initiative, Talk, Listen, Connect, to life for more than 368,000 U.S. troops and military families.  We’ve performed 631 shows on 145 military installations in 33 states and 11 countries.

We are kicking off our new world tour at a special USO Care Package Service Project event with help from Cookie Monster and our supporters on Capitol Hill.  Next, we’ll head to Alaska to begin performing for and meeting even more military families this year as our journey takes us to 41 bases in 8 European and Pacific countries over the next six months.

For those unfamiliar with our adventure, the tour’s first phase focused on deployment.  Kids and parents related when Elmo said, “Elmo’s Daddy had to go away on a very important trip for lots and lots of days. Elmo sure misses Daddy when he’s away, and sometimes Elmo feels sad.”  Elmo and friends got those same families singing, dancing, and there was even the occasional Muppet mosh pit.

As the military transitioned away from long deployments, The USO and Sesame Street created a brand new show tailored towards another challenge, military family relocation.  The new show introduced a new character named Katie.  Katie is a military kid, and her experiences really echo those faced by military kids.  The show is designed to help other military kids like Katie with issues related to relocation – letting kids know they can stay in touch with old friends and even make new ones when they move.

Kids perk up in surprise as Katie identifies with them, telling audience members, “I’m moving AGAIN.”  And it’s thanks to Katie and her Sesame Street pals Elmo, Rosita, and Cookie Monster, who help her realize that while moving can be scary, she can still rely on her friends to help her through life’s transitions.

The USO and Sesame Street know that families everywhere can relate to the anxiety of moving to a new place, and having to go to a new school and make new friends.  But for military families around the world, it’s a way of life.  According to our friends at the Military Child Education Coalition, kids with parents in the military move six to nine times during their pre-school through high school education.

That’s why it’s important our military families know that Sesame Street and the USO are there.  We know it’s hard to be away from a loved one and that some days are harder than others.  Whether you’re a child, a military spouse, a service member or a nonmilitary member, nothing can change the fact our troops and their families are serving this country every day.  And in the words of Elmo and his pals, “We’re gonna be there for [them].”

As we celebrate the fifth birthday of The Sesame Street/USO Experience for Military Families, we ask that you join in the celebration by offering your own support of military families.  We’ve come up with five things that everyone can do and we hope they will prompt and inspire you:

1.      Volunteer at one of the more than 160 USO locations around the world and discover ways you can take action locally.

2.      Offer to help a military family on the home front who live on or off base.  Whether you see that their lawn needs to be mowed or garbage cans taken in, helping with simple household chores and errands can really relieve some of the stress a family may be feeling.

3.      Teach your child how they can help support military kids in their school by visiting uso.org/get-involved.aspx and or Facebook.com/SesameStreetforMilitaryFamilies.

4.      Lend an ear to listen to a military spouse as sometimes just having someone there to vent to or talk to when you may feel all alone can be the greatest support of all.

5.      Say thank you to a military member and their family for their service, sacrifice and strength.  Our troops and their families make sacrifices so we don’t have to and those two simple words say so much.

Whether on the frontlines, with their loved ones, in recovery or in remembrance, the USO and Sesame Street are adapting to meet the needs of those who need us most.  The Sesame Street/USO Experience for Military Families is one of the ways we can help them navigate life’s challenges. To learn more and to see where the tour is headed next visit USO.org/Sesame.

Sesame Street characters pose for a photo with service members and their children following a performance of the USO/Sesame Street Experience for Military Families at Atsugi Naval Air Field in Japan, January 19, 2010. (USO Photo by Fred Greaves)

For Parents: Autism Spectrum Disorder In DSM-5

Wednesday, May 22nd, 2013

The DSM-5 has made major changes in the way that Autism Spectrum Disorder (ASD) is diagnosed. Here are 5 practical tips for parents based on these changes: 

1) Understand the implications of eliminating Asperger’s Disorder. For most children, this change should not have much impact in the diagnostic process. It will impact some children who are higher functioning and who would have, in the past, been diagnosed with Asperger’s Disorder. The DSM-5 includes severity criteria which were designed in part to incorporate these types of kids into the new diagnostic framework. That said, many in the field think that some kids may no longer receive a diagnosis if their symptoms are less severe. Some of the initial studies demonstrate that some kids who would have been diagnosed in the prior DSM will not receive a diagnosis using DSM-5. As a parent, be ready to have this discussion with a clinical provider – and be ready to ask questions like “If the old system was in place, would my child have been diagnosed as Asperger’s?” You may need to advocate more strongly than before for your child. Focus on the need for services that could make a difference for your child’s development and collaborate with your practitioners to make sure your child has every opportunity to benefit from intervention.

2) Understand the implications of eliminating other alternate diagnoses. DSM-5 does away with other diagnostic options like Pervasive Developmental Disorder Not Otherwise Specified. The impact may be felt for kids who have many symptoms of ASD but not necessarily the exact profile. There may be no alternative diagnosis despite the fact that they have many developmental issues that need attention. Make sure your practitioners seem savvy about DSM-V and know how to make sure a kid with this kind of mixed presentation doesn’t get lost in the transition to the new diagnostic framework. Have that discussion with them and be satisfied – or seek out another opinion.

3) Beware of the severity criteria and insurance. Many clinicians have told me that they are concerned that insurers may balk at covering services for some children who are rated to show less severe symptoms. We don’t know this yet. Make sure your clinician is on top of these issues and that the team is ready to take on battles if necessary. You want to have confidence in your providers because this is all new and it is not clear how it will all unfold.

4) Remain vigilant about the early signs of autism. Just because the way ASD is diagnosed has changed in DSM-5, that doesn’t mean the warning signs have changed. They remain the same and you should be aware of the 7 early signs of autism.

5) Remember that early intervention still matters. If you suspect that your child may have ASD, it is better to get started as early as possible with the evaluation process – and if necessary intervention. Intervention helps any child, no matter what the severity, and early intervention is, right now, the best we have to offer kids with ASD. The fact that we have switched to DSM-5 does not alter the importance of early intervention – though, again, you need to be aware that you might need to fight harder to get intervention. It’s a fight worth taking on.

Autism Awareness via Shutterstock.com

DSM-5: Why (and What) Parents Should Know About It

Tuesday, May 21st, 2013

As a parent, you may be wondering why such a fuss is being made about the release of the DSM-5 (the 5th edition of the Diagnostic and Statistical Manual of the American Psychiatric Association). Here is a brief overview of why it may be (0r become) relevant to you – and why it’s important to learn about the issues that are being debated.

Many Kids Will Experience A Mental Disorder

The primary reason parents need to know about DSM-5 is that many psychiatric disorders that originate in childhood are not uncommon. Consider some rough numbers:

• Around 1 in 50 kids are being diagnosed with Autism Spectrum Disorder
• Around 1 in 10 kids are being diagnosed with Attention Deficit Hyperactivity Disorder
• Around 1 in 10 kids are being diagnosed with Conduct Disorder
• Around 1 in 10 kids are being diagnosed  with an Anxiety Disorder
• Around 1 in 10 kids are being diagnosed with a Mood Disorder
• Around 1 in 2 teens have reported meeting diagnostic criteria for at least 1 disorder in their lifetime

Having a good look at these numbers means that lots of parents will be faced at some point in time with the possibility of having their child evaluated for a disorder – and will need to consider treatment options. That’s where the DSM-5 comes in.

DSM-5 Is The Primary Guide For Clinical Diagnosis

The DSM-5 is the handbook used by a broad range of health care professionals who evaluate individuals (youth and adults) for potential psychiatric disorders. It’s an authoritative guide that reflects a consensus statement on the best way to categorize disorders along with the specific symptoms and rules to be used to make a diagnosis. The intention is to make it reflect current clinical thinking that is supported by research. It is not perfect, it reflects a particular point of view by those charged with generating the guidelines, and there is much debate (and criticism) of the diagnostic approach taken by the DSM-5.

All that said, the fact remains that the DSM-5 will be used if you bring your child to a health care professional for evaluation. The clinician will consider lots of information during this process – the DSM-5 does not dictate what information they use and how they get it. It’s intended to serve as a guide to the endpoint of making (or not making) a diagnosis. And it serves as the template for a health care provider to request reimbursement from insurance companies to support treatment.

Why All The Controversy Now?

The DSM-5 is a revision of the prior version which was released in 2000. As such, it includes a number of changes – some of which are minor, some of which are major. Beyond the more general discussions about what’s “normal” and what isn’t, the key things that parents need to know are the practical implications of the changes. As a parent, you should be aware of the changes to disorders that are especially relevant for youth. Here’s a brief overview:

Autism Spectrum Disorder: Major changes have occurred. In the prior version, a spectrum of disorders were available to clinicians, reflecting important variations in symptom profile. Four disorders were listed: Autistic Disorder, Asperger’s Disorder, Childhood Disintegration Disorder, and Pervasive Developmental Disorder Not Otherwise Specified. The key change is that there is now just one diagnosis made of Autism Spectrum Disorder (ASD) – and the other diagnostic categories will no longer be used. Proponents of this change suggest that it is more accurate by defining the core features of ASD that were common to all of the disorders in the spectrum and allowing for differences in severity level under one diagnostic umbrella. Critics suggest that a number of youth who require diagnosis and treatment will not be diagnosed – and that the reliance on severity levels may make it harder for kids with more mild symptoms to receive treatments they need. There’s no answer to these issues yet – they will unfold over time as data are collected. But if your child is evaluated for ASD, it’s in your best interests to be up on the debates and have informed discussions with your clinician in order to make sure you are advocating for the best care for your child.

Attention Deficit Hyperactivity Disorder (ADHD): Minor changes have occurred. In the past, there had to be evidence that a child showed symptoms of ADHD before age 7. That has been extended to age 12 in the DSM-5. There is also more attention to making diagnoses in adults more manageable. All of these changes mean that if you have an older child who has never been diagnosed with ADHD, they might now be evaluated differently. It’s also important to know what isn’t in the DSM-5 – a lower limit on age. That is, there are no guidelines in terms of how young a child may be when making a diagnosis. This is relevant as there have been (controversial) suggestions that kids as young as 4 years of age could be diagnosed (and many in fact have). Know that DSM-5 does not offer guidance here and you will need to make up your own mind if this makes sense for your child –  hopefully with the appropriate guidance of a well-trained clinician. Overall, the worry here is that kids of all ages may be overdiagnosed.

Conduct Disorder (CD): Minor changes have occurred. Conduct disorder represents a persistent pattern of rule breaking behavior and behavior that violates the rights of others. It can be diagnosed in young children as well as teens. The primary change has been to incorporate symptoms indicating a callous and unemotional interpersonal style. The thinking here is kids with this profile may be especially prone to experience problems in the future – and require more intensive management and treatment. Be aware that these symptoms will receive more attention now in the diagnostic process.

Disruptive Mood Dysregulation Disorder (DMDD): This diagnosis reflects a major change – it is a new diagnostic category. The idea was to provide a diagnostic option for kids who show persistent irritability and extreme emotional and behavioral outbursts. The rationale for developing the DMDD criteria was to make sure kids who show these symptoms do not get mislabeled as having pediatric bipolar disorder – but still may qualify for treatment. The controversy is that many feel that there is not sufficient evidence to support this new diagnosis – and in the worst case scenario kids who do not have psychiatric problems will be diagnosed with a disorder and get treatment that they don’t need.

Over the next few days, I will publish blog posts that consider each of these four disorders in greater detail, and provide some guidance for parents to help sort through these complex issues. There are no straightforward answers to be found – rather parents need to know about DSM-5 so they can be prepared to navigate the best decisions for their child.

Why Playfulness Is More Important Than Play

Thursday, May 9th, 2013

We all know that it is critical for kids of all ages to play. And we know that play can take many forms. But there’s a deeper idea about the importance for kids to learn how to be playful – and how that spirit should permeate their development.

Such is the advice given by Steve Gross, Executive Director – and Chief Playmaker – of The Life is good Playmakers, the action arm of The Life is good Kids Foundation, a nonprofit organization established by Life is good to raise money to help kids in need. Life is good is a company with a positive purpose and is committed to spreading the power of optimism and donating 10% of its net profits to helping kids in need through The Life is good Kids Foundation.

Steve Gross, Chief Playmaker, Life is good Playmakers

The Life is good Kids Foundation directly funds the Life is good Playmakers program. The Life is good Playmakers provide training and support to childcare professionals, who use these tools to ensure that children grow up feeling safe, loved and joyful.

Steve certainly champions the essential nature of play in a kid’s life  (“Children need food and water to survive, but to truly live, they’ve gotta play”). But he points out that we often get the message that play happens in a designated time and space and includes specific activities – which means much of the time we don’t harness the power of playfulness in the majority of moments in a kid’s everyday life. He suggests that we want kids to develop the trait of playfulness as a style they bring to everything they do. Steve defines playfulness as “the motivation to freely and joyfully engage with, connect with, and explore the surrounding world.” It’s an attitude, and a style, that provides a cognitive and emotional platform for kids to embrace themselves and fuel for them to bring themselves to the world in a positive way.

Four ingredients make up Steve’s recipe for playfulness:

AFFECT: Kids need to experience joyfulness in their everyday moments – not just the time that’s “reserved” for play. Most of the opportunities for “play” happen in real time. Steve gives a wonderful example of how getting a kid ready to go to play is an ideal time to promote joyfulness – and also a moment that often turns in the other direction for parents. Rather than getting stressed about making sure a toddler has their shoes on and their coat ready, how about treating THAT time as the time to get silly and experience joy and anticipation. It may be even more fun than when you actually get outside to “play.” It’s these little moments that define the affective climate for a child – and bringing anticipation, lightness, joy, and overt silliness to the everyday tasks infuses a kid with a playful spirit that makes most of the day feel like play rather than the other way around.

SOCIAL CONNECTION: Interacting with people is play. It’s as important – if not more important – that your kid is looking at you and seeing you laugh and smile and express joy when you are playing than being engaged in the play itself. Think about all the moments you have to simply talk to your kid – especially babies and toddlers. Don’t underestimate how fun and rewarding (at a very deep level) it is for your kid to explore your face and your emotions and your tone of voice. It’s a constant stream of engaging content for them that they could never find in a toy or a device. So Steve proposes that treating the everyday interaction moments as opportunities to cultivate joyfulness helps a kid discover the power of social connection.

INTERNAL CONTROL: Steve suggests that kids need to feel like they are in control of themselves, and that the world is a safe place for them. They need to feel like they can explore without fear of bad consequences. Sure, you need to keep your kid safe. But a constant stream of “No No No” communicates two things to a little one: the world isn’t safe to explore, and your little one is not competent enough to explore it. One of the tricks of the trade is to practice redirection: rather than saying “Don’t do that!” focus on saying, “Do this instead!” Cultivate the curiosity and direct it in a safe way. That way, you are following Steve’s advice by showing your kid how to explore the world in a safe manner and you are making them feel like they can – and should – follow their instincts to do that.

ACTIVE ENGAGEMENT: One of the wonderful deliverables of playfulness is the ability to be focused and get in the flow of an activity – whatever that activity happens to be. Steve’s conception of active engagement is a core part of what we think of as creativity. Kids need to get lost in the moment, block out everything else, and just follow where the experience takes them. As Steve points out, this doesn’t just happen during what we think of as “play” (although those are of course opportune times to witness this). For younger kids, it can be looking at rocks, following a bug, watching mom put on lipstick, or playing with a zipper on a pocketbook. For older kids, “play” can involve math, English, science, music – whatever turns them on. This all goes to Steve’s overriding message – it’s all about kids bringing a sense of playfulness to everything they do.

In the busy world we live in, we often think it is difficult to find time to play with our kids and give our kids opportunities to play. But if we embrace the philosophy of Steve Gross – Executive Director AND Chief Playmaker of the Life is good Playmakers– we see that we actually have more than enough time to infuse our kids with a sense of playfulness, and a trait that will serve them well for their entire lifetime.

Steve in Haiti

Images courtesy of Life is good