by Shari Gent, MS
HEARING THAT YOUR CHILD HAS A MENTAL HEALTH CONDITIONin addition to ADHD can be devastating. Parents may feel hopeless and helpless, and often blame themselves for a condition that may have a neurobiological cause. Although healing takes time, with appropriate family, medical, educational, and community support, many children with ADHD and coexisting mental health conditions progress to lead productive lives.
Lyssa* took her son Kenny* out of a private kindergarten when classroom parents threatened to have him removed because he disrupted other students. “Every time he was asked to write, he burst out crying,” she recalls. Kenny was diagnosed with fine motor difficulties, ADHD, and depression. When Lyssa enrolled him in public school, he was placed in a general education class.
Changing schools was not a solution. After numerous outbursts, the school recommended placement in a class for children with emotional disturbance. Lyssa visited the class, but came home in tears: “I knew it wasn’t the right place for Kenny, but none of the other private schools would take him.” Kenny continued to cry and to have outbursts when he felt he was treated unfairly, and Lyssa decided she needed to obtain an IEP.
ADHD andmental health
While ADHD, the most commonly diagnosed mental health condition in children, has become more accepted and even embraced by some families, coexisting conditions such as depression, anxiety, reactive attachment disorder, and bipolar disorder continue to carry considerable stigma. Parents are often afraid that the label will follow their child throughout his or her life, affecting self-esteem and opportunities for employment. Additionally, families may fear that placement in special class will fail to meet their expectations of an appropriate educational setting for their child.
The reality is that fully one-third of the general population will be diagnosed with a mental health condition at some time during their life. Emotional disturbance, better known as emotional/behavioral disability (EBD), is one of the thirteen conditions that can qualify a child for special education services under the federal law, the Individuals with Disabilities Act (IDEA 2004). While just one percent of the school population qualifies for special education as a child with EBD, fully twenty percent of students will experience an emotional or behavioral condition that will interfere with their ability to learn at some time during their school career, according to the National Institute of Mental Health (NIMH).
For children with ADHD, this number is more than onehalf, according to the National Alliance on Mental Illness (NAMI). A small number of these students will qualify for special education as having an emotional/behavioral disability. Most will experience emotional difficulties that are not severe enough to qualify for EBD services, but continue to affect the student’s ability to make and keep friends and perform academically. To complicate matters, many symptoms of depression, anxiety, and abuse may mimic ADHD. ADHD itself can cause problems with emotional regulation; distinguishing between ADHD with emotional regulation problems and other mental health disorders requires professional expertise.
Mental health conditions affecting children and teens with ADHD fall into two primary categories: disruptive behavior disorders and mood disorders. Until May 2013, ADHD was grouped with disruptive behavior disorders in the Diagnostic and Statistical Manual IV (DSM-IV), the resource used by professionals to diagnose mental health conditions. Published in May 2013, the new DSM-5 groups ADHD in the neurodevelopmental disorders category. This is an important recognition that ADHD has a biological cause rather than simply being a constellation of behaviors. Recognition of neurobiological nature of ADHD may alleviate some of the stigma that many still attach to the diagnosis. The new classification may also make the diagnosis more credible to those who continue to doubt its existence.
Although the neurobiological causes for ADHD have been sanctioned, the lines between ADHD, disruptive behaviors, and mood disorders are not distinct. Approximately forty percent of youth with ADHD also have oppositional defiant disorder, according to CHADD’s National Resource Center on ADHD. Conduct disorder, a more severe behavior problem that can develop in a child with ODD, affects twenty-five percent of children and up to forty-five to fifty percent of teens. The most prevalent mood disorders affecting children and teens with ADHD are depression (ten to thirty percent) and anxiety (thirty percent). Bipolar disorder is a less frequently occurring but serious condition, affecting up to twenty percent of individuals with ADHD. See the sidebar on page 32 on when to seek a mental health evaluation for your child.
Shannon and her husband adopted their first child when he was nine months old. Although he was born in Guatemala during the civil war, they did not suspect that their beautiful, healthy boy had an anxiety disorder. In retrospect, Shannon suspects that as an infant, Tory may have experienced the terror of house-to-house searches. When he was diagnosed with ADHD in second grade, Tory continued to do fine in school and at home. At the beginning of fifth grade, however, when he was punished for forgetting to bring pencils to class, Tory broke down.
In his Midwestern school, fifth grade is the year when executive function demands increase exponentially. Suddenly, Tory had to go to six different classes with six different teachers and store his books and materials in a locker. “When I picked him up on the second day of school, he just fell apart,” Shannon recalls. “He couldn’t remember his pencils or his work. He was terrified to go to school. He acted like a cornered animal.”
After Tory was diagnosed with post-traumatic stress disorder, a type of anxiety disorder, he and his family were gradually able to put the pieces of his life back together. The school offered alternative placement at a site that focused on juvenile offenders or time at his previous school in “in-house suspension,” where he could receive one-to-one support. Shannon rejected both of these offers as inappropriate for Tory’s needs and homeschooled him for the balance of his fifth-grade year.
Tory’s family prepared for sixth grade by seeking out private placement. With the help of an attorney, they were able to work out a compromise with the school district. “The staff in the sixth grade was completely different,” says Shannon. “We connected with a wonderful resource guidance counselor who understood mental health issues. She was only available at teacher request. In this case, the superintendent requested.” Along with new medication, this connection with a trusted adult at school enabled Tory to overcome his fears and experience success.
Quality programs for studentswith EBD
If your child or teen has been diagnosed with coexisting mental health conditions, support from a mental health professional is essential. But what about school? What are the types of programs that have been demonstrated to provide these students with the best possible education? The solution is different for each child, but research has identified some basic components that characterize quality programs for students with emotional difficulties. These include:
Be sure to read the sidebar (page 33) on questions to ask when considering a potential general or special education placement for your child.
Persistence pays off
For Lyssa, Kenny’s mother, tireless effort for several years finally paid off. In his initial placement, she recalls, Kenny “would cry, then curl up in the fetal position. But the school district said that is the only class we think is appropriate.” Although there was a high adult-to-child ratio, the classroom behavior system was punitive. “The expectation that a child with ADHD could maintain perfect behavior for seven weeks to move up a level is unrealistic. It was just so not right for a student with ADHD,” she says. “Kenny’s disability is executive functioning. The school was not remotely considering this.”
Finally, after a long wait, the family was able to enroll Kenny in a university-based school designed for children with ADHD. “The difference is that when the day is over, it’s over,” says Lyssa. “You can turn around behavior. You can recover. You can let it go.” Parent participation is encouraged and parent training is required. Kenny is now in third grade and plans are being made to transition him back to a general fourthgrade class in the neighborhood public school next year.
Shari Gent, MS, is an education and behavior specialist with the Diagnostic Center, Northern California, California Department of Education. As a CHADD volunteer, she coordinates a parent support group, teaches Parent to Parent classes, and serves on the board of the Northern California chapter and the editorial advisory board of Attention magazine.