psychopharmacology

Psychopharmacology

Course Study Description

CCEUS17 Psychopharmacology: What A Counselor Needs To Know. [Approved for 10 contact hours by The National Board For Certified Counselors - Provider #5936] - [$50.00 - NO OTHER COURSE FEES APPLY] Students are being medicated today like never before. These drugs are prescribed for a number of reasons. Content of the course focuses on the uses, actions, side effects, interactions, and special precautions of employing medication with school-aged children. The information will center upon the the complexities of drug regimens commonly prescribed for: ADHD, Depression, Bipolar and Conduct Disorders, Anxiety, Self-Destructive Behaviors, and Tourette's Syndrome. Counselors should be aware of the nature and effects of the prescription drugs that students are taking. Being aware of these medications may also enable counselors to better serve students who are medicated. The myths and truths about the role of medications in managing behavior will be explored along with what to anticipate when medication is initiated, changed, or discontinued. Counselor approaches to addressing the family's unspoken concerns are outlined. Factors within the school setting that may either foster or hinder the treatment plan are mentioned.

Course Directions

Click on the Course Directions page to read course procedures.

Course Outcomes

As a result of the study in this course the student will:

	learn the five major classifications of medications.
	identify specific medications in these classifications.
	recognize the side effects/other reactions both positive or negative of specific medications.
	be aware of the drug-drug interactions of certain medications.
	learn the multiple effects of medications.
	become aware of the interactions of drugs and any conditions the client had in the past or is currently experiencing.
	be aware of allergic reactions to medications.
	differentiate among medications with similar names.
	learn where to get further information regarding medications used with clients.
	understand the client/counselor/psychiatrist-physician relationship.

Text [Required Reading To Be Prepared For The Exam]

Instant Pharmacology: A Guide For The Non-Medical Mental Health Professional. Ronald J. Diamond ISBN #0393702693 $17.00 on The Bookstore page .

Study Guide Questions

Name the major classification of psychotropic medications.
Describe briefly in a sentence or two the purpose of each classification.
Name three representative examples from each classification and tell what they do.
Give a brief discussion of how drugs work to achieve their purpose.
What effect does time have on the administration of these medications.
Discuss the important of drug-drug interactions.
For what purpose would anti-psychotic medications be prescribed?
For what purpose would anti-depressant medications be prescribed?
For what purpose would anti-Parkinson's medications be prescribed?
What might be expected as side effects from these medications?
Describe what anti-depressant medications are used for?
What are SSRI's? How are they used?
Describe any side effects with their use.
What is meant by the "New Generation" of anti-depressants?
What is a tricyclic anti-depressant and how is it used, and what are the dangers of its use?
What are MAOI's? How are they used?
Describe the main side effects of MAOI's.
How does a physician decide on which anti-depressant to describe?
What are mood-stabilizing medications and what are they used for?
Discuss three mood-stabilizing medications including their indications of use and their side effects.
Describe the role of anti-anxiety and sleeping medications.
Discuss three examples of these along with their indication of use and their side effects.
Under the category of miscellaneous medications, discuss three groups of medications that might be found here, the purposes of each, and any side effects of these drugs.
List the medications from these major classification that might be employed with children and adolescents.
Name five current websites where further information could be obtained regarding psychotropic medications [psychopharmacology].

Vocabulary

anti-psychotic
anti-depressant
SSRI
MAOI
psychopharmacology
psychotropic drugs
mood-stabilizers
anti-anxiety medications
neuroleptics
atypical anti-psychotics
side effect medications
sleeping pills
beta blockers
stimulants
Ritalin
Dexadrine
Cylert
Antabuse
Revia
acetycholine
dopamine
epinepherine
neoepinepherine
serotonin
absorption
drug interactions
brand name drugs
generic drugs
ADD
ADHD
schizophrenia
Parkinson's Disease
indication for use
side effects

Supplementary Readings [Required Reading To Be Prepared For The Exam]

Classroom Psychopharmacology

Classroom Psychopharmacology is the study of drugs as they affect children in classrooms, including

	medications prescribed with that intent;
	medications with classroom side-effects;
	drugs and chemicals taken or given unintentionally

Most drugs in classroom psychopharmacology affect children by affecting the communication between neurons in the brain. Neurons are the cells in the brain that communicate with each other. Other brain cells provide support, insulation, nutrition, and other environmental maintenance in the brain, but it is the neurons that do most of the brainwork. Each neuron receives input from many, many other neurons, and, in turn influences many, many other cells. The inputs come through synapses which terminate on a series of branches called dendrites, or on the cell body. As a result of the sum total of this input, the neuron either sends or doesn't send a signal down a longer branch called an axon to influence the many other neurons. The picture below shows a diagram of a typical neuron.

To understand these effects, you must understand something about cell membranes and the special protein structures in membranes that regulate the flow of substances and information in and out of the cell. Many of the important events in the brain, and most of the important actions of drugs happen near cell membranes, the thin covering that surrounds every cell. The structure of membranes is like a sandwich with a lipid (or oil-like) interior between two layers which are attracted more to water and water soluble substances. Just as oil and water do not mix, so this sandwich keeps the fluids and other substances that are outside the cell from easily passing into the cell. Specialized proteins in the cell membrane serve many different functions including the transport of substances or information across the cell membrane. Some of these structures regulate the passage of substances into or out of the cell. For example, ion channels regulate the coming and going of ions into and out of the cell. Others are specialized for bringing substances into the cell, for example seratonin reuptake proteins. A second general kind of membrane protein is not involved with the transport of substances into the cell at all, but serves to carry a signal from outside the cell to the inside. The broad class of G-reactive proteins are important examples of these "signal carrying" proteins.

Then you can understand how this regulation can result in an electrical signal which travels down the neuron and how this electrical signal can be transferred between neurons at synapses, where neurotransmitters are released from one cell to affect receptors on another cell. To understand the effects of these drugs, it is also helpful to understand something about neuroanatomy and something about what happens to drugs between the time they enter and leave the child's body. Many side effects of medications are the result of stimulating or blocking parts of the autonomic nervous system. Eric Chudler, at the University of Washington, has prepared a nice summary of the autonomic nervous system.Although it is not exactly a biological concept, it is also important to consider how we name the problems that get treated with drugs, whether as a disease, disorder, or simply a symptom.

The following represent some of the common reasons children may be affected by drugs in the classroom:

Attention Deficit Hyperactivity Disorder

The most common reason for a child to be treated with psychoactive medication is Attention Deficit Hyperactivity Disorder, or ADHD. Historically, ADHD is the most recent in a long series of names for problem behaviors exhibited by children, and more rece ntly adults. Core symptoms involve hyperactivity, impulsivity, and inattention. Using commonly accepted definitions, ADHD is usually said to affect between 3% and 5% of all children, although because the behaviors occur along a continuum, the prevalence depends greatly on where the line is drawn between normal and abnormal.

ADHD is currently defined entirely by the behaviors that are displayed. Boys are three to six times more likely to display ADHD behaviors which occur in all ethnic and socioeconomic groups. Although there is evidence that underlying biological factors a re important, there are currently no objective, physical or biological tests for these underlying factors. Children who display ADHD behaviors are more likely than other children to also show learning disabilities and/or conduct disorders.

Management of ADHD behaviors is best accomplished with a combination of environmental supports and accomodations, behavioral management techniques, supportive counseling to the family, and, when needed, stimulant medication. With or without effective management in the short term, children with ADHD are at high risk for future difficulty with academic performance and social adjustment.

Although some children gain additional controls over these symptoms with adolescense, at least 30% to 50% of children with ADHD behaviors continue to have problems with impulsivity and inattention into adulthood.

Investigation into the causes of ADHD has been hindered by substantial methodological problems (Whalen, 1989). Researchers may isolate a factor that is highly correlated with ADHD, only to find that it appears in levels comparable to those of "normal" children in most of the children diagnosed with ADHD. The population of children with ADHD is quite diverse, which leads most researchers to conclude that ADHD stems from no unitary causal agent or process. According to Rapoport and Quinn (1975), "The symptoms of hyperactivity and impulsivity are most probably a final common means by which a variety of congenital, toxic, and environmental influences may be expressed" (p. 41). The following discussion will focus upon the salient biological and genetic, psychological, and dietary factors implicated by the research as possible etiologies of ADHD. It is important to understand that it is unlikely that any one of these influences is solely responsible for ADHD symptoms. Any number of possible combinations of the above categories and their respective sub-processes may act as precursors of ADHD.

Currently, children diagnosed with ADHD are not automatically eligible for special education services. Commonly, however, these children display behaviors that cause them to be considered for special services. Qualification for services can occur under IDEA or Section 504 of the Rehabilitation Act of 1973.

Autism

About five in every 10,000 children today are diagnosed as autistic (Wing, 1981). Boys are much more at risk than girls and the prognosis for autism is very poor.

Autism affects every aspect of a child's functioning including intellegence, speech, movement, and social relationships. For many years children with autism were labeled as "schizophrenic," because their symptoms were severe and in some ways resembled adult schizophrenia. Today, however, most specialists distinguish between autism and childhood schizophrenia. Thus, schizophrenia is now considered a rare disease in children and most psychotic disorders in children are considered instances of autism.

Since autism effects nearly every part of a child's body, it comes to no surprise that the DSM-IV-R catagorizes autism under "pervasive developmental disorders." The symptoms of autism include emotional outbursts, inability to engage in close emotional relationships, social isolation, language difficulties, self-injury, repeated ritualistic movements, cognitive delays, and resistance to change.

There is no known cure for autism but there are a variety of treatments that can help in reducing its symptoms. Behavioral therapy is the most common treatment used. In some instances, medication is used for children who are agressive and do not respond to behavioral techniques.

Although, nobody knows for sure what exactly causes autism, there is evidence that organic factors are partly responsible for the disease. Such evidence suggests that the child's autistic pattern of behavior is associated with identifiable neurological abnormalities (Wing, 1981). Biochemical studies, however, reveal that many autistic children have high levels of serotonin and dopamine. Thus, these two neurotransmitters may play a role in detecting its cause. Other researchers state that autism may be without a single cause but, instead, with a common biological deficit (as in the case of cerebal palsy). Still, the cognitive, and behavioral, perspectives could also provide valuable insights into the possible origins of autism.

Autism encompasses all aspects of a child's functioning. Since the disorder is so pervasive, scientists and clinicians have difficulty differentiating autism from other diagnostic entities that share similar features. For instance, for many years clinicians labeled children with autism "psychotic" or "schizophrenic," because their symptoms were severe and in some ways resembled the adults with schizophrenia. Other conditions such as aphasia and Rett's disorder also share similiar characteristics with autism.

The major symptoms of children with autism include impaired social behavior, impaired cognition, language deficits, ritualistic motor activity, and the preservation of sameness. Although some children with autism may have average or above average intelligence, mental retardation is often associated with autism. Autism is also associated with epilepsy. According to Gillberg (1991), one third of the population of people with autism have developed seizures in early adult life. Although deafness is another condition that is associated with autism, it is often confused with autism. That is, since some children with autism are undersensitive to sounds, it is not easy to detect whether the child is merely unresponsive or is truly deaf. Last, it is important to note that autism occurs three to four times more in boys than in girls.

Other symptoms associated with autism include:

	Mood changes
	Failure to recognize danger
	Self-injury
	Repetitive and ritualistic movements of the limbs or entire body
	Hyperactivity and short atteniton span
	Sleep problems

Although the prognosis is poor for most children with autism, some will improve to the point of functioning independently and productively. Researchers seem to agree that a successful prognosis is closely related to cognitive functioning, specifically in the area of language development. Most children are likely to benefit from treatment if they have developed some meaningful speech by the age of five (Rutter, 1970). The child's IQ level could be another indicator of productive adjustment. Here, Schopler and Reichler (1971) suggest that IQ's of less than fifty indicate a poor prognosis, while IQ's of more than fifty suggest a greater variability in prognosis. Other researchers have found that a child's improvement in treatment was also associated with normal births and normal neurological records.

Bipolar Disorder

Bipolar Disorder, sometimes called, Manic Depressive Illness, is characterized by one or more manic or mixed episodes which may be interspersed with major depressive episodes. The individual with Bipolar Disorder may also have hypomanic episodes as well. All of the episodes in Bipolar Disorder must not be induced by chemical substances, such as drugs or toxins, or general medical conditions.

An individual may be diagnosed with Bipolar Disorder whether they are experiencing their first episode or having recurrent episodes. Recurrence is shown by a shift in polarity of the episode or an interval between two episodes of at least two months without manic symptoms. A shift in polarity is defined by the DSM-IV (1994) as "...a clinical course in which a Major Depressive Episode evolves into a Manic or Mixed Episode or in which a Manic or Mixed Episode evolves into a Major Depressive Episode." A Hypomanic Episode which evolves into a Manic or Mixed Episode or a Manic Episode which becomes a Mixed Episode, or vice versa, is not considered recurrent.

Bipolar Disorder is chronic and recurrent. It affects around 1% of the population of the world and more than 90% of individuals who have a single Manic Episode go on to have future episodes. There is conflicting but persistent evidence of a genetic link bipolar disorder. Males and females are equally affected with some differences. Manic Episodes tend to follow or precede Major Depressive Episodes. This varies among individuals. According to the DSM-IV (1994), prior to treatment with Lithium, the most commonly used medication to treat Bipolar Disorder, a person will average four episodes of Bipolar Disorder in 10 years time. The episodes of Bipolar Disorder appear to decrease with age. Approximately 5-15% of people diagnosed with Rapid Cycling Bipolar Disorder have multiple mood episodes which occur within a given year. Some individuals with Bipolar Disorder have psychotic features when having a Manic Episode. If an individual experiences psychotic symptoms, they are more likely to experience psychotic symptoms in future Manic Episodes.

Fetal Alcohol Syndrome

Fetal Alcohol Syndrome (FAS) is the term used for the severe end of a spectrum of problems caused by the effects of alcohol on the developing fetus. FAS occurs when a woman drinks heavily or at critical points during her pregnancy. Unfortunately, this is not a rare diagnosis with 1 in every 750 babies born with this syndrome. Individuals who have FAS have some degree of brain damage and this in turn , is what causes the behavioral and intellectual difficulties in these persons.

Individuals with FAS may exhibit any of the following: impulsivity, hyperactivity, learning and attention difficulties, lower intelligence, developmental delays, and motor problems. Additionally, physical and facial abnormalities will be present in individuals with the full syndrome. Moreover, great variability exists in terms of which symptoms are present in these individuals. Although the definition of the full syndrome requires some evidence of central nervous system involvement, not everyone who has FAS is mentally retarded. Some of these individuals fall within the normal range of intelligence.

Unfortunately, individuals with FAS often continue to experience difficulties throughout their lives. Although there are different programs and interventions that can help these individuals become more independent there is no cure for FAS.

According to a large body of research, alcohol is the only common variable in children with Fetal Alcohol Syndrome (FAS). Prenatal alcohol exposure has been shown to result in a broad spectrum of negative outcomes for the developing child. The nature and degree of such effects appear to fall along a continuum of severity. Where the child falls along this continuum depends upon the timing, the extent, and the chronicity of the prenatal exposure to alcohol (Phelps & Grabowski, 1992). Habitually heavy alcohol consumption (3 or more drinks per day) and/or one or more first-trimester alcoholic binges has been shown to raise the risks of global developmental damage to the fetus (Driscoll et al., 1990). Engaging in such behavior during the third trimester places the unborn child at risk for lowered intelligence and lifelong behavioral problems. Attention problems, memory deficits, and motor skills problems have been associated with habitual social drinking by the expectant mother throughout the pregnancy. Research has not confirmed the effects of light consumption during pregnancy, which may be subtle. It has been suggested that genetic factors may determine whether the child manifests the full syndrome or falls on the other end of the continuum with more mild effects (Abel, 1990). It has been observed that although children have undergone similar high levels of prenatal alcohol exposure, some will manifest severe FAS symptomology, some will manifest mild effects, and some children will appear unaffected (Able & Sokol, 1986; Phelps & Grabowski, 1992).

Individuals with FAS may also meet the criteria for learning disabilities or Attention Deficit Hyperactivity Disorder. Young people who have FAS tend to have certain behavioral characteristics in common. They are often distractible, impulsive, poor communicators, and may exhibit poor judgment. That is, they are not always able to predict the consequences of their behavior. Because these individuals tend to have difficulties with impulsivity and communication, they often have a hard time forming and maintaining friendships. As a consequence of these social difficulties, adolescents who have FAS may become depressed and anxious.

FAS tends to occur in family environments that are unstable. However, it should be emphasized that FAS can occur in any family.

There is no cure for these effects of alcohol on the developing fetus. That is, once the damage has been done there is no way of eradicating it. Individuals with FAS continue to have social and cognitive problems with some of the problems changing with age. Adolescents and adults who have FAS frequently display poor judgment, distractibility, poor communication skills, poor social judgment and may have more difficulty with reading, arithmetic, and spelling than other individuals. Additionally, their intellectual functioning and adaptive skills tend to remain below average.

The physical and facial abnormalities of individuals with FAS tend to become less noticeable after puberty. Although they may still be considered short and microcephalic into adulthood, their weight may be close to the normal range. As they mature their faces tend to be less distinctive because their nose, chin and the midfacial area grow towards the normal. There is also improvement of the molding of the upper lip and the area between the nose and lips.

However, it should be emphasized that there is great individual variability in terms of behavior, intelligence, and physical characteristics among those who have experienced some exposure to alcohol before they were born. For example, some individuals with FAS are mentally retarded while others function intellectually within the normal range. In addition, the outlook will depend greatly on the availability of psychological and environmental supports to the individual and to his or her family.

FAS itself is not one of the categories named in the federal special education law (IDEA). However, individuals with FAS may well qualify for services under the categories of mental retardation, learning disabilities, severe emotional disabilities, or other health impaired. Despite this, children with FAS often have academic and behavior difficulties and they sometimes do not receive special services in the school. Currently, most states do not provide funding specifically for either FAS or Fetal Alcohol Effects. There is no legal mandate for them to do so.

Conduct Disorder

Conduct disorders are characterized by a variety of antisocial behaviors that are both chronic and repetitive. These behaviors include: aggressiveness, stealing, lying, truancy, arson, and running away, and are often associated with hyperactivity, explosiveness, impulsivity, cognitive and learning problems, and poor social skills. Boys are four to five times more likely than girls to display conduct disorders and the age of onset is much earlier for boys (7 years-old for boys and 13 years-old for girls). The overall reported rate of the disorder is 4% to 9% in the population. Clinical populations differ significantly in the severity, frequency, and chronicity of maladaptive behaviors in comparison with the mild degree of antisocial behaviors typically found in normal children and adolescents.

The causes of conduct disorders have not been specifically identified; however, there are a multitude of factors thought to contribute to the disorder. Parental psychopathology, genetic, environmental, biological, sociological, and psychological factors, in addition to individual temperament, are thought to play a role in the development of conduct disorders.

Regular drug use (tobacco, alcohol, nonprescribed drugs) and early sexual behavior are often associated with conduct disorders. Other characteristics include low frustration tolerance, irritability, temper outbursts and recklessness. Anxiety and depression can coexist with conduct disorders. The child with conduct disorder also performs below average academically, often having reading difficulties and poor verbal skills. Symptoms of ADHD are very common with this disorder.

Mild forms of conduct disorder have a greater probability of improvement over time. The severe form tends to be chronic, especially if it has an early onset. Children with severe conduct disorders are likely to become adults with antisocial personality disorders. If social functioning is adequate, other antisocial behaviors such as illegal activities, are typical. Children whose conduct problems occurred mainly in the context of a group of peers often lead successful social and occupational lives as adults.

Conduct disorders are a major problem for society in terms of costs, treatment, and outcome. Longitudinal studies have found this disorder to be more stable over time than other childhood disorders regardless of the treatment. Rigorous efforts in diagnosing and treating this disorder are still being given so that the costs (to those with a conduct disorder and to society) may be mitigated.

Conduct disorders have been stated to be the most common psychiatric disorder in children as they represent the most common type of referral for children's mental health services. The prevalence of this disorder is estimated to be from 4% to 10% although self-reports of antisocial behaviors provide much higher estimates. As many as 60% of the teenagers questioned in one study admitted to more than one type of antisocial behavor. Furthermore, conduct disorders are four to fives times more frequent in boys than in girls. The median age of onset in boys is 7 years of age and in girls is 13 years of age. Boys appear to display more negative behaviors (i.e., noncompliance, aggression, and theft) whereas girls exhibit more sexually inappropriate behaviors.

The term Conduct Disorder is defined in the DSM-IV as:

A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated as manifested by the presence of the following criteria:

	Specifically defined symptoms of aggression, destruction, deceitfulness/theft, or serious violations of rules.
	Evidence that the disturbance in behavior cause clinically significant impairment in social, academic, or occupational functioning
	Criteria are not met for Antisocial Personality Disorder if the individual is age 18 years or older.

Attention deficit hyperactivity disorder (ADHD) and conduct disorder (CD) have been found to occur together in 30% to 50% in clinical and epidemiologic samples. Two positions concerning this overlap are:

(a) that the ADHD and CD are indistinguishable; they overlap completely with each other and

(b) ADHD and CD are partially or completely independent from one another.

Proponents of the first hypothesis believe that the identification of the other disorder does not add significant information to the case since there are similarities in the symptoms (i.e., aggressive, disruptive, and noncompliant behaviors), treatment, and outcome as well as differences in psychosocial, neurodevelopmental, and perinatal factors. Those adhering to the second hypothesis point to studies that have demonstrated children with ADHD and CD have a more serious clinical course and poorer outcomes than children with ADHD without CD. Furthermore, several studies have found:

(a) symptoms of hyperactivity and aggression are not highly correlated and

(b) conduct disorders are associated with parental antisocial behaviors and alcoholism but attention deficit hyperactivity disorders are not.

Most of the evidence appears to indicate that ADHD and CD are at least partially independent disorders. However, there is increasing evidence that children with ADHD and CD appear to have a particularly servere from of ADHD. Subgroupiong these individuals may be valuable in determining prognosis, family-genetic risk factors, and treatment interventions.

Careful assessment by psychologists and psychiatrists is necessary in order to obtain an accurate diagnosis. Schroeder and Gordon (1991) outlined several steps for assessing conduct disorders. These steps help differentiate those children and adolescents who have transient problems from those whose problems are persistent in a systematic and efficient manner.

Step 1: Initial Contact
Parents should be asked to complete a general questionnaire at the time of the initial referral. The questionnaire should cover the information regarding:

	(a) demographic background on the child and family,
	(b) medical history,
	(c) methods of discipline,
	(d) school history, and
	(e) parental concerns.

Other questionnaires that specifically focus on the child's conduct problems are also administered to the parents.. Frequently used standardized measures are the Child Behavior Checklist (CBCL) and the Eyberg Child Behavior Inventory (ECBI). Essential information about the parent's perceptions of their child's behavior is gathered through these measures.

Other measures may be given to the parents when the clinician wants to screen for the presence of other problems in the child or the family. For example, the Conners Parent Rating Scale is used to screen the presence of attention and/or hyperactivity problems and the Pareting Stress Index provides infomration about the marital relationship, parental depression, child temperament, and life stress.

Parents may be asked to keep a daily record of the child's or adolescent's negative beahviors. This will help the psychologist or psychiatrist to determine what the child is actually doing as well as obtaning information on the intensity and frequency of the behaviors.

Step 2: Parent and Child Interview

Parent Interview

Schroeder and Gordon (1991) stress the importance of both parents attending the initial interview since each parent often have different percpetions of the child's or adolescent's behavior. In addition, having both parents involved in the interview increases parental motivation for therapy. Approximately one and a half to two hours are allotted for this first interview. The following areas need to be addressed:

	(a) developmental history and current status of the child or adolescent,
	(b) parent and family characteristics,
	(c) praenting styles and techniques,
	(d) recent and ongoing stresses, and
	(e) persistence of problem behaviors.

Child Interview

Having the child present during the parental interview allows the clinician to observe and assess the child's behavior. The clinician can also model appropriate methods of interacting with the child during the interview. A short period of time is allotted for the to work with the child alone. This allows the clinician to observe the child's or adolescent's behavior when his or her parents are not in the room as well as determine the child's perceptions regarding his or her behaviors.

Step 3: Observation of Behavior

Direct observation of the parent-child interaction is a central feature in assessming conduct problems. Parent and the child/adolescent interact "as they would at home" for approximately five minutes. Then, the clinician gives the parent a list of simple tasks to do with the child. During this time, the clinician records (on a data sheet) the parent's behavior and the child's or adolescent's repsonse for about 10 minutes. Although most observations take place in the clinic, home and school observations are also seen as being useful.

Step 4: Futher Assessment

At this point, the clinician usually has a good idea of the nature and severity of the child's or adolescent's conduct problems. Further assessment is only needed when there are concerns about the developmental status of the child or about his or her performance in school. If parents have not been able to meet the demands of the treatment program further assessment would be needed as well.

Step 5: Referral to Allied Health Professionals

The psychologist needs to be alert to the possibility that ADHD may coexist with conduct problems. If ADHD symptoms are present, the clinican should consider referring the family to a psychiatristor physician to determine if medication is relevant for the child or adolescent if initial interventions are not sufficient. In addition, if the child or adolescent engages in severe aggression in which they are potentially dangerous to themselves or others, referral to an inpatient facility may be necessary.

Step 6: Communication of Findings and Treatment Recommendations

Once the clinician has an understanding of the nature, etiology, and severity of the behaviors, potential treatment approaches should be discussed. A clear understanding of the types of behavioral treatments, prognosis, and level of committment to the treatment plan is essential. It is usually recommended that the parent and child begin a behavioral treatment approach before using medication.

Juvenile delinquency is a term that is used by the legal system. It refers to an individual (under the age of 18) who has committed an index crime or a status offense. An index crime is an act that is considered to be illegal for a minor and an adult (e.g., theft, aggravated assault, rape, or murder) whereas a status offense is illegal only for a child or adolescent (e.g., truancy, violation of curfews, or incorrigibility). Conduct Disorder (CD) is a psychological term that is carefully defined by the DSM-IV. The criteria defined by the DSM-IV must be met to receive a diagnosis of CD.

This distinction is important because conduct disorders appear to be stable over time and more severe. Delinquent behavior is not usually considered to be a persistent psychological or social difficulty. Many professionals appear to see delinquent behavior as "within the normal range of adolescent experimentation". Approximately half of the juvenile delinquents commit only one offense. However, the probability of future acts rises dramatically with each additional offense. If the pattern of behaviors continue, the differences between these two terms begin to blur.

It is important to note that these two terms are used to communicate a set pattern of behaviors between individuals within a professional field. It is possible for an individual to have both or just one of the labels. The following example may be of clarify this point: If the a psychologists diagnosed an adolescent or child with a conduct disorder, this individual will be seen as juvenile delinquent within the legal system (if he or she had been involved with the law). However, if the legal system considers a child a juvenile delinquent, a psychologist or psychiatrist will not diagnose a child with conduct disorder until the criteria for CD are met.

Research has found that no single treatment yields a dramatic and long- lasting result for conduct disorders (CD). Treatments that are available include: behavior modification, parenting training, aversive conditioning, community-based treatments and pharmacotherapy. Psychosocial treatments should always be tried before considering the use of medication. In fact, pharmacotherapy is only be appropriate for aggressive and destructive behaviors with explosive outbursts. Children and adolescents do not display purely aggressive behaviors in most cases; thus, covert behaviors such as lying, stealing, and truancy may not respond to the medication.

After psychological interventions have failed, medication may be seen as an appropriate course of action. Before initiating pharmacotherapy, the physician should:

	(a) identify and carefully monitor the target symptoms related to the aggressiveness,
	(b) achieve a stable base line of the child's or adolescent's behavior, and
	(c) obtain a medical history.

This will allow the physician to clearly identify changes in behavior after treatment has been initiated.

Although medications may reduce aggressive behaviors, psychosocial interventions should also be used in the treatment of conduct disorders. The following drugs have been used to treat the symptoms of conduct disorder:

* Stimulants are frequently used when mild aggression coexists with ADHD. Specifically, methylphenidate has been found to be effective in milder cases of aggressiveness with and without hyperactivity. In addition, dextroamphetamine has been shown to be an appropriate drug in less severe cases of aggressive behavior.

The suggested starting dose for methylphenidate and dextroamphetamine is 5.0 mg/d and 2.5-5.0 mg, respectively. Daily dosages of these stimulants should not exceed 1.0 mg/kg. At higher doses, children and adolescents may experience several side effects.

The most frequent side effects include weight loss, tics, and stereotypic self-injurious behavior. Other side effects may be insomnia, dysphoria, hallucinations, sedation, and behavioral toxicity. Parents should be aware that long term use of stimulants has been associate with height and weight loss. However, periodic monitoring and drug holidays will help prevent these deficits.

* Neuroleptics are the most commonly used drugs in the treatment of aggressive behaviors, especially in children and adolescents who are mentally retarded (Campbell, Gonzalez, & Silva, 1992). Literature suggests that these drugs appear to be helpful in decreasing aggressive behaviors in mentally deficient individuals.

Research has shown that neuroleptics block dopamine receptors in animal and clinical populations. The result of this blockage in individuals with conduct disorder is the suppression of aggressiveness. However, it is still unclear whether these drugs have an anti-aggressive property or a nonspecific sedative effect on behaviors.

Although these drugs are effective, they have many side effects. Long term use of neuroleptics need to be carefully considered since there is an increased risk of tardive dyskinesia and cognitive impairments (i.e., clouds judgment or thought processes). The most common side effects to these drugs are sedation, parkinsonian side effects, acute dystonic reaction (which can be alleviated by incrementing dosage gradually), and weight gain.

The neuroleptics that are frequently use are haloperidol, pimozide, molindone, thioridazine, and chlorpromazine. Haloperidol appears to be as effective as lithium and reduces fighting, explosiveness, and bullying. Pimozide is not a potent as haloperidol and appears to have fewer and less intense side effects (i.e., sedation is mild). Although molindone and thioridazine have been found to reduce target symptoms , there is a lack of literature on the effects of these medications with adolescent and child populations. Chlorpromazine is one of the least potent neuroleptics that has been found to be effective in clinical populations. However, this drug should not be used with the mentally retarded because its administration is associated with a decrease in seizure threshold as well as an increase in seizures.

* Lithium Carbonate is a mood stabilizer that is known to enhance serotonergic activity in children and adolescents. An increase in serotonin appears to reduce aggressive behaviors. Lithium may not achieve clinical effectiveness for two to three weeks because it slowly accumulates within the body.

Although lithium has fewer side effects than neuroleptics (specifically haloperidol), careful clinical monitoring is necessary with this drug since is has a very narrow therapeutic window, below which lithium fails to have a therapeutic effect and above which side effects and toxicity may result. It is important to note that younger children appear to have more side effects than older children (Campbell et al., 1991).

Common side effects include nausea, vomiting, diarrhea, abdominal pain, slight tremors, lethargy, dizziness, slurred speech, ataxia, nystagmus, and muscle weakness. However, higher plasma levels can be very toxic. For example, seizures, enlarged thyroid gland, stupor, coma and even death may occur. During dosage regulation, serum levels need to be monitored two times a week. Once an optimal dosage is achieved, the levels need to be checked on a monthly basis.

The efficacy of lithium for children and adolescents with conduct disorder and mental deficiency is equivocal. Furthermore, the long-term safety of lithium is still unclear.

* Anticonvulsants are usually used when sudden, episodic outbursts or aggression are due to seizure disorders or head trauma. However, these drugs do not demonstrate a superiority over a placebo in children and adolescents diagnosed with just conduct disorders.

Carbamazepine is commonly used with this population because it has fewer adverse effects on cognition than other anticonvulsants. Carbamazepine has been found to reduce emotional lability, impulsivity, and aggressiveness in children. Therapeutic doses range from 400 to 600 mg/d in children and 400 to 800 mg/d in adolescents.

The most common side effects are drowsiness, poor coordination, leukopenia, and skin rash. These effects are usually controlled by reducing the child's or adolescent's dosage. At higher levels, there is an increased risk of seizure activity and behavioral toxicity.

* Beta Blockers -Propranolol is a beta-adrenergic blocking agent that effects both the central and peripheral nervous systems, This drug has been used to treat severe aggressiveness and violent behaviors, usually in patients who have failed to respond to other medications and have organic brain syndrome. Systematic research is needed on propranolol's safety and efficacy for children and adolescents.

Side effects that limit the use of this drug are hypotension and bradycardia. Monitoring of pulse rate, blood pressure and ECG is required when using propranolol.

* Benzodiazepines are minor tranquilizers that enhance the activities of the GABA systems. There are reports that the benzodiazepine chlordiazepoxide has decreased hostility in some children and increase aggressive behaviors in others. Thus, further studies are needed on the safety and effectiveness of this drug.
Researchers have found that there is potential for drug abuse and dependence with this class of drugs. Therefore, physicians should be very cautious in prescribing these drugs to adolescents and children. Common side effects among children and adolescents are behavioral toxicity, slurred speech, dizziness, ataxia, and sedation.

A pervasive problem exists within the schools because of the prevalence, poor prognosis, and severity associated with conduct disorder (CD). Antisocial behaviors result in destruction of school property, teacher and student stress/victimization, and disruption of classroom and school functioning. These behaviors lead to a substantial financial, emotional, educational and environmental problem for the school as well as society.

Attention to this disorder needs to be formally recognized so that successful outcomes are possible in the schools and for the students. School-based prevention (i.e., identifying and intervening with children in schools, school systems, and communities) may be more effective, economical, and productive than focusing on placement or exclusion of these children in specialized classrooms. Schools should also recognize the complexity and stability of CD. Effective service delivery should design interventions that deal with the multiple problems (i.e., substance abuse, precocious sexual activity, dropout, and school failure) that occur with CD.

Suggestions for intervention and prevention follow:

1) Primary prevention may be the most effective level of intervention for conduct disorders since they have been shown to be stable over time and have proven to be resistant to a variety of interventions. The goal of primary prevention is to lower their incidence rather than to treat occurring cases while the objective is to affect the behaviors and symptoms that may predict CD.

There are two primary prevention strategies: (a) protective factors and (b) risk factors. Interventions modify these factors by increasing the factors that protect against CD and decreasing factors that appear to be associate with this disorder.

The primary prevention approach may be cost a lot but the costs are outweighed by an increased effectiveness in the schools and society.

2) Most school-based services for CD have been limited to the classrooms (i.e., those who qualify for special edication services). The multiple areas affected by CD appears to exceed the school resources. Children and adolescents with CD may require services from a variety of agencies and service providers. Students with CD need comprehensive treatment plans in which the agencies work in collaboration with each other. Failure to communciate among the agencies results in inefficient and ineffective services.

School personnel may need to become more active in service activities occurring outside of the school. Activities may include parent training, family inteventions, community coordination, and group work. These activities may increase the school's commitment as well as awareness of CD within society.

3) Parents and family members play a critical role in their childs development. Therefore, parents with children who have CD need to become more involved with school personnel and the school psychologist.

The schools must develop ways for parents to become involved and empowered in the educational activities with their children. In addition, the school system and the school psychologist should emphasize intervetions that improve parental skills and management of their child. Training in these areas may be a critical component in the effectiveness of CD outcomes.

School Refusal

School attendance problems among children and adolescents has been a long-standing problem. Early pioneers had linked truancy with delinquency. However, it was not until 1932 that Broadwin described a variant of truancy that identified the role of anxiety in school attendance. In 1939, Partridge labled this form of truancy as "psychoneurotic truancy." Johnson et al. (1941) was the first to present this condition as school phobia in the professional literature. Today, this condition of school attendance problem is more commonly referred to as school refusal.

The condition of school refusal is not a diagnostic category in the fourth edition of the Disagnostic and Statistical Manual of Mental Disorders. Rather, school refusal is listed under the
Separation Anxiety Disorder as an associated feature. There is however, an internationally accepted definition/criteria of school refusal.

The prevalance rate of school refusal is unfortunately dependent on how one operationally defines school refusal. Nevertheless, the rate of this disorder is estimated to be between 1.7 to 5.4 percent. Delito & Hahn (1993) provides another report of the prevalence of school refusal. In elementary school children, school refusal is reported to affect at least 5 percent of the students. Among middle school children the rate is estimated to be 2 percent. etiology of school refusal Thus, school refusal has a generally low prevalance rate in among children and adolescents.

Although school refusal can occur throughout the school years, there are major peaks occurring at certain ages. The peak age at presentation is 11 to 12 years. In terms of the age of onset, there appears to be two peaks: 5 to 6 years and 11 to 12 years. These peaks coincide with school entry, and major school transitions. More importantly, the age of onset tends to also coincide with the clinical presentations of school refusal.

There are several treatment approaches to school refusal which may depend on the etiology of school refusal for a specific child as well as on the management of the disorder once treatment is initiated. Accurate assessment is important in terms of treatment formulations. The various treatments include behavioral therapy, psychodynamic therapy, family therapy, pharmacological treatment, and hospitalization. However, the most optimal approach is a multimodal approach which involves the use of various treatment approaches, along with the concerted effort of parents, teachers/school system, and relevant professionals. Regardless of the treatment modality, the primary goal of treatment is to return the child to school as efficiently as possible. Fortunately, the outlook or prognosis for school refusal is good. However, successful treatment of school refusal involve important *management issues.

Tourette Syndrome

Gilles de la Tourette syndrome, known as Tourette's Syndrome (TS) is a serious genetic disorder characterized by multiple motor and vocal tics with childhood onset and lifelong duration. The tics are annoying, embarrassing, and can increase under stress. As a results, tics in children have obvious personal and social ramifications.

Tourette's Disorder is an inherited disorder of vulnerability, such that not everyone with the vulnerability will express it. It is approximately 1.5-3 times more common in males than in females., and is found in diverse racial and ethnic groups. Tourette's is also considered to be a neurological-organic disorder in that partially successful treatment with neuroleptic medication suggests an enzyme or neurotransmitter dysfunction in the Central Nervous System. Tourette's is also often seen as a tic disorder on the extreme end of a continuum of a family of tic disorders.

In research studies, children with Tourette syndrome are often associated with Obsessive-Compulsive Disorder, Attention Deficit Hyperactivy Disorder, Learning Disorders, and Conduct Disorders. As many as 40% of individuals with Tourette Syndrome will present with the symptoms of Attention Deficit Hyperactivity Disorder two to three years before the development of the tics.

Self-consciousness, shame, and depressed mood often accompany Tourette syndrome. In view of the serious personal, social, and occupational ramifications involved with the display of motor and vocals tics, which are for the most part uncontrollable, students with other attentional and behavioral problems may easily experience exacerbation of those problems because of the motor and vocal tics. In addition, there is some evidence to suggest that the neurological mechanisms of Tourette syndrome are similar to or overlap with the above-mentioned disorders.

Tourette's Syndrome is usually a lifelong disorder, although there may be periods of remission lasting from weeks to years. In most cases the severity, frequency, and variability of the symptoms diminish during adolescence and adulthood. In some cases symptoms disappear entirely. Tics are often exacerbated by stress.

Tourette's Disorder is a serious disorder that affects a student's social, personal, and occupational functioning. Therefore, school adjustment may be difficult and require the full cooperation of school personnel in ensuring that the student is not discriminated against in any way. If the Tourette Syndrome significantly interfers with learning, the child may be entiitled to special services under the category of "Other Health Impaired" under the special education laws, and as a disabled individual under Section 504 of the Rehabilitation Act of 1974. This may include academic assistance and counseling with the student and parents. A multidisciplinary approach is best, including a physician if the student is receiving medication to reduce tics.

Depression

Almost all individuals experience being "depressed" at one time or another. However, when depressive symptoms are "devastating, persistent, and out of proportion to the loss, or when there is no apparent accompanying loss, then the person may be suffering true depression of clinical proportions" (Gelfand, Jensen, & Drew, 1988; p. 102). Depression afects many areas of functioning including the behavioral, emotional, somatic, and cognitive domains, indicating the pervasive nature of this disorder.

Common signs of clinical depression documented among both children and adults include sadness, lack of enjoyment from previously preferred activities, negative self-image, change in eating habits, sleep disturbances, loss of energy, withdrawal, difficulty concentrating and thoughts of death or suicide. Depression in children and adolescents is still often conceptualized in terms of adult criteria, and as such, fails to take into account the impact of development. Depression often occurs along with other childhood disturbances including anxiety disorders, conduct disorder, aggressive behaviors, and also among children with chronic medical conditions such as diabetes and seizure disorders.

The prevalence of depression among children and adolescents has been difficult to estimate due to the use of different assessment methods, different criteria, and the diverse populations studied. According to one study, the incidence of depression among a clinical population of adolescents was approximately 18% and among a non-clinical population of high school students, ranged from 6-12% (Reynolds, 1990). Depression tends to be more common in adolescents than in younger children aa well as more common in female adolescents than males. Despite the difficulty in determining the prevalence of this disorder among children and adolescents, depression is considered to be one of the most prevalent and pervasive psychological concerns for this age group.

The causes of depression have not been established and explanations for the occurence of the disorder vary as a function of the theoretical model applied. Biological, family, and social factors have all been found to play a role in the disorder. Depression may be most clearly conceptualized as occurring on a continuum between biological and environmental factors.

The biological theory of depression postulates that the disorder is caused by a defiency in one or more neurotransmitters, most likely serotonin and norepinenphrine, and possibly dopamine. Support for this theory comes from the fact that drugs that potentiate the effects of these neurotransmitters tend to result in a decrease in depressive symptoms for many adults. Psychological theories of depression vary greatly in their explanantion of the disorder and include causes such as unconscious conflict, distorted thinking, and a lack of positive reinforcement. There is evidence suggesting that depression may have a genetic basis. In studies of adopted children whose biological parents had depression, these children tended to show a higher incidence of the disorder than the general population.

Anxiety

Anxiety is a complex response characterized by subjective feelings of dread, apprehension, fear, tension, and often accompanied by psychomotor responses (e.g., motor tension, vigilance). Some degree of anxiety is a normal reponse to potentially dangerous situations. Anxiety becomes a problem when it interferes with one's daily functioning. Anxiety disorders are the most prevalent of all DSM-IV disorders (Julien, 1995). Anxiety coexists with almost every mental disorder and is common in many organic disorders. Generalized anxiety disorder (GAD) is the most common anxiety disorder.

Accurate assessment and diagnosis of anxiety is helpful in determining the most beneficial treatment. Less severe anxiety, especially phobias, can be effectively treated with cognitive behavioral therapy (e.g., systematic desensitization, flooding). The **benzodiazapines** are typically used to reduce the symptoms of acute anxiety, although their potential for addiction is a serious consideration. Nonbenzodiazapines such as **buspirone** are effective in treating chronic anxiety without addictive side effects. The most comprehensive treatment approaches use the antianxiety medication to relieve the symptoms of anxiety and psychotherapy to help the individual increase self-control over their thoughts and behaviors.

Lead Poisoning

Lead poisoning is caused by the ingestion of lead. Lead is found all around our environment in such places as lead-based paint, soil, dust, air, food, and water. There is no such thing as a safe amount of lead. Different levels of blood lead concentration have different implications.

Lead ingestion has been found to have detrimental affects on IQs and growth. An increase in behavior problems may also result from lead poisoning. However, there are no behaviors that only occur with lead poisoning so one cannot be diagnosed with this disease on the basis of the presence of a behavior alone. Additionally, lead appears to affect all organ systems to one degree or another and these effects can occur even though the lead level in the body may be low.

Unfortunately, one cannot tell whether an individual has lead poisoning just by looking at him or her. A blood test is needed to determine the actual levels of lead in the blood. This can be done at a health clinic, a family physician's or a pediatrician's office, or at the public health department. The Nebraska Department of Health recommends that everyone should be screened by the age of six years. Children who are considered to be high risk should be screened at 6 months of age and follow-up screenings should be done as needed. Children are considered high risk if they live in older housing, have a sibling with high lead levels, live with someone who gets exposed to high levels of lead on the job or reside near a business that releases lead into the air.

Luckily, lead poisoning can be prevented by such measures as proper hygiene, good nutrition, and abatement. That is, the act of washing hands before one eats can help prevent the absorption of lead into the body. Also, lead absorption is facilitated by a deficiency in iron or calcium. Therefore, a good nutritious diet can help prevent blood poisoning. The abatement of lead is also very important in the prevention of lead poisoning but can be extremely costly in terms of time and money.

Lead poisoning is caused by inhaling or swallowing lead. Children are particularly at risk because they tend to put just about anything into their mouths and their bodies absorb lead more readily than grown-upÕs bodies do.

There are several sources of lead in our environment. Lead paint and contaminated soil are two sources that may affect children the most. Lead paint can be found all over older homes including windows, doors, walls, floors, stairs, woodwork, porches, and fences. Lead paint chips and dust can contaminate soil posing another significant risk for children.

Water is additional source of lead with trace amounts being found in standing water. In households plumbing may be responsible for exposure when the following are used: lead water pipes, brass or bronze plumbing fittings, and lead solder. Other more rare sources of lead include food, cosmetics, and folk medicines.

Several problems are associated with lead poisoning. First, poor nutrition often accompanies lead poisoning and tends to make the disease worse. For example, it is not uncommon for an individual to have high levels of lead poisoning and experience anemia at the same time. Second, people who are impoverished or who happen to live in older housing may be more at risk for lead poisoning. However, it should be emphasized that lead poisoning affects all individuals and does not discriminate according to one's wealth or socioeconomic status.

The outlook for this disease is rather dismal in that lead accumulates in the body overtime and is not excreted. Extremely high exposure can cause seizures, high blood pressure, coma, and even death. However, on a more positive note, blood lead levels are down by 80% since lead has been removed from gas. Therefore, a great deal of progress has been made in the United States.

Epilepsy

Seizure Disorders are a group of disorders characterized by the episodic occurrance of abnormal ele ctrical activity in the brain resulting in abnormal muscle activity and/or altered consciousness. Although often lumped together under the term epilepsy, which can be taken to mean a recurrent and continuing seizure disorder, this group of problems is ex tremely heterogeneous with a wide range of causes (often unknown) and a wide range of outcomes from a benign course to severe generalized deterioration.

As a group children with epilepsy have a higher frequency of behavioral and academic problems. However, this should be interpreted with caution because of the wide range of problems included in the group. In addition, school problems may arise not only from the seizures themselves, but from brain damage that may cause or accompany the seizures, fr om the medications used to treat the seizures, from the emotional impact of a chronic illness, and from the expectations and attitudes of those around the child.

Careful observation of the nature of the seizures, and of the effects of treatment is i mportant both to the initial characterization of the seizures, and the monitoring of drug effects and side-effects.

Epilepsy can result from various causes: defects in the brain, brain injury before, during, or after birth, head trauma, poor nutrition, childhood high fevers, some infectious diseases, brain tumors, and some poisons. In many cases a specific cause cannot be found.

Epilepsy is in itself not inherited, but a vulnerability to certain diseases may increase the risk of acquiring epilepsy.

Epilepsy is not contagious, but at any time anyone could experience an illness or injury that would lead to temporary or permanent seizure activity.

Next to strokes, epilepsy is the most common neurological disease, with about 0.5 to 1% of the population affected. The two major forms of epilepsy, focal and generalized, produce distinctive <a href="/tcweb/pharm/glossary/eeg.html>EEG patterns. During focal epilepsy changes in the EEG are restricted to a circumscribed area of the cortex, but may spread. Generalized seizure activity, on the other hand, spreads across vast areas of the cerebral cortex. Any seizure activity disrupts cerebral processes. Therefore, seizures may have significant effects on learning, consciousness, and motor behavior. Seizure activity is prevalent in mental retardation, tic disorders, and brain-injury. It is not thought to cause other disorders, but its presence may indicate the possibility for susceptability to other disorders. That is, organic damage may predispose a person to other behavioral/emotional dysfunctions.

There are many factors that influence the outlook for students with epilepsy. The etiology of the disorder, the age of onset, the type and location of the seizure activity, the frequency and intensity of the seizures, the IQ before the onset of seizures, and whether the student takes antiepileptic medication all affect the outcome of student growth personally, socially, and academically. There is no concrete evidence that seizures cause brain damage, with possibly the exception of Òstatus epilecticusÓ (prolonged severe seizure activity), which can result in death if not treated quickly.

The classroom manager must help the student with epilepsy to deal with the emotional and behavioral aspects of the disorder. Embarrassment, shame, and cognitive disruption follow seizure activity. A time of rest may be necessary after a seizure, even though this will obviously call attention to the seizure. A multidisciplinary approach involving the teacher, student, parents, and physician can help the student deal with the disorder. Education for the studentÕs classmates might also be helpful. While cognitive interruptions are part and parcel of the disorder, the teacher must guard against focusing only on the students impairment.

Rutter (1970, cited in Trimble & Cull, 1988) found that 29% of 63 children with uncomplicated epilepsy had psychiatric problems, compared with only 7% of the general population. Teachers have rated children as poor achievers, especially in mathematics. Hoare (1984, cited in Trimble & Crull, 1988) found greater psychopathology in a group with epilepsy compared with a group with diabetes in school. Other researchers have found similar evidence of greater behavioral and cognitive problems in students with epilepsy.

Seizures may be accompanied by transient visual and/or auditory hallucinations, fear, anger, delusions, sexual feelings, paranoia, and loss of body control. Temperal lobe seizures are sometimes associated with personality change, manifested by exaggerated expressions of emotions and ideas not present prior to the onset of the seizure activity.

Epilepsy is a serious, usually lifelong disorder whose symptoms vary in intensity, duration, and cognitive impairment. School adjustment is likely to be difficult and requires the full cooperation of school personnel in ensuring that the student is not discriminated against in any way. Federal guidelines mandate that special services are to be provided to a student with epilepsy if the disorder interferes with schoolwork. Academic tutoring and counseling may be necessary. Students with epilepsy should be given every opportunity to participate in all normal school activities, unless the studentÕs physician and family suggest otherwise.

Asthma

Asthma is a chronic respiratory illness that is characterized by bronchoconstriction and bronchial hyperresponsiveness. The contraction of bronchial airways causes the individual to engage in "recurrent, episodic bouts of coughing, shortness of breath, chest tightness, and wheezing" (Boushey, 1995).

Pathological features of this illness include contraction of airway smooth muscle and the formation of abnormally thick, viscid plugs of mucus as a result of mucosal thickening from edema and cellular infiltration. However, asthma is also a diverse illness varying greatly in symptom severity and symptom frequency among patients. Treatment depends upon the presenting problems. For instance, contraction of the smooth muscle is most easily reversed by the current therapy; which is the use of bronchodilators such as beta-adrenoceptor stimulants and theophylline, a methylxanthine drug. Antimuscarinic agents can also be used to reverse constriction of the airways. Treatment of edema and cellular infiltration requires sustained treatment with anti-inflammatory agents; including cromolyn, nedocromil and corticosteroids.

Physicians and researchers work from conceptual models to understand and explain the causes and mechanics of a disease. Asthma has been explained via a classic immunological model. More specifically, the individual was exposed to a stimuli, had a reaction to the stimuli, and developed antibodies as a result of the exposure. Upon reexposure, the individual's body undergoes chemical reactions as a result of an antigen-antiboy interaction. These chemical reactions effect changes throughout the airway wall; i.e. contraction of muscle, edema, cellular infiltration, and changes in mucous secretion.

However, this model does not account for several features of asthma. For instance, many adults with asthma do not respond immediately upon first exposure to an antigen and/or the severity of the attack may be unrelated to the amount of antigen in the atmosphere. Also, contraction of the airways can be caused by non-antigenic stimuli, such as distilled water, exercise, cold air, sulfur dioxide, and rapid respiratory maneuvers (Boushey, 1995). Thus, a classic immunological model appears insufficent for explaining the pathology associated with asthma.

As a result, researchers continue to analyse differences and similarities between nonasthmatic and asthmatic people and then hypothesize regarding the mechanisms that can account for the data. One key difference between nonasthmatics and asthmatics is the finding that asthmatics exhibit bronchial hyperactivity or an "exaggerated sensitity of the airways". The mechanisms underlying bronchial hyperactivity are unknown. However, the condition may be related to inflammation of the airway mucosa and "an increase in the number of eosinophils found within and beneath the airway epithelium" of asthmatics (Boushey, 1995, p. 306). Activation of the epithelial cells may generate eosinophil products that cause "epithelial sloughing" and contraction of the smooth muscle found in the airway. This process has not been confirmed as the only mechanism to explain asthmatic attacks because the products of other cells in the airways, i.e. macrophages, mast cells, sensory nerves, and epithelial cells, also alter the functioning of the airway smooth muscle.

Based upon our understanding of the causes of asthma, we have clues to the direction of study and treatment but our knowledge is incomplete. More specifically, we know asthmathic bronchospasms result "from a combination of release of mediators and an exaggeration of responsiveness to their effects" (Boushey, 1995, p.307). Therefore, asthma can be treated with drugs that work on different sites of operation. For example, some drugs can work to prevent mast cell degranulation (i.e. cromolyn or nedocromil, beta agonists, calcium channel blockers), muscarinic antagonists can inhibit the effect of acetylcholine released from vagal motor nerves, and sympathomimetic agents and theophylline work by directly relaxing airway smooth muscle .

Asthma can also be treated by reducing the increased responsivity of the airway system. Since increased responsiveness is associated with airway inflammation; physicians can use agents, such as cromolyn and corticosteroids, to treat individuals with asthma. Methotrexate and gold can also be used to treat the chronic inflammation of the airways, thereby, reducing the frequency of asthmatic attacks.

With the passage of PL 94-142, the Educational for All Handicapped Children Act of 1975, chronically ill students in all states are eligible for special education services if their health problems adversely affect the child's educational performance. Generally, these students are verified under the "other health impaired" category which requires that a child have limited strength, alertness, or vitality due to a chronic or acute health condition which adversely affects academic performance.

Depending upon their specific academic needs, chronically ill children may or may not receive instructional support. However, many times chronically ill children are eligible for related support services such as "occupational and physical therapy, adaptive physical education, special transportation, school health services, and counseling and psychological services" (Potter, 1987.p.101). Children with asthmatic conditions could be considered for any or all of these services depending upon their individual needs. For instance, children with asthma may be assigned to a school building, other than their home school, if they need an air conditioned environment. Students reassigned for this purpose are generally also eligible for free transportation services.

The roles school personnel take with a child with a chronic illness will differ depending upon the nature of the specific student-educator interaction. For instance, the interactions between a child with asthma and the school nurse is likely to be different that the interactions between the child and the classroom teacher or the child and the school psychologist. However, some general guidelines are helpful to keep in mind for all personnel working with a child with a chronic illness. These key points as outlined by Potter (1987) are:

	1. Interact with the child in a manner appropriate for their developmental level and understanding of their illness. Furthermore, recognize and be aware that as a child matures physically and emotionally their understanding and acceptance of their illness changes with different developmental ages.
	2. Accurate information needs to be available at all times and presented in a timely and understandable manner.
	3. Easy communication among all--students, parents, professionals--is vital.
	4. Expectations must be individualizied; it can be very misleading to compare the cognitive and emotional development of a chronically ill child with the expectations for an "average" child who has not had similar life experiences.
	5. One overall goal for working with a chronically ill child is to be flexible and innovative when issues arise. Another goal is to help the chronically ill child live as normal a life as possible.

These key points can only be achieved if all involved--student, parents, and professionals--
work together as a team to meet the needs of the student now and in the future.

Best Practices for Asthma

During personal conversations with Geri Hansen, supervisor of the Omaha Public School school nurses, and Kathy Owens, a school nurse with the Omaha Public Schools, they shared several examples of best practices guidelines and prevention interventions used in the Omaha Public Schools with students with asthma. These best practices guidelines and prevention interventions are used to manage the health needs of students with asthma and to support the academic, social, and emotional development of these same students.

Preparation

At the start of the school year, building school nurses receive a computerized printout with the names of students identified as having health conditions. This printout includes students with a variety of medical conditions; i.e. asthma, epilepsy, diabetes, etc. Using the information on this printout the school nurse contacts classroom teachers who will be working with these students to notify the teachers of these students health needs. For example, the school nurse may contact the student's regular classroom teachers, special education teachers (if applicable), the physical education teacher, and other specialists who will be working with the student on a regular basis.
At the time of the contact, the school nurse will provide the teachers with information concerning the students medical condition and health needs. Information shared will include the name of the medical condition and general information about this condition; especially as it relates to school performance and special health needs. The school nurse will also summarize the student's medical history, current health status, current medications the student is taking at school and/or at home, medication schedules for this student's, possible side effects, and any limitations or restrictions placed on this student per physician orders. The goal of the school nurses' early contact with other school personnel working with an identified student is to make these educators aware of the students needs and to set appropiate expectations for these students.

Parental Communication

In addition to contacting the student's teachers, the school nurse will review health cards and make a parental contact early in the school year to update information and try to obtain relevant information concerning this student. For instance, the school nurse might discuss with the parent specific factors that may trigger an asthmatic attack for this child, is there a seasonal pattern to the asthma attacks, how responsible is this student regarding management of his asthma, was the student hospitalized over the summer because of an asthma attack, and are there any special restictions placed on this student because of his asthmatic condition.

Throughout the school year, the school nurse will contact the parents as the need arises.
The school nurse, in turn, relies upon the parents to contact school personnel verbally or in writing regarding the student's health status; ie. hospitalizations, changes in medications, other health problems, etc. Furthermore, anytime there is a change in medication or restrictions/limitations placed on the student, the school nurse is required to have written authorization from the physician. The school nurse will also contact the physician to clarify uncertainties or inconsistencies that may arise.

Student Education

School nurses also serve as a resource for educating students regarding management of their asthma and for helping students try to develop healthy attitudes and constructive coping skills .
By encouraging the student to take an active part in the management of their asthma, school nurses teach students to recognize subtle cues of an impending asthma attack. They also teach students to communicate "how they feel" . These practices provide the student with an "empathetic" listener and encourage the student to assume responsibility for reporting and managing his health needs.

Support

As students with asthma mature, the school nurse working in conjunction with parents and physicians can also help students cope with emotional issues associated with the illness. For example, the school nurse can assist student's in learning to cope with feelings of frustration arising from often feeling tired. By encouraging the student to participate in activities even when they feel less than par , the school nurse sends the message that some involvement is better than none. In this way, the school nurse may help the student learn to live as normal a life as possible and also avoid patterns of malingering and withdrawal.

Examination

The examination for this course is attached to this page. PRINT OUT THE EXAM. All examinations consist of both True-False and/or Multiple-Choice items with five answers. You must score 80% on the exam to gain the contact hours. When you have printed the exam, read each question carefully, choose the BEST answer and circle the letter of the answer you choose. Return the exam by mail to Dr. Budd A. Moore, Exam Scoring At CounselingCEUsOnline along with the signed Honor Pledge and a check or money order for $36.00 payable to Dr. Budd A. Moore. The exam and the honor pledge can also be faxed to our office at 1(717)597-2302; however, it will not be scored until the scoring fee is paid in full. When the fee and all of the materials are received, the exam will be scored within 48 hours. Results will be e-mailed to you as soon as they are available. A letter of congratulations, a certificate from CounselingCEUsOnline, and an official transcript will be mailed to you. Examinations will not be returned to the student. Records of your scores will be maintained by CounselingCEUsOnline and will be available for you for a $5.00 transcript fee.

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Step 1: Initial Contact Parents should be asked to complete a general questionnaire at the time of the initial referral. The questionnaire should cover the information regarding: