Child and Adolescent Psychopathology for School Psychology PDF

 Child and Adolescent i Psychopathology for School Psychology Terry Diamanduros, PhD, completed her doctoral studies at New ii York University, earning a PhD in school psychology. Dr. Diamanduros has several years of experience working with children and adolescents in school and cl...

 Child and Adolescent i Psychopathology for School Psychology Terry Diamanduros, PhD, completed her doctoral studies at New ii York University, earning a PhD in school psychology. Dr. Diamanduros has several years of experience working with children and adolescents in school and clinical settings in New York City. She is currently a professor in the school psychology program at Georgia Southern University and has been a faculty member in the program since 2004. Her research interests focus on childhood trauma, cyberbullying, and the influence of technology on child development. She currently teaches courses in child psychopathology, developmental diagnosis, personality and behavioral assessment, assessment in academic achievement, and practicum in school psychology. Dr. Diamanduros is a member of the National Association of School Psychologists (NASP) and served as an NASP delegate for the state of Georgia. She is an active member of the Georgia Association of School Psychologists (GASP) and has served on its executive board. Dr. Diamanduros also serves on the editorial boards for the Journal of Aggression, Maltreatment and Trauma; School Psychology Review; Psychology in the Schools; and Journal of Child Sexual Abuse. P. Dawn Tysinger, PhD, NCSP, earned a doctorate in pychology with a concentration in school psychology and a subspecialization in counseling interventions from the University of Memphis in Memphis, Tennessee. Dr. Tysinger has also earned the Nationally Certified School Psychologist credential from the National Association of School Psychologists (NASP). Dr. Tysinger is a full professor and program director in the nationally recognized and NASP-approved school psychology program at Georgia Southern University. Before coming to Georgia Southern University, she practiced in the public schools in both Louisiana and Kansas and served as an adjunct faculty member for Emporia State University in Emporia, Kansas. Dr. Tysinger has contributed to her field through active participation in NASP, publications in school psychology journals, and presentations given at the local, state, regional, national, and international levels. She currently serves as a reviewer for the NASP program review board and is a member of the editorial boards of Psychology in the Schools, School Psychology Training and Pedagogy, National Youth- At-Risk Journal, and Journal of Online Learning Research. Jeffrey A. Tysinger, PhD, NCSP, is a professor at Georgia Southern University. From 2003 to 2007, he was a member of the faculty at Emporia State University, in the nationally accredited school psychology program. He has worked as a school psychologist in Anchorage, Alaska, and in Lafourche Parish, Louisiana. He obtained his doctorate in school psychology with an emphasis in counseling and interventions from the University of Memphis. Working at all levels of the profession (specialist, doctoral practitioner, and now a trainer) has given him a unique perspective and influenced his philosophy of school psychology. He regularly presents at local, state, regional, national, and international conferences. He has been the president of the Kansas Association of School Psychologists (KASP), editor of the KASP Newsletter, a committee member of KASP Futures, and a KASP National Certification in School Psychology (NCSP) committee member. He has been a member of the National Association of School Psychologists (NASP) since 1997 and has been a nationally certified school psychologist since 1997. He has also been an NASP program reviewer, an NCSP portfolio reviewer, and a member of Georgia Association of School Psychologists. Pamela A. Fenning, PhD, ABPP, is a professor and co-director of the school psychology program at Loyola University Chicago. She is a licensed clinical and school psychologist in Illinois and holds board certification in school psychology. Her research and clinical work focus on multitiered academic and behavioral interventions at the high school level, racial bias in exclusionary discipline and entry to the juvenile justice system, inequities in school discipline policy, evaluation of state-level discipline reform, and professional development of school personnel in creating more equitable and inclusive school environments as well as school-based supports of military youth. She has published widely in these areas. She is the immediate past-president of the Trainers of School Psychologists, the chair of the National Association of School Psychologists (NASP) Professional Positions Committee, and a member of the NASP [Graduate] Program Accreditation Board.  Child and Adolescent iii Psychopathology for School Psychology A Practical Approach Terry Diamanduros, PhD P. Dawn Tysinger, PhD, NCSP Jeffrey A. Tysinger, PhD, NCSP Pamela A. Fenning, PhD, ABPP Copyright © 2023 Springer Publishing Company, LLC iv All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750- 8400, fax 978-646-8600, [email protected] or at www.copyright.com. Springer Publishing Company, LLC 11 West 42nd Street, New York, NY 10036 www.springerpub.com connect.springerpub.com/ Acquisitions Editor: Rhonda Dearborn Compositor: S4Carlisle Publishing Services ISBN: 978-0-8261-3578-0 ebook ISBN: 978-0-8261-3587-2 DOI: 10.1891/9780826135872 SUPPLEMENTS: Instructor materials: A robust set of instructor resources designed to supplement this text is available. Qualifying instructors may request access by emailing [email protected]. Instructor Manual ISBN: 978-0-8261-3723-4 Instructor PowerPoints ISBN: 978-0-8261-3724-1 Instructor Test Bank ISBN: 978-0-8261-3722-7 22 23 24 25 26 / 5 4 3 2 1 The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Library of Congress Cataloging-in-Publication Data Names: Diamanduros, Terry, author. | Tysinger, P. Dawn, author. | Tysinger, Jeffrey A., author. | Fenning, Pamela, author. Title: Child and adolescent psychopathology for school psychology : a practical approach / Terry Diamanduros, P. Dawn Tysinger, Jeffrey A. Tysinger, Pamela A. Fenning. Identifi ers: LCCN 2021060484 (print) | LCCN 2021060485 (ebook) | ISBN 9780826135780 (cloth) | ISBN 9780826135872 (ebook) Subjects: LCSH: Child psychopathology–Textbooks. | Adolescent psychopathology–Textbooks. | School children–Mental health–Textbooks. | School psychology– Textbooks. Classifi cation: LCC RJ499.D497 2023 (print) | LCC RJ499 (ebook) | DDC 618.92/89–dc23/eng/20220211 LC record available at https://lccn.loc.gov/2021060484 LC ebook record available at https://lccn.loc.gov/2021060485 The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Contact [email protected] to receive discount rates on bulk purchases. Publisher’s Note: New and used products purchased from third- party sellers are not guaranteed for quality, authenticity, or access to any included digital components. Printed in the United States of America.  Contents v Preface Instructor Resources UNIT 1: ADDRESSING CHILD AND ADOLESCENT MENTAL HEALTH DISORDERS IN SCHOOLS 1. Child and Adolescent Mental Health Introduction Addressing Child and Adolescent Mental Health in the Schools: The Role of School Psychologists Identification of Mental Health Problems in Schools: Diagnostic and Statistical Manual of Mental Disorders Versus Individuals With Disabilities Education Improvement Act Concluding Remarks Summary Points UNIT 2: MENTAL HEALTH DISORDERS IN CHILDREN AND ADOLESCENTS: NEURODEVELOPMENTAL DISORDERS 2. Attention Deficit Hyperactivity Disorder Introduction Diagnostic Issues: DSM-5 and School-Based Services  Cultural Issues Related to Attention Deficit Hyperactivity Disorder in Youth Impact of Attention Deficit Hyperactivity Disorder on Social– Emotional and Behavioral Functioning in School and Home Environments Impact of Attention Deficit Hyperactivity Disorder on Learning in the Classroom Implications for School Psychologists Educational Supports School-Based Mental Health Interventions and Supports Summary Points 3. Intellectual Disabilities Introduction Diagnostic Issues: DSM-5 and IDEA Cultural Issues Related to Intellectual Disability in Youth Impact of Intellectual Disability on Social–Emotional and Behavioral Functioning in School and Home Environments Impact of Intellectual Disability on Learning in the Classroom Implications for School Psychologists Educational Supports School-Based Mental Health Interventions and Supports Summary Points 4. vi Autism Spectrum Disorder Introduction Diagnostic Issues Related to Autism Spectrum Disorder Cultural Issues Related to Autism Spectrum Disorder in Youth Impact of Autism Spectrum Disorder on Social–Emotional and Behavioral Functioning in School and Home Environments Impact of Autism Spectrum Disorder on Learning in the Classroom Implications for School Psychologists Educational Supports School-Based Mental Health Interventions and Supports Summary Points UNIT 3: MENTAL HEALTH DISORDERS IN CHILDREN AND ADOLESCENTS: DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDERS 5. Conduct Disorder Introduction Diagnostic Issues: DSM-5 and School-Based Services Cultural Issues Related to Conduct Disorder in Youth Impact of Conduct Disorder on Social–Emotional and Behavioral Functioning in School and Home Environments Impact of Conduct Disorder on Learning in the Classroom Implications for School Psychologists Educational Supports School-Based Mental Health Interventions and Supports Summary Points 6. Oppositional Defiant Disorder Introduction Diagnostic Issues: DSM-5 and School-Based Services Cultural Issues Related to Oppositional Defiant Disorder in Youth Impact of Oppositional Defiant Disorder on Social–Emotional and Behavioral Functioning in School and Home Environments Impact of Oppositional Defiant Disorder on Learning in the Classroom Implications for School Psychologists Educational Supports School-Based Mental Health Interventions and Supports Summary Points 7. Intermittent Explosive Disorder Introduction Diagnostic Issues: DSM-5 and School-Based Services Cultural Issues Related to Intermittent Explosive Disorder in Youth Impact of Intermittent Explosive Disorder on Social–Emotional and Behavioral Functioning in School and Home Environments  Impact of Intermittent Explosive Disorder on Learning in the Classroom Implications for School Psychologists Educational Supports School-Based Mental Health Interventions and Supports Summary Points UNIT 4: vii MENTAL HEALTH DISORDERS IN CHILDREN AND ADOLESCENTS: ANXIETY DISORDERS 8. Generalized Anxiety Disorder Introduction Diagnostic Issues: DSM-5 and School-Based Services Cultural Issues Related to Generalized Anxiety Disorder in Youth Impact of Generalized Anxiety Disorder on Social–Emotional and Behavioral Functioning in School and Home Environments Impact of Generalized Anxiety Disorder on Learning in the Classroom Implications for School Psychologists Educational Supports School-Based Mental Health Interventions and Supports Summary Points 9. Separation Anxiety Disorder Introduction Diagnostic Issues: DSM-5 and School-Based Services Cultural Issues Related to Separation Anxiety Disorder in Youth Impact of Separation Anxiety Disorder on Social–Emotional and Behavioral Functioning in School and Home Environments Impact of Separation Anxiety Disorder on Learning in the Classroom Implications for School Psychologists Educational Supports School-Based Mental Health Interventions and Supports Summary Points 10. Social Anxiety Disorder Introduction  Diagnostic Issues: DSM-5 and School-Based Services Cultural Issues Related to Social Anxiety Disorder in Youth Impact of Social Anxiety Disorder on Social–Emotional and Behavioral Functioning in School and Home Environments Impact of Social Anxiety Disorder on Learning in the Classroom Implications for School Psychologists Educational Supports School-Based Mental Health Interventions and Supports Summary Points 11. Selective Mutism Introduction Diagnostic Issues: DSM-5 and School-Based Services Cultural Issues Related to Selective Mutism in Youth Impact of Selective Mutism on Social–Emotional and Behavioral Functioning in School and Home Environments Impact of Selective Mutism on Learning in the Classroom Implications for School Psychologists Educational Supports School-Based Mental Health Interventions and Supports Summary Points UNIT 5: viii MENTAL HEALTH DISORDERS IN CHILDREN AND ADOLESCENTS: MOOD DISORDERS 12. Major Depressive Disorder Introduction Diagnostic Issues: DSM-5 and School-Based Services Cultural Issues Related to Major Depressive Disorder in Youth Impact of Major Depressive Disorder on Social–Emotional and Behavioral Functioning in School and Home Environments Impact of Major Depressive Disorder on Learning in the Classroom Implications for School Psychologists Educational Supports School-Based Mental Health Interventions and Supports Summary Points 13. Disruptive Mood Dysregulation Disorder Introduction Diagnostic Issues: DSM-5 and School-Based Services Cultural Issues Related to Disruptive Mood Dysregulation Disorder in Youth Impact of Disruptive Mood Dysregulation Disorder on Social– Emotional and Behavioral Functioning in School and Home Environments Impact of Disruptive Mood Dysregulation Disorder on Learning in the Classroom Implications for School Psychologists Educational Supports School-Based Mental Health Interventions and Supports Summary Points 14. Persistent Depressive Disorder Introduction Diagnostic Issues: DSM-5 and School-Based Services Cultural Issues Related to Persistent Depressive Disorder in Youth Impact of Persistent Depressive Disorder on Social–Emotional and Behavioral Functioning in School and Home Environments Impact of Persistent Depressive Disorder on Learning in the Classroom Implications for School Psychologists Educational Supports School-Based Mental Health Interventions and Supports Summary Points UNIT 6: MENTAL HEALTH DISORDERS IN CHILDREN AND ADOLESCENTS: OBSESSIVE-COMPULSIVE DISORDERS 15. Obsessive-Compulsive Disorder Introduction Diagnostic Issues Related to Obsessive-Compulsive Disorder  Cultural Issues Related to Obsessive-Compulsive Disorder in Youth Impact of Obsessive-Compulsive Disorder on Social–Emotional and Behavioral Functioning in School and Home Environments Impact of Obsessive-Compulsive Disorder on Learning in the Classroom Implications for School Psychologists Educational and Social–Emotional Supports School-Based Mental Health Interventions for Obsessive- Compulsive Disorder Summary Points 16. ix Hoarding Disorder Introduction Diagnostic Issues: DSM-5 and School-Based Services Cultural Issues Related to Hoarding in Youth Impact of Hoarding on Social–Emotional and Behavioral Functioning in School and Home Environments Impact of Hoarding on Learning in the Classroom Implications for School Psychologists Educational Supports School-Based Mental Health Interventions and Supports Summary Points UNIT 7: MENTAL HEALTH DISORDERS IN CHILDREN AND ADOLESCENTS: TRAUMA- AND STRESSOR-RELATED DISORDERS 17. Posttraumatic Stress Disorder Introduction Diagnostic Issues: PTSD and Developmental Trauma Disorder Cultural Issues Related to Posttraumatic Stress in Childhood Impact of Child Trauma on Social–Emotional and Behavioral Functioning in School and Home Environments Impact on Learning in the Classroom Implications for School Psychologists Educational and Social–Emotional Supports  School-Based Mental Health Interventions Summary Points 18. Reactive Attachment Disorder Introduction Diagnostic Issues Related to Reactive Attachment Disorder Cultural Issues Related to Reactive Attachment Disorder in Youth Impact of Reactive Attachment Disorder on Social–Emotional and Behavioral Functioning in School and Home Environments Impact of Reactive Attachment Disorder on Learning in the Classroom Implications for School Psychologists Educational and Social–Emotional Supports School-Based Mental Health Interventions and Supports Summary Points 19. Disinhibited Social Engagement Disorder Introduction Diagnostic Issues Related to Disinhibited Social Engagement Disorder Cultural Issues Related to Disinhibited Social Engagement Disorder in Youth Impact on Disinhibited Social Engagement Disorder on Social– Emotional and Behavioral Functioning in School and Home Environments Impact of Disinhibited Social Engagement Disorder on Learning in the Classroom Implications for School Psychologists Educational Supports School-Based Mental Health Interventions and Supports Summary Points Index  Preface xi x Child and Adolescent Psychopathology for School Psychology: A Practical Approach is designed as a textbook for school psychology graduate students enrolled in child and adolescent psychopathology courses. This textbook provides a comprehensive view of mental health disorders in children and adolescents that incorporates a school psychological approach in addressing issues related to diagnosis based on criteria of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) and educational disability determination under the federal legislation of the Individuals with Disabilities Education Improvement Act (IDEA) of 2004 (U.S. Department of Education, n.d.). It also examines culturally related issues associated with specific disorders and the social, emotional, and behavioral needs of youth with mental health conditions. Implications for school psychologists and ways in which they can have a pivotal role in helping schools meet the mental health and learning needs of children and adolescents are addressed. Furthermore, evidence- based educational and mental health supports and interventions applicable to schools are offered. In this preface, we provide information on (a) the overall goal of this textbook and our reasons for developing it, (b) tools created to support school psychology graduate students’ learning of the content covered in the chapters, (c) instructor resources, (d) the intended audience, and (e) content covered in the major sections of the textbook. OVERALL GOAL OF THE BOOK Our overall goal in writing Child and Adolescent Psychopathology for School Psychology: A Practical Approach was to create a textbook for school psychology graduate students that provides training about child and adolescent mental health disorders from the viewpoint of a school psychologist. As experienced graduate educators in school psychology, we have found it challenging to find a child and adolescent psychopathology textbook that gives consideration to a school psychological perspective in identifying mental health problems in children and adolescents. Most child and adolescent psychopathology textbooks are written from a clinical psychology perspective and do not focus on ways in which children’s and adolescents’ mental health and educational needs can be addressed in schools through the work of school psychologists. We wanted to create a textbook that was specifically designed for school psychology graduate students that addressed issues beyond DSM-5 criteria, focusing on how mental health conditions in youth can be addressed by the provision of school psychological services. We aimed to provide a comprehensive view of identifying mental health disorders in children and adolescents using DSM-5 diagnostic features and examining disability categories under IDEA that multidisciplinary teams in schools may consider when determining eligibility for special education services. By addressing both types of classification systems (DSM-5 and IDEA disability categories), school psychology graduate students gain knowledge of DSM-5 criteria and eligibility criteria of possible educational disabilities. We also sought to guide school psychology graduate students in considering cultural issues that may be related to specific mental health disorders and the impact that a disorder may have on the child’s or adolescent’s social–emotional and behavioral functioning in school and at home. Child and Adolescent Psychopathology for School Psychology: A Practical Approach further advances the knowledge of school psychology graduate students by examining how learning is affected by a child’s mental health struggles and how school psychologists can work with teachers to address the educational needs of students. Furthermore, it was our goal to guide future school psychologists in considering the multiple aspects of xii a child or adolescent’s functioning to help them better recognize and understand the social–emotional and behavioral needs of youth with specific mental health disorders and the potential roles that they, as future school psychologists, can have in providing school-based mental health services. It is our hope that school psychology graduate educators who teach child and adolescent psychopathology courses and their students will find the textbook to be an effective, yet practical approach in which mental health conditions in youth can be addressed from a school psychological perspective. LEARNING TOOLS Child and Adolescent Psychopathology for School Psychology: A Practical Approach includes several learning tools that will be helpful to school psychology graduate students as they progress through the chapters on various mental health disorders. The Quick Facts feature in each chapter highlights major points about a particular disorder such as diagnostic issues, cultural considerations, impact on social–emotional and behavioral functioning, learning difficulties that might be experienced by the child or adolescent with mental health conditions, implications for school psychologists, and types of educational and mental health supports that could be applied in a school setting. Each chapter covering a specific mental health disorder includes a case study that discusses diagnostic features and challenges that the child and family may encounter and possible ways in which the school may respond. In addition, each chapter has a Test Your Knowledge feature, which includes multiple-choice and true–false questions as well as discussion questions. We have also included a list of resources in each chapter that may be helpful to school psychology graduate students in their future work with students, parents, and school personnel. RESOURCES FOR INSTRUCTORS In our textbook, Child and Adolescent Psychopathology for School Psychology: A Practical Approach, we have provided resources that may be helpful for instructors. Within each chapter, learning objectives as well as a few test questions and discussion questions are provided. Each chapter also has a case study that can be an effective tool for instructors in helping students conceptualize a case and learn how educational and mental health needs may be addressed in the school. Ancillary materials are also provided for course instructors. These include an Instructor’s Manual, which offers (a) National Association of School Psychologists (NASP) domains (2020), (b) learning objectives, (c) chapter summary, (d) discussion questions with suggested main points that need to be covered in the response, and (e) useful resources to consider for each chapter. As an instructional tool, a PowerPoint presentation has been created for each chapter that highlights the main points covered. Instructors can easily add more content to the PowerPoints. In addition, a test bank of 10 multiple-choice questions covering material from each chapter is also included in the ancillary materials for instructors. INTENDED AUDIENCE The audience for Child and Adolescent Psychopathology for School Psychology: A Practical Approach is intended to be school psychology graduate students enrolled in a school psychology training program. We hope that school psychology graduate educators will find the book useful in helping graduate students in their programs to understand the differences between DSM-5 diagnostic and educational disability (i.e., IDEA) criteria and the ways in which mental health conditions can affect a child’s or adolescent’s functioning across social, emotional, behavioral, and learning domains. Examples of titles of graduate-level courses for which this book is intended include the following: Child psychopathology, Child and adolescent psychopathology, Psychopathology of childhood and adolescence, Developmental psychopathology in educational settings, Developmental psychopathology of childhood, Advanced child and adolescent psychopathology, and xiii Child and adolescent abnormal psychology. ORGANIZATION OF THE TEXTBOOK CONTENT The content of the book is organized into seven parts. In the first part of the book, mental health disorders in youth and the need for school-based mental health services are addressed. The remaining parts of the book include Chapters 2 through 19, which focus on specific categories of mental health disorders. Each chapter is organized into the following sections: Introduction, Diagnostic Issues, Cultural Issues, Impact on Social–Emotional and Behavioral Functioning in School and Home Environments, Impact on Learning in the Classroom, Implications for School Psychologists, Educational Supports, School-Based Mental Health Interventions and Supports, Case Study: Background and Discussion, and Chapter Resources. Unit I: Addressing Child and Adolescent Mental Health Disorders in Schools The first part of the book includes a chapter that provides the audience with an introduction to child and adolescent mental health. The first chapter includes information on the prevalence of mental health disorders in youth; stress-related challenges that impact mental health such as poverty, racial stress, social media, and cyberbullying; risk factors; and protective factors. The role of school psychologists in addressing mental health conditions in youth at school and the importance of school-based mental health services are discussed. The chapter also examines the identification of mental health problems in schools and compares the DSM-5 diagnosis of mental health disorders and educational disabilities classified under IDEA. Unit 2: Mental Health Disorders in Children and Adolescents: Neurodevelopmental Disorders Chapters 2 through 4 focus on neurodevelopmental disorders. Specific disorders covered in this section include attention deficit hyperactivity disorder (ADHD), intellectual disabilities, and autism spectrum disorder. Unit 3: Mental Health Disorders in Children and Adolescents: Disruptive, Impulse-Control, and Conduct Disorders The third part of the textbook includes Chapters 5 through 7, which examine conduct disorder, oppositional defiant disorder, and intermittent explosive disorder. Unit 4: Mental Health Disorders in Children and Adolescents: Anxiety Disorders Chapters 8 through 11 focus on anxiety disorders in youth. Specific disorders examined in this part of the textbook include generalized anxiety disorder, separation anxiety, social anxiety, and selective mutism. Unit 5: Mental Health Disorders in Children and xiv Adolescents: Mood Disorders Part 5 of the textbook includes chapters that examine three mood disorders in youth: major depressive disorder, disruptive mood dysregulation disorder, and persistent depressive disorder (formerly referred to as dysthymia). Unit 6: Mental Health Disorders in Children and Adolescents: Obsessive-Compulsive Disorders This part of the textbook includes Chapters 15 and 16, which focus on obsessive-compulsive disorder (OCD) and hoarding disorder. Unit 7: Mental Health Disorders in Children and Adolescents: Trauma- and Stressor-Related Disorders The content in Part 7 of the textbook focuses on trauma- and stressor-related disorders. Chapters 17 through 19 examine posttraumatic stress disorder (PTSD), reactive attachment disorder (RAD), and disinhibited social engagement disorder (DSED). Terry Diamanduros P. Dawn Tysinger Jeffrey A. Tysinger Pamela A. Fenning REFERENCES American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 National Association of School Psychologists. (2020). The professional standards of the National Association of School Psychologists. Author. U.S. Department of Education. (n.d.). Individuals with Disabilities Education Improvement Act. https://sites.ed.gov/idea/  Instructor Resources xv Child and Adolescent Psychopathology for School Psychology includes quality resources for the instructor. Faculty who have adopted the text may gain access to these resources by emailing [email protected]. Instructor resources include: Instructor’s Manual: ○ NASP (2020) Domains ○ Learning Objectives ○ Chapter Summaries ○ Discussion Questions ○ Useful Resources for Instructors Test Bank ○ Multiple-Choice Questions With Answers/Rationales Chapter-Based PowerPoint Presentations xvi  UNIT 1 1 ADDRESSING CHILD AND ADOLESCENT MENTAL HEALTH DISORDERS IN SCHOOLS 2  CHAPTER 1 3 Child and Adolescent Mental Health LEARNING OBJECTIVES Gain an understanding of the current status of child and adolescent mental health. Describe current stress-related events that may impact a child’s mental health. Discuss the need for school-based mental health services. Discuss the role of school psychologists in the provision of mental health services. Compare the use of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) in diagnosing mental health disorders in medical/clinical settings and the Individuals with Disabilities Education Improvement Act (IDEA) in identifying disability categories in schools. INTRODUCTION Mental Health in Children and Adolescents Social–emotional development provides a child with the skills needed to interact socially with others and to express their feelings in appropriate ways. Children who are mentally healthy have effective coping skills, view themselves positively, interact appropriately in social situations, and are able to regulate their emotions. However, some children struggle in managing their emotions and behaviors and may become overwhelmed in social situations. They may begin to exhibit behavioral outbursts, or “meltdowns,” because they cannot manage their emotions and begin to socially isolate themselves because it is too overwhelming to be around others. In the United States, concern about the mental health status of infants, children, and adolescents has been growing for over 20 years and was even considered a public health crisis two decades ago (U.S. Department of Health and Human Services, 2000). Specific concerns included inaccurate diagnoses, limited availability of research-based treatments and services, limited access to available services, and unidentified/untreated mental health problems in youth. In response to the need for a call to action, the U.S. Surgeon General held a conference in 2000 titled “Children’s Mental Health: Developing a National Action Agenda” (U.S. Department of Health and Human Services, 2000). Although that conference took place over 20 years ago, the same concerns about children’s mental health persist today. According to the American Psychological Association (n.d.), it is estimated that approximately 15 million children and adolescents have diagnosable mental health disorders. Although this number is alarming, it is equally, if not more concerning that only 7% of children who are in need of psychological services actually receive therapeutic services from a mental health provider. Scholars have examined the impact of adverse childhood experiences (ACEs) on a child’s mental and physical health. This type of experience is one that is stressful and potentially traumatic and includes events such as abuse or living in environments that may be emotionally or physically harmful (Boullier & Blair, 2018). It is estimated that almost 35 million children in the United States have experienced at least one ACE (Child and Adolescent Health Measurement Initiative, 2013). Children in our country today face several psychosocial challenges that can perhaps be viewed as ACEs that affect their lives on a daily basis. These stress-related challenges include poverty, racial stress, school violence, and social media and cyberbullying. It is estimated that approximately 15 million children and 4 adolescents have diagnosable mental health disorders. Poverty The Children’s Defense Fund State of America’s Children 2021 report indicated that children in the United States are the “poorest age group in America, with children of color and young children suffering the highest poverty rates” (2021, p. 10). The report found that one in seven children, or 10.5 million children, live in poverty. The findings of the report also indicated that approximately 71% of children living in poverty were children of color and almost one in six children under the age of 6 were poor, with approximately half of the children living in extreme poverty (Children’s Defense Fund, 2021). Scholars have reported that children living in poverty experience difficulties in self-regulation (regulating one’s emotions and behaviors), executive functioning (cognitive skills such as working memory and planning), impulsivity, inattention, poor peer relationships, and defiance (American Academy of Pediatrics [AAP], 2016). These types of problems render a child vulnerable to the onset of mental health disorders such as attention deficit hyperactivity disorder (ADHD). The AAP (2016) reports that stress associated with poverty, such as inadequate food, energy, housing, and transportation, can influence parenting. Poverty is also associated with poor developmental and psychosocial outcomes (AAP, 2016). Racial Stress Scholars have examined the impact of racism on the social– emotional well-being of minority youth. Evidence in the literature indicates that continued racial discrimination against Black adolescents results in increased symptoms of anxiety, depression, and trauma (Priest et al., 2013). Graham and colleagues (2017) have noted that boys of color may experience at least five ACEs prior to their 18th birthday. Other scholars have found that, on average, Black adolescents experience race-related acts five times per day (English et al., 2020). Examples of race-related acts included being teased because of one’s race or being told an offensive joke. Community violence against youth of color has been found to be associated with symptoms of posttraumatic stress (Deane et al., 2020). The social–emotional well-being of youth of color can be negatively influenced by community violence (Lanier et al., 2017), and some scholars contend that the impact of this violence may be intensified by racial stress (Saleem et al., 2020). Over time, race-related acts can have a cumulative effect on a child or adolescent that makes them sensitive to situations in which a threat might be experienced (National Child Traumatic Stress Network [NCTSN], Justice Consortium, Schools Committee, and Culture Consortium, 2017). Racial stress may be exhibited as anxiety, depression, and hypervigilance as well as maladaptive behaviors such as aggression (NCTSN, Justice Consortium, Schools Committee, and Culture Consortium, 2017). According to some scholars, race-related events can be perceived as chronic violence that can make a young child or adolescent of color vulnerable emotionally and at risk for posttraumatic stress disorder (PTSD; Tynes et al., 2019). It is important to keep in mind that media coverage of high-profile cases involving violent acts against an ethnic group may be traumatic triggers for a child (Proctor et al., 2020). School Violence School violence, unfortunately, is not a new occurrence. In fact, scholars consider it a public health concern (Janosz et al., 2008). The Centers for Disease Control and Prevention’s (CDC) Youth Risk Behavior Survey (2019) reports that one in five high school students acknowledges being bullied at school, and about 8% of high school students have been in a fight at school. A study conducted by Flannery et al. (2004) examined exposure of violence to children in grades 3 through 12. Approximately 56% of children had witnessed another child being beaten up, and 87% watched someone else being slapped or hit (Flannery et al., 2004). The study also revealed that about 44% of students had been threatened when they were at school. The authors found that students with exposure to high 5 levels of violence at school tended to experience more clinical levels of trauma than students exposed to low levels of violence at school (Flannery et al., 2004). Other scholars have found that school violence victimization was positively linked to depressive symptoms (Estévez et al., 2005) and observing violence at school was a better predictor of subsequent externalizing behaviors than actual victimization (Janosz et al., 2008). Based on the results of the CDC’s Youth Risk Behavior Survey (2019), more than 7% of high school students surveyed indicated that they had been threatened or harmed with a weapon at school and approximately 9% of students had not attended school because they felt that they would not be safe while at school. Mental health outcomes of youth exposed to mass shootings include depression, anxiety, traumatic stress, suicide, and substance abuse (Cimolai et al., 2021). One concerning line of research proposes that the internet could provide a support group for male shooters if they decide to shoot peers at their school (Markward et al., 2001). Social Media and Cyberbullying Although social media may serve as a way for people to connect and maintain friendships, its use as a tool to cyberbully others can have a concerning impact on the social–emotional and behavioral well-being of youths. For example, Richards and colleagues (2015) reviewed studies to examine the impact of cyberbullying on the health of children and adolescents. The findings revealed the greatest impact was on their mental health. Specifically, the findings indicated an association between social media use and self-esteem and body image. The authors emphasize that cause and effect is difficult to determine and suggest that more research is needed. Other studies have found that cyberbullying was associated with an increase in depression. Some scholars have conducted longitudinal studies to examine the relationship between cyberbullying and symptoms of depression and anxiety. Rose and Tynes (2015) followed a sample of youth between grades 6 and 12. The study was done over a 3- year period. The results of the study revealed a reciprocal relationship between cyber-victimization and depression and cyber- victimization and anxiety (Rose & Tynes, 2015). Overall, these findings revealed that cyberbullying may have adverse impacts on the mental well-being of children and adolescents. Prevalence As noted earlier, concern has been expressed by professionals about the number of youth with mental health problems. The CDC (n.d.-a) reports data from the National Survey of Student Health on the prevalence of mental health disorders. According to the CDC (n.d.-b), approximately 13% to 20% (one out of five) have a mental health condition. Among externalizing behaviors, ADHD occurred most frequently, whereas anxiety disorders occurred more often than other internalizing disorders. Externalizing Disorders: Attention Deficit Hyperactivity Disorder and Behavioral Problems ADHD occurs more frequently than other disorders. Among children between the ages of two and 17, approximately 9.4%, or 6.1 million, are diagnosed with ADHD (CDC, n.d.-a). With regard to emotional– behavioral types of referrals, most school psychologists are likely to get more referrals regarding issues related to ADHD than any other disorder. Among children between three and 17, disruptive behaviors are diagnosed in about 7.4% of children in this age range, which is about 4.5 million children (CDC, n.d.-a). It should be noted that boys are more likely to be diagnosed with ADHD than are girls (CDC, n.d.- b). In addition, behavior problems are reportedly more common in children between the ages of six and 11 compared to either younger or older children (CDC, n.d.-a). Internalizing Disorders: Anxiety and Depression Among internalizing disorders, anxiety disorders occur most frequently in the general population. Based on the data reported by the CDC (n.d.-a), anxiety disorders occur in 7.1% of children between the ages of three and seventeen, or 4.4 million. It occurs more frequently than depression, which is diagnosed in 3.2% of children and adolescents between the ages of three and 17, or 1.9 million children. It should be noted that anxiety and depression become more common with increased age. Comorbidity 6 When disorders coexist with each other, this is referred to as comorbidity, which is associated with worse outcomes. According to the CDC (n.d.-a), about three in four children (73.8%) with depression between the ages of three and 17 will most likely be diagnosed with anxiety. Also, about one in two children (47.2%) with depression between the ages of three and 17 will be diagnosed with a disruptive behavior disorder. Among children ages three and 17 who are diagnosed with anxiety, more than one in three (37.9%) will also have behavior problems and about one in three (32.3%) will also be diagnosed with depression. With regard to comorbidity among children ages three to 17 with behavior problems, more than one in three (36.6%) will also be diagnosed with an anxiety disorder and approximately one in five (20.3%) will also be diagnosed with depression. Risk Factors and Protective Factors Vulnerability to the effects of a mental health disorder is influenced by the presence of risk and protective factors. It is helpful for the school psychologist to have a thorough developmental history and background information on the student to determine whether there are factors that make the child more at risk to the influence of mental health problems or whether there are factors in the background that protect them. According to a report by the U.S. Surgeon General (U.S. Public Health Service et al., 2009), risk factors are linked with a higher chance of developing some negative outcome. For example, risk factors may be biological, resulting from genetics, or familial, such as having a family member with a mental illness. Common risk factors for developing mental health problems include low self- esteem, negative family home environment, stressful events, peer rejection, etc. (U.S. Public Health Service et al., 2009). On the other hand, there are factors known as protective factors that help protect the child from the adverse effects of mental illness. Examples of protective factors include having good coping skills, high self- esteem, supportive relationships, and so on (U.S. Public Health Service et al., 2009). Common risk factors for developing mental health problems include low self-esteem, a negative home environment, stressful events, and peer rejection. ADDRESSING CHILD AND ADOLESCENT MENTAL HEALTH IN THE SCHOOLS: THE ROLE OF SCHOOL PSYCHOLOGISTS The Need to Address Child and Adolescent Mental Health in the Schools In 2004, the Committee on School Health of the American Pediatrics Association published a policy statement on the need for school- based mental health services. The statement noted that, at that time, more than 20% of youth experienced mental health problems. The statement acknowledged the responsibility of the healthcare profession to inform interdisciplinary professionals who work with children and adolescents about the adverse impact that mental health problems may have on children and the need for school- based mental health services. According to the policy, the need for mental health services is evident in the rising number of children struggling with mental health conditions who are seen by pediatricians. In a 20-year span, the percentage of children with psychiatric problems seen in pediatric clinics increased from 7% to 19% (Kelleher et al., 2000, as cited in American Pediatric Association Committee on School Health, 2004). School violence, bullying, and suicides among youth were commonly reported events at that time. Concern was expressed regarding the outcomes of untreated mental health disorders among the young such as increased school dropout rates, juvenile incarceration rates, and family dysfunction. With regard to the types of mental health disorders experienced by youths, it was reported that 13% experienced anxiety, 6.2% had a mood disorder, 10.3% had disruptive behaviors, and 2% experienced substance use (American Pediatric Association Committee on School Health, 2004). The policy also noted barriers that are associated with the provision of mental health services in settings outside the school. These barriers 7 included financial constraints for services not covered by insurance, transportation issues in getting to facilities, and the stigma associated with mental health problems. Barriers such as these can lead to premature termination of therapeutic services. On the other hand, benefits of school-based mental health programs noted in the policy included identifying mental health problems early, which can lead to children and adolescents obtaining therapeutic services. It is interesting to note that the policy statement strongly advocated for collaboration between school mental health providers and the pediatric community and endorsed the use of a system of service support within schools. Others have also recognized the need for school-based mental health services to address the emotional and behavioral needs in children and adolescents. Davis and colleagues (2006) point out that much attention has been given to documenting prevalence rates of mental health problems in this population, yet in the literature, less attention has been given to provision of school-based mental health services. Davis et al. also note that the problem of untreated mental health problems in youth had, however, been acknowledged at the federal level by the President’s New Freedom Commission on Mental Health (2003), which acknowledged that services could be provided in schools to address the mental health needs of youth. Perfect and Morris (2011) note prevalence rates indicate that as many as 20% of youth experience emotional and behavioral problems, including anxiety, obsessive-compulsive disorder, and disruptive behaviors. The authors contend that untreated mental health conditions can lead to school-related problems such as absenteeism, discipline problems, poor grades, grade retention, and juvenile delinquency (Perfect & Morris, 2011). Perfect and Morris (2011) emphasize the need for the provision of school-based mental health services and encourage support for school psychologists as providers of mental health services in schools. Similarly, the National Association of School Psychologists (NASP; 2015) points out the connection between emotional and behavioral wellness and positive gains in achievement and graduation rates, safe school environments, reduced disciplinary actions, and prevention of risk- taking behaviors. In addition, these factors are important to the future lives of students in regard to interpersonal relationships, higher salaries, higher employment stability, and decreased likelihood of being involved in criminal acts (NASP, 2015).  Although these studies support the provision of school-based mental health services, one must also examine the results of studies investigating the effectiveness of such services. Salerno (2016) reviewed research studies investigating mental health awareness interventions that were targeted to improve emotional and behavioral outcomes in K-12 students in the United States. The findings of the study revealed that there was improvement in knowledge about mental health in all studies and most studies revealed improvement in attitudes toward mental health and help-seeking behaviors. The authors concluded improvement existed in regard to mental health, but more research is needed because there were methodological problems in some of the research studies reviewed. O’Connor et al. (2018) also conducted a systematic review of studies that investigated the effectiveness of school-based mental health services. Their analysis revealed three themes of effectiveness related to school-based mental health interventions that include help- seeking and coping, social–emotional well-being, and psychoeducational effectiveness. Overall, the authors concluded that the findings were promising, but more robust research is needed. National Association of School Psychologists Practice Model and School Psychologists as Mental Health Providers School psychologists are in a unique position to advocate for provision of mental health services in the school and to deliver school-based mental health services. The role of school psychologists as mental health providers is endorsed by NASP (2020) as evident in its Model for Comprehensive and Integrative School Psychological Services, which is often referred to as the NASP Practice Model (NASP, 2021). The NASP endorses the role of school psychologists as mental health providers in schools. The model (NASP, 2020) consists of 10 domains: Domain 1: Data- Based Decision-Making; Domain 2: Consultation and Collaboration; Domain 3: Academic Interventions and Instructional Supports; 8 Domain 4: Mental and Behavioral Health Services and Interventions; Domain 5: School-Wide Practices to Promote Learning; Domain 6: Services to Promote Safe and Supportive Schools; Domain 7: Family, School, and Community Collaboration; Domain 8: Equitable Practices for Diverse Student Populations; Domain 9: Research and Evidence-Based Practices; and Domain 10: Legal, Ethical, and Professional Practice. Domain 4 of the NASP Practice Model, Mental and Behavioral Health Services and Interventions (NASP, 2020), acknowledges the unique training preparation of school psychologists, their knowledge of factors that influence a child’s mental health and behavior, and their understanding of supports needed. NASP encourages school psychologists in their role as mental health providers in the school and in their collaborative work with other school professionals to evaluate student need. NASP states: School psychologists understand the biological, cultural, developmental, and social influences on mental and behavioral  health; behavioral and emotional impacts on learning; and evidence-based strategies to promote social-emotional functioning. School psychologists, in collaboration with others, design, implement, and evaluate services that promote resilience and positive behavior, support socialization and adaptive skills, and enhance mental and behavioral health. (2020, p. 5) Moreover, comprehensive mental health services should be suitable for the learning environment. School psychologists understand how children’s social–emotional and behavioral well- being, learning, and family lives combine to affect behavior in the classroom, as well as how teaching that occurs in the classroom and the context of the school all interact together to guide children’s and adolescents’ development and well-being (NASP, 2021). In providing comprehensive school-based mental health services, there are specific roles that school psychologists can have to ensure the social–emotional and behavioral well-being of the children with whom they work. NASP (2021) has identified school psychologists as being leaders in the implementation of Multi-Tiered Systems of Support (MTSS) in schools. MTSS typically consist of three tiers that are used to deliver supports and services of increasing intensity to meet the needs of students. The first tier provides universal social– emotional wellness and behavioral supports to all students. The second tier provides services that are targeted for students identified as needing additional social–emotional and/or behavioral services beyond those provided in Tier 1 that could be provided in a small group. The third tier provides more intensive mental health supports and interventions to individual students (NASP, 2016). Through the use of a framework, such as MTSS, that provides academic, social– emotional, and behavioral supports, children’s mental health needs can be identified and addressed before they fully manifest (as in the case of universal prevention), worsen, or become long-lasting. MTSS can also provide services that are data driven and increasingly intensive for individual children (NASP, 2021). NASP (2021) has proposed a continuum of comprehensive school-based mental and behavioral services that consists of the following levels: (a) universal wellness promotion and prevention services such as social–emotional learning programs and universal screening for all students, (b) early identification of and support for mental and behavioral health concerns which could include services such as trauma-informed services, (c) targeted school mental and behavioral interventions such as group counseling and functional behavioral assessments, (d) intensive school interventions such as direct therapeutic interventions for individual students, and (e) intensive community services such as psychiatric services or family counseling. NASP (2016) has aligned this comprehensive school-based mental health model with federal legislation, the Every Student Succeeds Act (ESSA), which recognizes the importance of comprehensive and integrative mental and behavioral health services. ESSA acknowledges school psychologists are qualified mental health professionals and specialized instructional support personnel who are instrumental in (a) school and district assessment and accountability, (b) provision of supports that are targeted toward school improvement, (c) efforts to enhance school climate and school safety, and (d) ensuring access to high-quality comprehensive learning and mental-health–related supports (Every Student Succeeds Act, 2015). NASP (2016) contends that, in addition to providing direct services to children and adolescents, school psychologists can be instrumental in (a) establishing and delivering system-wide prevention supports delivered in MTSS; (b) understanding and interpreting data for program- planning purposes; (c) creating and monitoring program services; (d) consulting with professionals at the system-wide, classroom, and individual 9 case levels; (e) creating crisis prevention and response protocols; as well as (f) planning and coordinating services with community providers (NASP, 2016). Moreover, NASP (2016) contends that school psychologists can effectively support decision- making across levels that will lead to improved MTSS services. The framework for the comprehensive school-based mental health services proposed by NASP (2021) includes a continuum of school and community services. Community services that some children may need may go beyond the capability of the school. Hence, community resources and support may become involved in the tiered system at the point when the intensity of the support increases. Integrating both school and community services requires much planning and coordination between school and community professionals. School psychologists could be involved in these efforts and effectively guide them by establishing partnerships with community sources such as mental health clinics or agencies that can provide more intensive services. In order to reduce an overlap or redundancy in services and to avoid creating stress for the family, clear communication between the school and community agency regarding the contribution of each group is essential. Each group must understand what its role will be in this partnership. As part of this partnership, school psychologists would play a pivotal role as a liaison between the school and community mental health providers (NASP, 2021). IDENTIFICATION OF MENTAL HEALTH PROBLEMS IN SCHOOLS: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS VERSUS INDIVIDUALS WITH DISABILITIES EDUCATION IMPROVEMENT ACT As mental health providers in schools, it is important for school psychologists to understand the classification system used by the community resources or agencies providing more intensive mental health services as well as the classification system used in the schools to identify a child as having a disability. Knowledge of Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM- 5; American Psychiatric Association, 2013) disorders provides school psychologists with an understanding of symptoms associated with a particular disorder and how symptoms may manifest in the classroom and impact the child or adolescent in the school setting. Differences in the medical and educational models are described in the next section. Medical Model: The Use of the DSM-5 Classification In medical or clinical settings, such as a child psychiatric outpatient clinic or a community-based mental health agency, mental health disorders are diagnosed using the DSM-5 (American Psychiatric Association, 2013). The first version of the DSM was published in 1844 as a “statistical classification of institutionalized mental patients” (American Psychiatric Association, 2013, p. 6). Its purpose was to enhance communication about the various types of clients served in hospital settings. As noted by the American Psychiatric Association (2013), the DSM underwent major revisions to evolve into a system that allowed psychiatrists, clinical psychologists, and other mental health professions to use a common language to describe the primary features of a mental disorder. In the current edition, DSM-5 (American Psychiatric Association, 2013), diagnostic criteria are presented and based on these, the mental health professional determines whether diagnostic criteria are met for a particular disorder. The DSM-5 indicates that it is designed to help guide medical and clinical practitioners in decisions regarding treatment and management of disorders. Within the DSM-5, disorders are classified by major groups that share a common characteristic. For example, neurodevelopmental disorders, such as an intellectual disability, ADHD, or autism spectrum disorder (ASD), all have a neurodevelopmental basis. There were major revisions from the previous version that are described in the manual (American Psychiatric Association, 2013). (For those who would like more information about these changes, please see American Psychiatric Association, 2013.) In the medical or clinical setting, a child or adolescent may be referred to a clinical or medical professional who evaluates the child to determine whether a mental disorder is present. Although comprehensive psychiatric or psychological evaluations may differ, they share some common elements. During this evaluation, 10 the practitioner will ask the parent and child (if developmentally appropriate) to describe the symptoms or behaviors that the child or adolescent is experiencing (John Hopkins, n.d.). Questions will attempt to ascertain when the behavior began, the duration of the behavior, how often it occurs, the types of conditions in which it occurs, and so on. The evaluation also attempts to determine the effect that the behaviors have had on the child (John Hopkins, n.d.). A criterion for many disorders within the DSM-5 is whether the symptoms have had a significant impact on the child’s or adolescent’s functioning. For example, a medical or clinical professional evaluating a child for suspected ADHD will ask questions that are related to symptoms of inattentiveness and hyperactivity/impulsivity and how the child’s behavior has affected school functioning, such as whether there are indications that the child has a difficulty time staying seated, listening to the teacher, organizing material, and so forth. Information is gathered regarding whether these types of behaviors have impacted the child’s functioning, such as a decline in grades or disciplinary action for disruptive behaviors. There may be other components to the evaluation depending on the professional conducting the evaluation. For example, a licensed clinical psychologist may also do a psychological assessment using norm-referenced standardized tests, whereas a psychiatrist, who is a medical doctor, may assess the need for medication to manage the presenting symptoms. Following the evaluation, the clinical or medical professional will determine whether the child or adolescent meets the criteria for a DSM-5 diagnosis. Based on all of the information gathered during the evaluation, a treatment plan will be developed if applicable. Educational Model: The Use of the IDEA Disability Classification In school, the classification of disabilities is based on the Individuals with Disabilities Education Improvement Act (IDEA) of 2004. This federal legislation originated from the Education for All Handicapped Children Act (Public Law 94-142), which stipulated that students with disabilities have the right to a free, appropriate public education (FAPE; Salvia et al., 2016). This law also stipulated that students with disabilities must be educated in the least restrictive environment possible, have an Individual Education Program (IEP), and be assessed with instruments and practices that are fair and unbiased. It also indicates that parents of students with disabilities have the right to inspect their child’s school record and to challenge changes in the child’s placement. In 1986, amendments were made to the law to ensure that the law extended to preschoolers with disabilities and that every school district “conduct a multidisciplinary assessment and develop an individualized family service plan for every preschooler with a disability” (Salvia et al., 2016, p. 26). Four years later, the law was reauthorized in 1990 and became known as IDEA (U.S. Department of Education, n.d.). IDEA was reauthorized again in 1997 and in 2004. IDEA of 2004 includes 13 disability categories. These are Autism, Deaf-Blindness, Developmental Delay, Emotional Disturbance, Hearing Impairment, Intellectual Disability, Multiple Disabilities, Orthopedic Impairment, Other Health Impairment, Specific Learning Disability, Speech–Language Impairment, Traumatic Brain Injury, and Visual Impairment (U.S. Department of Education, n.d.). Each of the 13 disability categories has a set of eligibility criteria that must be met. Teachers make many of the referrals for an evaluation, although parents may request an evaluation. Prior to getting a referral, students will have received supports or interventions to address any social–emotional, behavioral, or learning problems that were evident in the classroom. Students who fail to respond to these supports or interventions may be referred for an evaluation to determine eligibility for special education services. Once parental consent is obtained, hearing and vision tests are conducted by the school nurse. The school psychologists and other members of the multidisciplinary team will have 60 days to conduct an evaluation (U.S. Department of Education, n.d.). Once the evaluation is completed, a multidisciplinary team reviews all of the assessment data collected from multiple sources and determines whether the child is considered a student with a disability under IDEA. To be determined to be a student with a disability, eligibility criteria for one of the 13 disability categories must be met and a need demonstrated for special education services and/or related services for the child to be successful in the classroom (Salvia et al., 2016). Hence, the child’s disability is found to have an adverse impact on the child’s classroom performance. If a child is found to be eligible for special education services, the team has 30 days to develop an IEP, which is a legal written plan that identifies the specific special education services the child will receive (Salvia et al., 2016). If the multidisciplinary team determines that the child is not in 11 need of special education services, consideration may be given to developing a 504 plan, which determines accommodations needed for the child to succeed. This plan is provided through Section 504 of the Rehabilitation Act of 1973, which is civil rights legislation. It provides students with any type of disability equal access to services if their disability limits an area of daily life functioning. CONCLUDING REMARKS As future school psychologists, the services that you provide to the school will play a major role in the decisions made about the children’s education. These decisions can influence their time spent in the educational system and affect their future career/vocational choices. SUMMARY POINTS The prevalence of mental health disorders in children and adolescents is high. School-based mental health services are needed to address the social–emotional and behavioral needs of youth. Domain 4 of the NASP Practice Model applies to the role of school psychologists in regard to the provision of school-based mental health services. While IDEA classification of disabilities is used in schools to identify children in need of special education services, the DSM-5 classification of mental health disorders is used to make a medical diagnosis.  TEST YOUR KNOWLEDGE 12 1. Which of the following domains of the NASP Practice Model supports the role of school psychologists as mental health providers? a. Domain 2 b. Domain 3 c. Domain 4 d. Domain 5 2. Protective factors help protect, or decrease the likelihood of, the child developing a mental health condition. a. True b. False 3. The DSM-5 is the classification system used to identify disability categories for special education services. a. True b. False 4. Common risk factors for developing mental health problems include low self-esteem, a negative home environment, stressful events, and peer rejection. a. True b. False 5. Which of the following disorders is the most common among children and adolescents? a. ADHD b. Anxiety disorders c. Depressive disorder d. Disruptive behavior problems Answers: (1) c, (2) a, (3) b, (4) a, (5) a. DISCUSSION QUESTIONS 1. Describe the differences between the medical model used to classify disorders with the DSM-5 and the education model, which uses IDEA disability categories. 2. Identify three risk factors and three protective factors that are associated with mental health problems. 3. Discuss how racial stress can impact a child’s mental health. 4. Discuss the need for school-based mental health services. 5. Discuss the role of school psychologists as providers of mental health services in schools.  CHAPTER RESOURCES National Association of School Psychologists Comprehensive School-Based Mental and Behavioral Health Services and School Psychologists: www.nasponline.org/resources-and- publications/resources-and-podcasts/mental-health/school- psychology-and-mental-health/comprehensive-school-based- mental-and-behavioral-health-services-and-school-psychologists National Association of School Psychologists Practice Model: Improving Outcomes for Students and Schools: www.nasponline.org/standards-and-certification/nasp-practice- model National Association of School Psychologists Position Statement: Ensuring High-Quality, Comprehensive, and Integrated Student Supports: http://www.nasponline.org/research-and- policy/policy-priorities/position-statements National Association of School Psychologists The Professional Standards of the National Association of School Psychologists: www.nasponline.org/standards-and-certification/nasp-2020- professional-standards-adopted REFERENCES 15 14 13 American Academy of Pediatrics Council on Community Pediatrics. (2016). Poverty and child health in the United States. Pediatrics, 137(4), e20160339. https://doi.org/10.1542/peds.2016-0339 American Pediatric Association Committee on School Health. (2004). School-based mental health services. Pediatrics, 113(6), 1839–1845. https://doi.org/10.1542/peds.113.6.1839 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 American Psychological Association. (n.d.). Children’s mental health. https://www.apa.org/pi/families/children-mental-health Boullier, M., & Blair, M. (2018). Adverse childhood experiences. Paediatrics and Child Health, 28(3), 132–137. https://doi.org/10.1016/j.paed.2017.12.008 Centers for Disease Control and Prevention. (n.d.-a). Data and statistics on children’s mental health. https://www.cdc.gov/childrensmentalhealth/data.html Centers for Disease Control and Prevention. (n.d.-b). KeyFindings: Children’s mental health report. https://www.cdc.gov/childrensmentalhealth/features/kf-childrens-mental-health- report.html Centers for Disease Control and Prevention. (2019). Youth risk behavior survey. https://www.cdc.gov/violenceprevention/youthviolence/schoolviolence/fastfact.html Child and Adolescent Health Measurement Initiative. (2013). Overview of adverse child and family experiences among US children. Data Resource Center, supported by Cooperative Agreement 1-U59-MC06980-01 from the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). https://www.childhealthdata.org. Revised 5/10/2013 Children’s Defense Fund. (2021). State of America’s children 2021. https://www.childrensdefense.org/wp-content/uploads/2021/04/The-State-of-Americas- Children-2021.pdf Cimolai, V., Schmitz, J., & Sood, A. B. (2021). Effects of mass shootings on the mental health of children and adolescents. Current Psychiatry Report, 23, 12. https://doi.org/10.1007/s11920-021-01222-2 Davis, A. S., Kruczek, T., & McIntosh, D. E. (2006). Understanding and treating psychopathology in schools: Introduction to the special issue. Psychology in the Schools, 43(4), 413–417. https://doi.org/10.1002/pits.20155 Deane, K., Richards, M., & Santiago, C. D. (2020). Violence exposure, posttraumatic stress, and affect variability among African American youth: A time sampling approach. Development and Psychopathology, 33(3), 1085–1096. https://doi.org/10.1017/S095457942000036X English, D., Lambert, S. F., Tynes, B. M., Bowleg, L., Zea, M. C., & Howard, L. C. (2020). Daily multidimensional racial discrimination among Black U.S. American adolescents. Journal of Applied Developmental Psychology, 66. https://doi.org/10.1016/j.appdev.2019.101068 Estévez, E., Musitu, G., & Herrero, J. (2005). The infl uence of violent behavior and victimization at school on psychological distress: The role of parents and teachers. Adolescence, 40(157), 183–196. PMID: 15861625. Every Student Succeeds Act. (2015). Public law 114-95. Flannery, D. J., Wester, K. L., & Singer, M. I. (2004). Impact of exposure to violence in 16 school on child and adolescent mental health and behavior. Journal of Community Psychology, 32(5), 559–573. https://doi.org/10.1002/jcop.20019 Graham, P. W., Yaros, A., Lowe, A., & McDaniel, M. S. (2017). Nurturing environments for boys and men of color with trauma exposure. Clinical Child and Family Psychology Review, 20(2), 105–116. https://doi.org/10.1007/s10567-017-0241-6 Individuals with Disabilities Education Improvement Act. (2004). 20 U.S.C. § 1400. Janosz, M., Archambault, I., Morizot, J., & Pagani, L. S. (2008). School engagement trajectories and their differential predictive relations to dropout. Journal of Social Issues, 64(1), 21–40. https://doi.org/10.1111/j.1540-4560.2008.00546.x John Hopkins. (n.d.). What is a comprehensive psychiatric evaluation? https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/comprehensive- psychiatric-evaluation Kelleher, K. J., McInerny, T. K., Gardner, W. P., Childs, G. E., & Wasserman, R. C. (2000). Increasing identifi cation of psychosocial problems: 1979–1996. Pediatrics, 105, 1313–  1321. https://doi.org/10.1542/peds.105.6.1313 Lanier, Y., Sommers, M. S., Fletcher, J., Sutton, M. Y., & Roberts, D. D. (2017). Examining racial discrimination frequency, racial discrimination stress, and psychological well-being among Black early adolescents. Journal of Black Psychology, 43(3), 219–229. https://doi.org/10.1177/0095798416638189 Markward, M. J., Cline, S., & Markward, N. J. (2001). Group socialization, the internet and school shootings. International Journal of Adolescence and Youth, 10(1–2), 135–146. https://doi.org/10.1080/02673843.2001.9747895 National Association of School Psychologists. (2015). School psychologists: Qualifi ed health professionals providing child and adolescent mental and behavioral health services [White paper]. Author. National Association of School Psychologists. (2016). Ensuring high quality, comprehensive, and integrated specialized instructional support services [Position statement]. Author. National Association of School Psychologists. (2020). The professional standards of the National Association of School Psychologists. Author. National Association of School Psychologists. (2021). Comprehensive school-based mental and behavioral health services and school psychologists [Handout]. Author. National Child Traumatic Stress Network, Justice Consortium, Schools Committee, and Culture Consortium. (2017). Addressing race and trauma in the classroom: A resource for educators. National Center for Child Traumatic Stress. O’Connor, C. A., Dyson, J., Cowdell, F., & Watson, R. (2018). Do universal school-based mental health promotion programmes improve the mental health and emotional wellbeing of young people? A literature review. Journal of Clinical Nursing, 27(3–4), e412–e426. https://doi.org/10.1111/jocn.14078 Perfect, M. M., & Morris, R. J. (2011). Delivering school-based mental health services by school psychologists: Education, training, and ethical issues. Psychology in the Schools, 48(10), 1049–1063. https://doi.org/10.1002/pits.20612 President’s New Freedom Commission on Mental Health. (2003). http://www.mentalhealthcommission.gov/subcommittee/children_family020703.doc Priest, N., Paradies, Y., Trenerry, B., Truong, M., Karlsen, S., & Kelly, Y. (2013). A systematic review of studies examining the relationship between reported racism and health and wellbeing for children and young people. Social Science & Medicine, 95, 115–127. https://doi.org/10.1016/j.socscimed.2012.11.031 Proctor, S. L., Li, K., Chait, N., Owens, C., Gulfaraz, S., Sang, E., Prosper, G., & Ogundiran, D. (2020). Preparation of school psychologists to support Black students exposed to police violence: Insight and guidance for critical training areas. Contemporary School Psychology, 1–17. https://doi.org/10.1007/s40688-020-00317-6 Richards, D., Caldwell, P. H., & Go, H. (2015). Impact of social media on the health of children and young people. Journal of Paediatrics and Child Health, 51(12), 1152–1157. https://doi.org/10.1111/jpc.13023 Rose, C. A., & Tynes, B. M. (2015). Longitudinal associations between cybervictimization and mental health among US adolescents. Journal of Adolescent Health, 57(3), 305– 312. https://doi.org/10.1016/j.jadohealth.2015.05.002 Saleem, F. T., Anderson, R. E., & Williams, M. (2020). Addressing the “myth” of racial trauma: Developmental and ecological considerations for youth of color. Clinical Child  Family Psychology Review, 23, 1–14. https://doi.org/10.1007/s10567-019-00304-1 Salerno, J. P. (2016). Effectiveness of universal school-based mental health awareness programs among youth in the United States: A systematic review. Journal of School Health, 86, 922–931. https://doi.org/10.1111/josh.12461 Salvia, J., Ysseldyke, J., & Witmer, S. (2016). Assessment in special and inclusive education. Cengage Learning. Tynes, B. M., Willis, H. A., Stewart, A. M., & Hamilton, M. W. (2019). Race-related traumatic events online and mental health among adolescents of color. Journal of Adolescent Health, 65(3), 371–377. https://doi.org/10.1016/j.jadohealth.2019.03.006 U.S. Department of Education. (n.d.). Individuals with Disabilities Education Improvement Act. https://sites.ed.gov/idea/ U.S. Department of Health and Human Services; U.S. Department of Education; U.S. Department of Justice. (2000). Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda. U.S. Department of Health and Human Services. Conference Summary. https://www.ncbi.nlm.nih.gov/books/NBK44237/ U.S. Public Health Service. Office of the Surgeon General, United States. Substance Abuse, Mental Health Services Administration, Center for Mental Health Services (US), & National Institute of Mental Health (US). (2009). Mental health: A report of the surgeon general. Author.  UNIT 2 15 MENTAL HEALTH DISORDERS IN CHILDREN AND ADOLESCENTS: NEURODEVELOPMENTAL DISORDERS 16  CHAPTER 2 17 Attention Deficit Hyperactivity Disorder LEARNING OBJECTIVES Summarize the diagnostic features for the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) diagnosis of attention deficit hyperactivity disorder (ADHD). Highlight the risk factors for ADHD in children and adolescents. Describe common social–emotional and behavioral concerns for children with ADHD. Understand the classroom implications for students with ADHD. Identify effective social, emotional, and behavioral interventions for students with ADHD. INTRODUCTION According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013), Attention Deficit Hyperactivity Disorder (ADHD) is categorized as a Neurodevelopmental Disorder. Neurodevelopmental Disorders feature onset primarily during childhood. Though they have an early age of onset, the issues associated with these conditions frequently persist into adulthood. These disorders are characterized by broad deficits across a number of domains, including academic, social, and emotional concerns. Some examples of other Neurodevelopmental Disorders include intellectual disability and autism spectrum disorder (APA, 2013). The inclusion of ADHD under this umbrella is new to the DSM-5; it was previously included in the category of Disorders Usually Diagnosed in Infancy, Childhood, and Adolescence (Carlew & Zartman, 2017) in the prior edition, the DSM-IV-TR (APA, 2000). DIAGNOSTIC ISSUES: DSM-5 AND SCHOOL-BASED SERVICES DSM-5 Diagnosis The DSM-5 outlines five criteria for the diagnosis of individuals with ADHD. The first criterion describes the inattentive and hyperactive/impulsive behaviors typically associated with ADHD. This criterion is subdivided into two parts. The first part outlines nine symptoms of inattention. These symptoms are inattention to details, challenges with maintaining attention to tasks, appearing distracted when addressed, failure to finish activities, disorganization, avoidance of tasks that require focus, issues with losing items or possessions, concerns with distractibility, and forgetfulness. The second part of the first ADHD diagnostic criterion addresses symptoms related to hyperactivity and impulsivity. This subpart also consists of nine symptoms. They are frequent fidgeting or squirming, out-of-seat behavior when remaining seated is the expectation, inappropriate running or climbing, inability to engage in quiet activities, perpetual movements in most situations, excessive talking, interrupting during conversation or blurting inappropriately, impatience with waiting, and intrusive behaviors. Across the two subparts of the first criterion, a child (younger than age 17) must demonstrate six symptoms (of either subpart—inattention or hyperactivity/impulsivity) over a course of 6 months to meet this criterion, and an individual older than 17 years must exhibit five 18 symptoms over the same period of time. In addition, in order to meet the first criterion, the aforementioned symptoms must not be the result of purposeful defiance or lack of understanding. The second criterion for diagnosis relates to the onset of symptoms. The DSM-5 notes that several of the symptoms of inattention or hyperactivity should have been noted prior to the age of 12 (APA, 2013). This age-of-onset criterion represents a change in the DSM-5 as previous versions dictated symptom onset by the age of 7. According to Chandra et al. (2021), this change was supported by research that found that later-onset cases were just as consistent with ADHD symptoms and impairment as earlier detection of symptoms, and those researchers further validated the change through consistency in symptoms, functioning, quality of life, and psychiatric comorbidity between those who report later (less than 12 years of age) versus those who report earlier (less than 7 years of age) symptom onset. The third criterion for ADHD prescribes that several of the symptoms must be present in two or more settings. The fourth criterion for diagnosis of ADHD indicates that the symptoms impair the individual’s functioning in at least one domain of daily life, and the final criterion states that the symptoms do not occur solely during psychotic episodes or in relation to another psychiatric condition (APA, 2013). Beyond the criteria for diagnosis, the DSM-5 also stipulates three different specifiers that may be applied to the diagnosis of ADHD. The first specifier relates to the presentation of symptoms. A child or adolescent may be diagnosed with combined presentation if they meet the required number of symptoms for both inattention and hyperactivity/impulsivity within the 6 months prior to diagnosis. If that is not the case, then the youth can be described as having either predominantly inattentive presentation or predominantly hyperactive/impulsive presentation based on symptom expression (APA, 2013). Prior versions of the DSM referred to these as subtypes, so the notion of presentations is new to the DSM-5 and reflects that symptomatology of an individual may vary across the life span (Woolraich et al., 2019). Of note, some research suggests that there may be underdiagnosis of ADHD among individuals who have predominantly inattentive symptomatology (Mowlem et al., 2019). The second specifier is noted when one is in partial remission from symptoms. This specifier is applied when the individual previously met criteria but has not demonstrated the required number of symptoms in the past 6 months. Yet, the individual with this specifier must continue to struggle with issues related to remaining symptoms in at least one area of life functioning (APA, 2013). In fact, research has found that as individuals age, they often struggle with fewer ADHD symptoms even when their impairment in daily life remains high (Ramtekkar et al, 2010). Finally, the third specifier is indicative of the determination of severity. With mild severity, there are few symptoms beyond the number required for diagnosis and impairment in life functioning is considered minimal. On the other end of the continuum, the individual’s severity is considered severe when the person exhibits numerous symptoms beyond the minimal criteria for diagnosis, and many of the symptoms are ­significant in nature and lead to serious impairment in at least one domain. Last, moderate severity is noted when the expressed symptomatology and level of impairment are between the descriptors noted for mild and severe impairment (APA, 2013). The severity specifier represents a new addition to the ADHD diagnostic criteria with the DSM-5 (Carlew & Zartman, 2017). Some research suggests that ADHD may be underdiagnosed among individuals who have predominantly inattentive symptomatology (Mowlem et al., 2019). Although the name may have changed over time, Woolraich et al. (2019) note that descriptions of ADHD-like symptoms and behaviors were discussed among professionals as early as 1902. These symptoms and behaviors were commonly thought to be associated with brain damage until evidence suggested otherwise. When the DSM-II was published in 1968, diagnostic criteria were included for a mental health condition calledhyperkinetic reaction of childhood disorder (Carlew & Zartman, 2017; Woolraich et al., 2019). The nameattention deficit disorder with or without hyperactivity first appeared in the DSM-III in 1980 after the focus on the issues with functioning evolved from those related to hyperactivity to those associated with inattention, and the name ADHD emerged with the publication of DSM-IV in 1994 (Carlew & Zartman, 2017). Although some researchers suggest that the DSM criteria for ADHD have become more research based over time, others indicate that they continue to fall short of where they should be in terms of specificity, empirical evidence, and ability to discriminate (Carlew & Zartman, 2017; Fabiano & Haslam, 2020). In fact, research by 19 Fabiano and Haslam (2020) found evidence of diagnostic- ­ inflation for ADHD based on decreased stringency in the criteria for diagnosis over time. Their study revealed that diagnoses of ADHD increased 18% from DSM-III (APA, 1980) to DSM-III-R (APA, 1987), 33% from DSM-III-R to DSM-IV, and another 17% from DSM-IV to DSM-5 (Fabiano & Haslam, 2020). ­Similarly, Fairman et al. (2020) found that from 2008 to 2013, diagnoses of ADHD climbed by 36% in adults and 18% in children (22% for girls and 17% for boys), whereas the National Institute of Mental Health (NIMH; n.d.) indicates an increase in diagnosis of 42% from 2003 to 2007 based on the ­National Survey of Children’s Health (NSCH). Finally, statistics from the Centers for Disease Control and Prevention (CDC; n.d.) and Xu et al. (2018) also reflect increasing rates of diagnosis among children and adolescents in the United States. In their comprehensive study of data from 1997 to 2016, Xu et al. (2018) found increases in prevalence of ADHD across all subgroups related to age, gender, race/ethnicity, family income, and geographic region within the United States. Perhaps related, Martinhago et al. (2019) warn that over time, diagnostic criteria have shifted in a way that has begun to pathologize normal behaviors of childhood, and this can be seen in the criteria for ADHD. Regardless of the cause of diagnostic inflation, this certainly warrants clinicians to be cautious to ensure accuracy in diagnosis so as to prevent overdiagnosis of ADHD among children and adolescents. At the time of publication, the DSM-5 noted the prevalence of ADHD to be approximately 5% among children and adolescents around the globe (APA, 2013). This is consistent with research by Chung et al. (2019), who found a prevalence of 4.78% from 2007 to 2016 in their large U.S. clinical sample; however, they also noted an increase in prevalence of 26.4% during that same time span. This would provide further support for the diagnostic inflation in ADHD noted previously by Fabiano and Haslam (2020). According to the CDC (n.d.), approximately 6.1 million children in the United States have been diagnosed with ADHD at some point in their lives. This includes 388,500 children aged 2 to 5, and 2,400,000 and 3,300,000 from ages 6 to 11 and 12 to 17, respectively. As would be expected given the psychosocial difficulties of individuals with ADHD, Baggio et al. (2018) found a staggering prevalence of ADHD (26.2%) among people living in detention (including psychiatric facilities), but the retrospective prevalence from childhood was estimated at 41.1%. Finally, for every 1,000 physician office visits in the United States in 2012 and 2013, 52.05 resulted in ADHD diagnoses among children (Fairman et al., 2020). A relationship has been noted between the severity of children’s ADHD and their age of onset of symptoms and subsequent diagnosis. Data from the NSCH indicates that the median age of onset across all children is 6 years. However, children with mild severity have a median age of diagnosis at age 7, and children with moderate severity are typically diagnosed by age 6. Finally, for those children who demonstrate symptomatology consistent with the specifier of severe ADHD, the median age of diagnosis is merely 4 years old. According to the DSM-5, the primary characteristic of ADHD at preschool ages is hyperactivity (APA, 2013). Consistent with these age-based findings related to severity, Manfro et al. (2019) found that childhood onset of ADHD is associated with a higher number of psychiatric symptoms based on both parent and teacher report as compared with adolescent or adult onset of this mental health condition. With regard to age of referral, research supports that girls are referred at younger ages than boys when they demonstrate externalizing behavioral issues that are similar to those that are more common in boys (Arcia & Conners, 1998). Similarly, qualitative research with teachers also supports that they find the behaviors of children and adolescents with ADHD to be more acceptable among boys than among girls (Lawrence et al., 2017). Despite the generally early age of onset of ADHD and the diagnostic criterion requiring symptom presence prior to age 12, a growing body of research is supporting a form of later-onset ADHD with emergence of symptoms in adolescence or even adulthood (Asherson & Agnew-Blaise, 2019; Lin & Gau, 2020; Moffitt et al., 2015; Shaw & Polanczyk, 2017). With regard to gender, the DSM-5 notes that the diagnosis of ADHD in males is twice as common as in females during childhood and adolescence. Recent data from Davis et al. (2021) also indicate that in one state, twice as many males as females were diagnosed with ADHD in 2017, but Mowlem et al. (2019) suggests a ratio of 2.5:1 male-to-female children with ADHD among their large sample of youth. However, data from the National Comorbidity Survey Replication Adolescent Supplement records a discrepancy of 3 to 1 in diagnosis of males to females aged 13 to 18 in the United States (NIMH, n.d.). Not surprising, research by Mowlem et al. (2019) 20 indicates that greater symptom severity increases the probability of diagnosis in both male and females. They further noted that in population-based samples, males exhibit higher symptom severity than females across all domains under study, and that females may be underdiagnosed with ADHD unless they demonstrate externalizing concerns. In fact, hyperactivity/impulsivity and conduct problems were significantly greater predictors of diagnosis in females as compared to their male counterparts. They state that their data “may indicate a greater symptom threshold requirement for referral and diagnosis in females” (Mowlem et al., 2019, p. 486). With regard to comorbidity, the DSM-5 indicates significant co- occurrence of the following disorders with ADHD: oppositional defiant disorder, conduct disorder, disruptive mood dysregulation disorder, specific learning disorder, anxiety disorders, major depressive disorder, intermittent explosive disorder, substance abuse disorders, antisocial personality disorder, obsessive- compulsive disorder, tic disorders, and autism spectrum disorder. Most of the aforementioned mental health conditions occur with greater frequency among children and adults with ADHD than they do within the general population (APA, 2013). Larson et al. (2011) report that approximately 67% of children with ADHD have at least one other co-occurring psychiatric diagnosis. This is comparable to the 60% reported by the CDC (CDC, n.d.). According to recent research by Sun et al. (2019), the combined subtype of ADHD in childhood is related to greater comorbidities than the inattentive type alone, particularly in relation to oppositional defiant disorder, conduct disorder, and sleep disorders. In reference to those comorbidities most common in childhood and adolescence, Gnanavel et al. (2019) report a co-occurrence of 30% to 50% between externalizing disorders (oppositional defiant disorder and conduct disorder) and 70% between ADHD and learning disorders (with challenges with writing being the most common difficulty). Comorbidity with depression ranges from 12% to 50% and from 15% to 35% for anxiety among youth with ADHD, depending on the research and its methodology (Gnanavel et al., 2019). The CDC reports comorbid depression and anxiety among children and adolescents with ADHD at 17% and 33%, respectively. Research further documents significant comorbidity between ADHD and autism spectrum disorder despite the fact that they were not able to be diagnosed together prior to the DSM-5 (Antshel et al., 2016; Gnanavel et al., 2019), and comorbid ADHD and autism spectrum disorder often lead to greater symptom expression and severity for both disorders (Gargaro et al., 2014). Gnanavel et al. (2019) report the comorbidity between the two to be at 42%, and they highlight the symptom overlap between these two neurodevelopmental disorders. However, the CDC reports this figure at a much lower rate of 14% (CDC, n.d.). Ramtekkar (2017) also found a struggle with sleep disturbances to be common within both diagnoses. The sleep disturbances for children and adolescents with ADHD include anxiety or resistance at bedtime, difficulty falling asleep, challenges with staying asleep, and daytime sleepiness (Cortese et al., 2009). Research by Walsh et al. (2020) suggests that ADHD may even serve as a precursor to bipolar disorder. Beyond comorbidity with other psychiatric diagnoses, ADHD is also associated with other health and psychosocial issues. A number of individual studies and meta-analyses have documented the co- occurrence of ADHD and obesity (Hanc & Cortese, 2018; Inoue et al., 2019). ADHD is also associated with delinquent and criminal behavior, and individuals with ADHD often engage in these behaviors at significantly younger ages than their non-ADHD counterparts (Philipp-Wiegmann et al., 2017). In addition, when incarcerated for their criminal acts, people with ADHD are more likely to engage in verbal and physical aggression with peers and staff (Gordon et al., 2012), and they are more likely to return to incarceration for subsequent convictions following release (Gonzalez et al., 2016). Finally, and alarmingly, ADHD is associated with an overall greater number of hospitalizations and hospitalizations from injury (Fleming et al., 2017), and an increased likelihood of premature death, including suicide and accidents (Dalsgaard et al., 2015; Sun et al., 2019). Also very alarming, Chen et al. (2019) found suicidality to be 3 times higher among children with ADHD in Taiwan in relation to children without this diagnosis. In the research of Sun et al. (2019), a later age of onset of psychiatric comorbidities appears to be especially related to untimely dea