Autism Spectrum Disorder

(1) DSM-IV Pervasive Developmental Disorders (PDD): the 5 “official” types.
We start our review of each Autistic Spectrum syndrome by presenting the diagnostic criteria for each of the DSM-IV PDD disorders, as defined out by the American Psychiatry Association:

1. Autistic Disorder (click here for more details about autism)

(A) total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):

1. qualitative impairment in social interaction, as manifested by at least two of the following:

(a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction

(b) failure to develop peer relationships appropriate to developmental level

(c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)

(d) lack of social or emotional reciprocity

2. qualitative impairments in communication as manifested by at least one of the following:

(a) delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gestures or mime)

(b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others

(c) stereotyped and repetitive use of language or idiosyncratic language

(d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

3. restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:

(a) encompassing preoccupation with one or more stereotyped patterns of interest that is abnormal either in intensity or focus

(b) apparently inflexible adherence to specific, nonfunctional routines or rituals

(c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)

(d) persistent preoccupation with parts of objects

(B) Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.

(C) The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder.

2. Asperger’s Syndrome

Symptoms of Asperger’s include: impaired ability to utilize social cues such as body language, irony, or other “subtext” of communication; restricted eye contact and socialization; limited range of encyclopedic interests; perseverative, odd behaviors; didactic, verbose, monotone, droning voice; “concrete” thinking; over-sensitivity to certain stimuli; and unusual movements.

Official DSM-IV criteria are similar to that for Autistic Disorder except do not include the “communication” problem areas: in other words, autistic people who talk well. [Many experts would argue that although verbal speech is preserved in Asperger’s, other communication problems certainly exist.]

(A) Qualitative impairment in social interaction, as manifested by at least two of the following:

1. marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction

2. failure to develop peer relationships appropriate to developmental level

3. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people(e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)

4. lack of social or emotional reciprocity.

(B) Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:

1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus

2. apparently inflexible adherence to specific, non-functional routines or rituals

3. stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)

4. persistent preoccupation with parts of objects

(C) The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.

(D) There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years)

(E) There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood.

(F) Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.

Listen to the speech pattern of kids with Asperger's



3. PDD-NOS (PDD-Not Otherwise Specified)

This category should be used when there is a severe and pervasive impairment in the development of reciprocal social interaction or verbal and nonverbal communication skills, or when stereotyped behavior, interests, and activities are present, but the criteria are not met for a specific Pervasive Developmental Disorder, Schizophrenia, Schizotypal Personality Disorder, or Avoidant Personality Disorder. For example, this category includes atypical autism --- presentations that do not meet the criteria for Autistic Disorder because of late age of onset, atypical symptomatology, or subthreshold symptomatology, or all of these.



4. Rett’s Disorder

The current DSM-IV criteria are given below. Thanks to the development of a new genetic blood test, though, we are finding Rett’s Disorder in children with much milder symptoms.

(A) All of the following:

1. apparently normal prenatal and perinatal development

2. apparently normal psychomotor development through the first 5 months after birth

3. normal head circumference at birth

(B) Onset of all of the following after the period of normal development:

1. deceleration of head growth between ages 5 and 48 months

2. loss of previously acquired purposeful hand skills between ages 5 and 30 months with the subsequent development of stereotyped hand movements (e.g., hand-wringing or hand washing)

3. loss of social engagement early in the course (although often social interaction develops later)

4. appearance of poorly coordinated gait or trunk movements

5. severely impaired expressive and receptive language development with severe psychomotor retardation



5. Childhood Disintegrative Disorder (CDD)

(A) Apparently normal development for at least the first 2 years after birth as manifested by the presence of age-appropriate verbal and nonverbal communication, social relationships, play, and adaptive behavior.

(B) Clinically significant loss of previously acquired skills (before age 10 years) in at least two of the following areas:

1. expressive or receptive language

2. social skills or adaptive behavior

3. bowel or bladder control

4. play

5. motor skills

(C) Abnormalities of functioning in at least two of the following areas:

1. qualitative impairment in social interaction (e.g., impairment in nonverbal behaviors, failure to develop peer relationships, lack of social or emotional reciprocity)

2. qualitative impairments in communication (e.g., delay or lack of spoken language, inability to initiate or sustain a conversation, stereotyped and repetitive use of language, lack of varied make-believe play)

3. restricted, repetitive, and stereotyped patterns of behavior, interests, and activities, including motor stereotypies and mannerisms

(D) The disturbance is not better accounted for by another specific Pervasive Developmental Disorder or by Schizophrenia.



(2) Expanded Autistic Spectrum Disorders
Next, we turn our attention to those Autistic Spectrum Disorders that are not included in DSM-IV:

High Functioning Autism

For some authors, this term is synonymous with Asperger’s syndrome. For others, it implies milder autism without retardation, or PDD-NOS.

Non-Verbal Learning Disabilities (NVLDs): trouble with the gestalt/integration of non-verbal information

NVLDs are a cluster of symptoms presumably related to poor ability to integrate information by the non-dominant hemisphere (typically the right hemisphere). Although rote verbal language is spared, non-verbal areas may be debilitating. These children have trouble with the ability to integrate it all together, i.e., to see the big gestalt picture rather than the details. In short, they can’t “see the forest for the trees.”

Although verbal communication is highly prized in school (good talkers, readers, and writers), up to 2/3 of communication actually occurs non-verbally. Thus, in the long run, the maladaptive learning of NVLD may be more destructive than typical LD. Estimates are that 0.1 to 1% of population has a NVLD, compared to 10% of population has a LD, although these numbers may be an artifact of who and how we test.

Difficulty integrating non-verbal information occurs in three main areas:

(1) Motoric integration problems:
Gross motor: clumsy, unbalanced walking leading to clinging behaviors, bumping in to things, fear of climbing, hesitant to explore physically, difficulty bike-riding, uncoordinated at sports.
Fine motor: using scissors, shoe tying (which she’ll talk herself through), poor handwriting using awkward and tight grip, finger agnosia.
(2) Visual-Spatial-Orientation integration problems, with inability to form visual images:
Resultant focus on detail rather than the important gestalt.
Labels everything verbally, since that is the only—albeit not always accurate—way she can process the visual/spatial information. For example, she may find her way home by counting houses and labeling landmarks verbally.
Unaware where she is in space, so unaware of where to place answers on the homework sheet, or how to navigate the school.
These elaborate “naming” strategies break down with changes in routine, leading to an inability to cope with change.
(3) Social/communication problems:
Trouble integrating non-verbal communication with verbal communication to achieve full social interaction.
The children do clearly appear to want social acceptance (vs. Asperger’s, where the children do not usually appear interested socially).
However, typically labeled as “annoying” because of their dependence on others, their constant speech, and their misinterpretation of social cues.
Very literal interpretation of others; concrete thinking; seeing the world in black and white; trouble understanding dishonesty; trouble seeing hidden meanings, prompting others to say “You know what I meant!”—when they didn’t.
Don’t read the social cues of give and take conversation, thus appearing self-centered, weird, or impolite.
NVLD symptoms change through the lifespan:

Symptoms as toddlers:
Uncoordinated (gross motor and fine motor).
Trouble with social interactions, non-verbal clues (such as a peer’s facial expression of “Enough is enough!”), and adjustments to change. They may appear “confused.”
Warning signal: You always have to tell the child, “I shouldn’t have to tell you that.” Obviously, with these kids, you do have to tell them. That’s how you know there is a problem.
Trouble with spatial orientation.
As a young child:
Often exceptional rote speech, memory, and reading skill, which the children use to compensate for lack of intuitive social interaction. The child tries to “remember” how to interact, rather than the skill coming automatically in each different situation.
These exceptional reading and “adult” pedantic speech patterns may be interpreted as preciousness.
Clumsy monologues replace typical to-and-fro conversations.
Older children:
Academic problems in the later elementary years with organization, inferential reading, and written output.
Math facts better than concepts.
Typically PIQ Sustains focus on details, does not attend to big picture.
A life of social blunders, without ever figuring out why.
May have secondary depression or anxiety.
NVLD is determined by neuropsychological testing, whereas Asperger’s is determined by detailed history and observation. There is great overlap in these two conditions—perhaps due to co-morbidity; or perhaps, as some authors feel, they are essentially the same condition but labeled by different specialties. However, Asperger’s is most primarily notable for not appearing interested in forming human bonds. [The degree to which Asperger’s kids actually are painfully aware of their trouble making bonds is debated in the literature. Nevertheless, they typically appear uninterested.] NVLD kids, though, do typically appear interested in human bonds--even though they may be clueless how to actually achieve them successfully. Additionally, children with Asperger’s more typically have diminished “symbolic play” than in NVLD. For example, the toy school bus is a box that rolls, rather than something that little plastic figures climb into.

So, how about this for a gross oversimplification? NVLD kids recognize that you exist while they miss the subtext of what you are saying. Asperger’s kids appear behind a plane of glass as they miss the subtext of what you are saying.

References: Sue Thompson’s article NVLD at http://www.nldontheweb.org/thompson-1.htm

David Dinklage, in the Spring 2001 issue of the AANE (Asperger's Association of New England). Article can be found at http://www.nldontheweb.org/Dinklage_1.htm.



Semantic-Pragmatic Communication Disorder

From “Semantic and Pragmatic Difficulties” by Caroline Bowen at

http://members.tripod.com/Caroline_Bowen/spld.htm.

See also an excellent site on SPLD at http://www.geocities.com/DeniseV2/

and www.hyperlexia.org/sp1.html on SPLD by Margo Sharp.

“Semantics” refers to the ability to use and understand words, phrases and sentences, including abstract concepts and idioms. “Pragmatics” refers to the practical ability to use language in a social setting, such as knowing what is appropriate to say, where and when to say it, the give and take nature of a conversation, and the ability to know what the other person does or does not already know. (See above for further discussion.)

Thus, semantic-pragmatic communication disorder kids have the root problem in:

Difficulty understanding the literal meaning of words and sentences. (semantics)
Difficulty with abstract words, words about emotions, idioms, and words about status such as “expert.” (semantics)
Difficulty extracting the central idea. (pragmatics)
Trouble with the appropriate rules of conversation (monologues, talking “at” you). (pragmatics)
This inability to understand verbal language and the purpose of language leads to the typical secondary problems we have discussed before:

An almost obsessive need for sameness and routine, since new situations are hard to understand.
Too much stimulus is overwhelming, leading to avoidance.
Things are more predictable than people, perhaps one reason why these children may be more drawn to objects than interpersonal relationships.
Trouble attending to correct task
Impulsive “butting in” on conversations.
Take everything literally, leading to confusion, anxiety, and social rejection.
Life of a child with SPLD through the years:

Often, very easy infants.
Delayed development of speech with few words even by two years old.
Trouble with creative or symbolic play.
Simple speech improves with therapy, but in school child is “odd.”
Good rote skills in math and computers, perhaps, but poor writing and socialization skills.
Parrot back more than they understand, leading to an aura of intellectual maturity out of synch with their social skills.
Trouble understanding what others are really thinking or feeling, i.e. trouble with theory of mind.
Many have fine motor problems; some have gross motor difficulties as well.
They may have trouble knowing what is socially acceptable, but are not usually conduct disorder teens.
May be “eccentric” adults.
Differentiation of SPLD from other Autistic Spectrum Disorders

SPLD kids tend to have somewhat better socialization skills than Asperger's.

SPLD kids tend to have more early delays in speech than Asperger's.

The appropriate label may change over time as the child matures.



Hyperlexia

The following description comes largely from: Phyllis Kupperman, et al. “Hyperlexia” at the American Hyperlexia Association website at http://www.hyperlexia.org/hyperlexia.html.

Hyperlexia is a condition almost always in boys where Austistic Spectrum symptoms are accompanied by a striking capacity for rote reading. By 18-24 months of age, these kids have taught themselves the ability to name letters and numbers. By three years old, they may read printed words, exceeding even their ability to talk. By five years old, all have a fascination with the printed word. Some of the children seemed to have a mild regression at 18—24 months (less severe than as in Autism).

In addition to this unusual reading skill, there are the other typical common Autistic Spectrum Disorder symptoms we have seen, such as:

Language problems
Good rote or echoed language.
Trouble translating words into larger gestalt ideas.
Repetitive, idiosyncratic speech.
Pragmatic language problems.
Unusual prosody (rhythm) of speech.
Socialization problems
See “Secondary Problems from Failure to Understand.”
Stereotyped, ritualistic behaviors.
Anxiety.
Trouble making friends.
?ADHD
ADHDers typically have trouble with “Executive Functions,” with subsequent difficulties in their relationship with others. Usually, though, they have adequate capacity for empathy—but may have trouble inhibiting their behavior long enough to show it. Conversely, many children with Autistic Spectrum may appear to have a short attention span, but just aren’t able to stay focused on situations they don’t understand.

It is probably best to consider ADHD as sometimes sharing the following symptoms with—but not part of—the Autistic Disorders Spectrum:

· Poor reading of social clues (“Johnny, you’re such a social klutz. Can’t you see that the other children think that’s weird.”)

· Poor ability to utilize “self-talk” to work through a problem (“Johnny, what were you thinking?! Did you ever think this through?”)

· Poor sense of self awareness (Johnny’s true answer to the above question is probably “I don’t have a clue. I guess I wasn’t actually thinking.”)

· Do better with predictable routine.

· Poor generalization of rules (“Johnny, I told you to shake hands with your teachers. Why didn’t you shake hands with the principal?)



Conclusion (Finally!)
The classification of the Autistic Spectrum Disorders is in a state of flux. The problems can overlap, cause each other, occur simultaneously in different combinations and severities, change over time, and don’t even have one “official” group attempting the classification of the whole spectrum. (Hence, this paper.)

However, unless we know all of the possible syndromes, we will continue to squeeze everyone into the same category or two. Most importantly, unless we know the full range of the Autistic Spectrum Disorders, we will not identify all of the individual symptoms which require treatment.

With trepidation, I offer the following gross oversimplifications. I am reminded of my professor’s comment on the first day of medical school: “One third of what I am going to tell you this year is wrong. Unfortunately, I don’t know which third.”

Autistic Spectrum disorders are marked by their difficulty in communication/socialization in areas other than the literal meaning of words.
Once a child has trouble with getting the big picture of communication and socialization, there will often be secondary symptoms such as: anxiety, holding back from peers, a rigid adherence to sameness, a relative preference for things (which are predictable) rather than people, and an appearance of “oddness.”
Asperger’s and Autism share primarily the difficulty of recognizing the existence of others—trouble with theory of mind. Asperger’s can talk; autism usually has limited speech.
Asperger’s children appear less interested in forming bonds and have more trouble with “theory of mind” than NVLD and Sematic-Pragmatic Disorder.
NVLDs are marked by integration problems of pragmatic language gestalt; spatial orientation; and motoric coordination.
Hyperlexia is marked by fascination with the printed word starting at an early age.
“High Functioning Autism” is used by different authors to mean either Autistic Disorder with relatively spared speech and cognition; Aspergers’s Syndrome; or PDD-NOS.

10 Ways to Deal with Tantrums

10 Ways to Deal with Tantrums

The strategies for dealing with tantrums in autistic children may not be appropriate for everyone. Your parenting style is a factor to consider and following through with temper taming techniques that go against your personality may not be effective. In some cases, the techniques work after some trial and error.
Withhold attention, formerly referred to as "planned ignoring", may seem like an ineffective way to deal with tantrums but when you think about the possible reasons the behavior occurs, it can work. The approach requires parents to continue as if nothing is wrong, giving the child no feedback for the behavior. The approach may require several trials before it takes effect. Keep in mind that you are ignoring the behavior, not the child.
Stay calm and consistent although this may seem impossible considering the emotionally-charged nature of the behavioral outburst. Highly emotional responses can feed the behavior.
Get to a safe environment to ensure that your child does not harm himself, others or property.
Redirect the behavior at its onset. Once you recognize that a meltdown is about to occur, immediately redirect the child's behavior to something else.
Use signal phrases to help your child calm and organize his behavior. This can include prompting her to say "Not yet" or "I wait" as a way to internalize the directions. The phrases empower the child rather than controlling him. Consider the difference between telling your child that he has to wait and him telling himself that it is time to wait.
Visual cues may help children who can't talk. The Picture Exchange Communication System (PECS) uses image cards that include quiet, stop, wait and other cues that can help the child know what is expected and what to expect.
Make consequences swift and meaningful to ensure that the child recognizes that the behavior will not result in what she wants. Sometimes this translates into riding it out, which can be painfully embarrassing in public places but giving in to demands to quell the outburst only reinforces the behavior.
Counting can help for some children who know that they have till the count of three to calm down. With practice, may kids immediately stop the behavior at the count of one. When practicing this strategy, use no other words than the numbers and when you get to three, follow through with a consequence, like a time-out.
Use familiar objects to redirect attention. Some children may have sensory issues that need to be met. Choose a favorite object and allow the child to "stim" in stressful situations.
Keep focus on your child is another difficult piece of advice to follow when the eyes of strangers pour over the incident. However, worrying about what other people think about your parenting skills is not going to help matters.

Learning Disability

WHAT IS A LEARNING DISABILITY?
A learning disability is a neurological disorder.

A learning disability can't be cured or fixed; it is a lifelong issue.

Parents can help children with learning disabilities achieve such success by encouraging their strengths, knowing their weaknesses, understanding the educational system, working with professionals and learning about strategies
for dealing with specific difficulties.


FACTS ABOUT LEARNING DISABILITIES:

Fifteen percent of the U.S. population, or one in seven Americans, has some type of learning disability, according to the National Institutes of Health.

Difficulty with basic reading and language skills are the most common learning disabilities.

Learning disabilities often run in families.

Learning disabilities should not be confused with other disabilities such as mental retardation, autism, deafness, blindness, and behavioral disorders.

Attention disorders, such as Attention Deficit/Hyperactivity Disorder (ADHD) and learning disabilities often occur at the same time, but the two disorders are not the same.


COMMON SIGNS OF LD:
Speaks later than most children

Pronunciation problems

Slow vocabulary growth, often unable to find the right word

Difficulty rhyming words

Trouble learning numbers, alphabet, days of the week, colors, shapes

Extremely restless and easily distracted

Trouble interacting with peers

Difficulty following directions or routines

Fine motor skills slow to develop

Autism

UNDERSTANDING AUTISM

What is Autism?

A developmental disability that severely hinders the way information is gathered and processed by the brain, causing problems in communication, learning and social behaviors. (Autism Society Philippines)
Keynotes in the definition of Autism:

Not a disease

Pervasive Developmental Disorder

Spectrum disorder (ASD)

Behaviorally-defined


How prevalent is Autism?

*Estimated global figure:

1:166 (TIME MAGAZINE, May 2006)
1:170 (TIME MAGAZINE, October 2006)

*Philippine Situationer:

1 in every 500 Filipino children
- Phil. Advocacy Program for Autism 1997

1.4 million Filipino children affected
- Manila Bulletin, January 1999

Incidence of Autism – PCMC
(Neurodevelopmental Section : 1990-1999)
Total patients evaluated 1040
Total patients with Autism 312



How does Autism rate with other neurological disorders?

Estimated prevalence figures per 10,000 population of various
Neurological disorders

Alzheimer’s disease
100-470

Childhood epilepsy

65

Autistic spectrum disorder

10-50

Down’s syndrome

10-15

Parkinson’s disease

16

Neurofibromatosis I

3

Phenylketonuria

1

Multiple Sclerosis

0.5-3

Childhood brain tumors

0.25

Rapin, 2001



Age/Gender/Racial/Social Distribution:

Age: Autism typically occurs within the first 3 years of life

Gender: Males are 4 times more affected as compared to Females
Race/Social: Autism knows no racial, ethnic and social boundaries
What causes Autism?

Note: There is no known specific cause of Autism at present.

*Psychogenic Theory of Autism (Kanner):

1. Poor parenting causes Autism

2. Autism is caused by a lack of love

3. Autism is an emotional condition that is caused by a child’s withdrawal from his/her parents

4. Certain vaccination causes autism

*The Psychogenic theory of Autism was debunked in the 1970s when several factors have led to another theory which associates symptoms of Autism with specific abnormalities in certain parts of the brain.




*Biological/Neurological Theory of Autism:


-several neural systems in the brain are affected causing complex deficits in social, language, and behavioral areas

-3 main areas of the brain most commonly affected as pointed by current research data:

Amygdala:
- critical in emotional arousal

important in discerning fear in facial expressions
plays a role in pleasure and other emotions
Temporal lobe:

recognizing and discriminating faces

reading facial expressions and social intent thru eye-gaze direction


Frontal lobe:

holds areas critical for “social cognition” i.e.; thinking about other’s thoughts, feelings and intentions (Theory of Mind Ability)


*Genetic Theory:

- currently the most favored assumption

- believes that autism runs in families

- states that Autism is a heritable, complex genetic disorder with a heterogeneous etiology

*Evidences for the role of genetics in Autism:

Family studies:

Autism-like symptoms occur more often in parents and siblings of people with Autism, compared to families with no Autistic relatives.

Close relatives of children with autism are at higher risk (3-5%) chance for developing Autism

A member of the general population has 0.2% chance of having autism.
Twin studies:

Identical twins are more behaviorally similar than other relatives, due to genetic influence
monozygotic twin of a patient with Autism has a 60% chance of having autism, and >90% chance of being in the Autistic spectrum
Dizygotic twin of patient has 3-5% chance of having Autism
What are the Signs and Symptoms of Autism?

*Autism Triad of Impairments:

Impaired reciprocal Social interaction
Impaired reciprocal communication
Restricted, repetitive, interests/activities
*Specific Symptoms of Autism:

*Social:

-displays indifference (acts as if deaf)

-joins only if adult insists and assists

-one-sided interaction

-no eye contact

-does not play with other children

-lack of creative, pretend play


*Language:

-indicates needs by using an adult’s hand

-echolalic-copies words like a parrot

-exhibits pronoun reversals

-absence of speech



*Stims:

-talks incessantly about only one topic

-inappropriate laughing or giggling

-bizarre behavior

-handles or spins objects

-variety is not the spice of life

-some can do things very well, very quickly but not tasks
involving social understanding.



Other symptoms seen in Autism:

a.) Physical:
-is generally goodlooking

-is a picky-eater, tends to smell food/objects and put things in his mouth

-exhibits disturbed sleeping patterns

-does not seek attention when hurt; has high pain threshold and is unable to localize pain


b.) Attentional:
-poor attentional span

-overselectivity/Tunnel vision

c.) Behavioral Patterns:
-is hyperactive

-some may exhibit passive behavior

-others may display self-injurious behaviors

d.) Abnormal responses to sensory stimuli:
-overlysensitive to touch/under responsive to pain

-sight, hearing, touch, pain, smell, taste may be affected to a lesser or greater degree

e.)Cognitive Characteristics:
-splinter/savant skills(memory, music, math, art, geographical, and multiple skills)

-50% of Children with Autism(CWA) have Mental Retardation

DIFFERENTIAL DIAGNOSIS:

PERVASIVE DEVELOPMENTAL DISORDERS

SIGNS AND SYMPTOMS

Autism Spectrum Disorder

Marked impairments in communication, socialization, restricted, repetitive, interests/activities, that typically occurs within the first 3 years of life.
Asperger’s Syndrome

Severe social deficits and restricted, repetitive, interests/activities; language and cognition are normal
Rett’s Disorder

Genetically defined cause for autistic behaviors affecting virtually only girls; with physical manifestations that take place after first 6 months of life
Childhood Disintegrative Disorder

Normal early language development, followed by severe regression in language, social, cognitive, and functional skills, between 2-10 years of life


How is Autism diagnosed?

*No biological marker for Autism

*Diagnosis remains clinical

Demonstration of significant impairments in social interaction and reciprocal communication and restricted, repetitive interest/behaviors USING:

a.) Diagnostic Criteria in DSM-IV or ICD 10 manuals

b.) Childhood Autism Rating Scale (CARS)

c.) Wing Autistic Diagnostic Interview Checklist (WADIC)

d.) Others_



Who are qualified to diagnose?

Neurologists

Pediatricians

Developmental Pediatricians

SPED Diagnosticians/Specialists

Psychiatrists

Psychologists
Available Treatments/Interventions for Autism:

Note: Autism is a life-long developmental disability. There are no known cures for Autism but a wide variety of Interventions are currently available to suit the CWA’s needs:

a.) Occupational Therapy: Focuses on Sensory Integration(SI) techniques to address sensory problems of CWA.

b.) Speech Therapy: Focuses on using Picture Exchange Communication System (PECS) and Facilitated Communication techniques to develop or enhance language among CWA.

c.) Special Education(SPED): Provides wholistic Individual Educational Programs (IEP), done in a center-based one-on-one or group therapy setting.

d.) Behavior Modification:Applied Behavior Analysis(ABA)
A one-on-one, home-based intensive teaching Program designed to eliminate disruptive behaviors and build socially useful ones through carefully task-analyzing behaviors and behavioral processes.

See also : Attention Deficit Hyperactive Disorder (ADHD)

ADHD

What is AD/HD?

ADHD is a common behavioral disorder that affects an estimated 5% to 10% of school-age children.
Boys are three times more affected than girls
Children with ADHD act without thinking, are hyperactive, and have trouble focusing.


WHAT ARE THE SYMPTOMS OF AD/HD?

HYPERACTIVE-IMPULSIVE TYPE

fidgeting or squirming
excessive running or climbing
difficulty remaining seated
always seeming to be "on the go"
difficulty playing quietly
excessive talking
blurting out answers before hearing the full question
difficulty waiting for a turn or in line
problems with interrupting or intruding
INATTENTIVE TYPE

distractibility
inability to pay attention to details or a tendency to make careless errors in schoolwork or other activities
difficulty with sustained attention in tasks or play activities
difficulty following instructions
avoidance or dislike of tasks that require mental effort
problems with organization
tendency to lose things like toys, notebooks, or homework
forgetfulness in daily activities
COMBINED TYPE

involves a combination of the other two types and is the most common
WHAT CAUSES AD/HD?

ADHD is not caused by poor parenting, too much sugar, or vaccines.
Experts have found that certain areas of the brain are about 5% to 10% smaller in size and activity in children with ADHD.
ADHD has biological origins that aren't yet clearly understood.
Recent research also links smoking/alcoholism during pregnancy to later ADHD in a child.
Other risk factors may include premature delivery, very low birth weight, and injuries to the brain at birth.
Some studies have even suggested a link between excessive early television watching and future attention problems.
WHAT ARE SOME RELATED PROBLEMS?

Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD)
Mood Disorders (such as depression)
Anxiety Disorders
Learning Disabilities
HOW IS AD/HD DIAGNOSED?

a child must display behaviors from one of the three subtypes before age 7
these behaviors must be more severe than in other kids the same age
the behaviors must last for at least 6 months
the behaviors must occur in and negatively affect at least two areas of a child's life (such as school, home, day-care settings, or friendships)
The behaviors must also not be linked to stress, depression, or anxiety at home.
How Is AD/HD Treated?

Medications
Stimulants
Nonstimulants
Antidepressants
Behavioral Therapy

Applied Behavior Analysis

ABA
(Applied Behavior Analysis)

History

Applied behavior analysis is the applied side of the experimental analysis of behavior. Its origin can be traced back to Teodoro Ayllon & Jack Michael's 1959 article The psychiatric nurse as a behavioral engineer.[13] The research basis of ABA can be found in the theoretical work of behaviorism and radical behaviorism originating with the work of B. F. Skinner.

Applied Behavior Analysis now encompasses treatments in applied settings in things as varied as leisure skills development, improving sports performance, cigarette smoking cessation, increasing exercise, and other areas.

Definition: "[ABA is] the design, implementation, and evaluation of environmental modifications to produce socially significant improvement in human behavior. ABA includes the use of direct observation, measurement, and functional analysis of the relations between environment and behavior. ABA uses antecedent stimuli and consequences, based on the findings of descriptive and functional analysis, to produce practical changeThis definition places emphasis on socially significant changes, but ABA can be used to alter virtually any behavior irrespective of its social relevance.

The components of any behavior are as follows: A.B.C

Antecedent: a verbal or physical stimulus such as a command or request. This may come from the environment or from another person, or even internal to the subject.
Behavior: the student's response
Consequence: What happens conditional to the behavior. In controlled situations the consequence is that the student receives something motivational to him/her: commonly food, rewards, praise, a toy, etc. Consequence could also include correction (or punishment, but this is rarely used).


The key aspects of ABA are

Observation of current behavior for topography (what the movement looks like), frequency, antecedents and consequences
Breaking down desired skills into steps
Teaching the steps through repeated presentation of discrete trials
Data on performance is tracked to show changes over time


Facts about ABA

ABA is one of the most common, and the only proven, method used to treat autism
Applied Behavior Analysis has been shown to be an effective means of intervention for adults and children with pervasive developmental disorder and is one of the most widely used with this population.
The ABA approach teaches social, motor, and verbal behaviors as well as reasoning skills.
ABA therapy is especially useful in teaching behaviors to children with autism who do not otherwise "pick up" on these behaviors on their own as other children would.
ABA teaches these skills through use of careful behavioral observation and positive reinforcement or prompting to teach each step of a behavior.
Generally ABA involves intensive training of the therapists, extensive time spent in ABA therapy (20-40 hours per week) and weekly supervision by experienced clinical supervisors known as a certified behavior analyst.[10]



An increasing amount of research in the field of ABA is concerned with autism; and it is a common misconception that Behavior Analysts work almost exclusively with individuals with autism and that ABA is synonymous with Discrete Trials teaching. ABA principles can also be used with a range of typical or atypical individuals whose issues vary from demonstrating developmental delays, significant behavioral problems or undesirable habits.

ABA is often confused as a table-only therapy. Properly performed, ABA should be done in the table and natural environments, depending on the student's progress and needs. Once a student has mastered a skill at the table, the ABA team should move the student into a natural environment for further training and generalization of the skills just learned.

Frequently, the Assessment of Basic Language and Learning Skills (ABLLS) is used to create a baseline of the autistic (or otherwise diagnosed) learner's functional skill set. The ABLLS breaks down the learner's strengths and weaknesses to best tailor the ABA curriculum to them. By focusing on the exact skills that need help, the teacher does not waste time teaching a skill the student knows. This can also prevent student frustration at attempting a skill for which he or she is not ready.


Discrete trials

Discrete trials were originally used by B. F. Skinner in his experimental studies with rats and pigeons to demonstrate how learning was influenced by rates of reinforcement. The discrete trials method was adapted as a therapy for developmentally delayed children and children with autism. For example, Ivar Lovaas pioneered the use of discrete trials for autistic children to help them learn skills ranging from making eye contact and following simple instructions to advanced language and social skills. Discrete trials involve breaking a behavior into its most basic functional unit and presenting the units in a series.

A discrete trial usually consists of the following: The antecedent, possibly combined with a prompt (a non-essential element used to assist learning or correct responding), the behavior of the student, and a consequence. If the student's behavior is what is desired, the consequence is something positive: food, candy, a game, praise, etc. If the behavior was not correct, the teacher offers the correct answer, then repeats the trial, possibly with more prompting if needed.

There is usually an inter-trial interval that allows for a few seconds to separate each trial, to allow the student to process the information, teaches the student to wait, and makes the onset of the next trial more discrete. Discrete trials can be used to develop most skills, which includes cognitive, verbal communication, play, social and self-help skills.

Techniques used in Applied Behavior Analysis

1. Chaining

Main article: Chaining
The skill to be learned is broken down into the smallest units for easy learning. For example, a child learning to brush teeth independently may start with learning to unscrew the toothpaste cap. Once the child has learned this, the next step may be squeezing the tube, and so on.

2. Prompting

The parent or therapist provides assistance to encourage the desired response from the child. The aim is to use the least intrusive prompt possible that will still lead to the desired response. Prompts can include:

* Verbal cues ie. "Take the toothpaste cap off" (Used the least as they are the hardest to fade)
* Visual cues ie. pointing at the toothpaste
* Physical guidance ie. moving the child's hands to unscrew the lid
* Demonstration ie. taking the cap off to show the child how it is done.

3. Fading

The overall goal is for a child to eventually not need prompts. This is why the least intrusive prompts are used, so the child does not become overly dependent on them when learning a new behavior or skill. Prompts are gradually faded out as then new behavior is learned. Learning to unscrew the toothpaste lid may start with physically guiding the child's hands, to pointing at the toothpaste, then just a verbal request.

4. Generalization

Once a skill is learned in a controlled environment (usually table-time), the skill is taught in more general settings. Perhaps the skill will be taught in the natural environment. If the student has successfully mastered learning colors at the table, the teacher may take the student around the house or his school and then re-teach the skill in these more natural environments.

5. Shaping

Main article: Reinforcing successive approximations
Shaping involves gradually modifying the existing behavior of a child into the desired behavior. If a child engages with a dog by hitting it, the child could have their behavior shaped by reinforcing interactions in which the child touches the dog more gently. Over many interactions, successful shaping would replace the hitting behavior with patting or other gentler behavior.

6. Differential reinforcement

Reinforcement provides a response to a child’s behavior that will most likely increase that behavior. It is “differential” because the level of reinforcement varies depending on the child’s response. Difficult tasks may be reinforced heavily whereas easy tasks may be reinforced less heavily. We must systematically change our reinforcement so that the child eventually will respond appropriately under natural schedules of reinforcement (occasional) with natural types of reinforcers (social).

7. Video modeling

One teaching technique found to be effective with some children is the use of video modeling (the use of taped sequences as exemplars of behavior). It can be used by therapists to assist in the acquisition of both verbal and motor resoponses, in some cases for long chains of behavior.[11]




Maintaining parental and professional relationships in the ABA approach

An adequate communication and a supportive relationship between educational systems and families allow children to receive a beneficial education. This pertains to typical learners as well as to children who need additional services. It was not until the 1960s that researchers began exploring Applied Behavior Analysis as a method to educate those children who fall somewhere on the autism spectrum. Behavioral analysts agree that consistency in and out of the school classroom is key in order for autistic children to maintain proper standing in school and continue to develop to their greatest potential.

Applied behavior analysis involves an entire team working together to address a child's needs. This team includes professionals such as speech therapists as well as the children's primary caregivers, who are treated as key to the implementation of successful therapy in the ABA model. The ABA method relies on behavior principles and a recommended curriculum that reflects an individual child's needs and abilities. As such, regular meetings with professionals to discuss programming are one way to establish a successful working relationship between a child's family and their school. When a caregiver can be the outlet source for the generalization of skills outside of school, it helps the child's therapy process by catering to the child's individual needs. In the ABA framework, developing and maintaining a structured working relationship between parents and professionals is essential to ensure consistency of thought and practice of behavioral methods.

Criticisms of ABA

Applied behavioral analysis has been criticized for several perceived failings.

Outcomes - The long term outcomes of ABA therapy have not been established, and there have been no investigations of improved quality of life in adulthood, as measured by criteria like the ability to maintain meaningful employment or relationships.[citation needed]. In the case of Auton (Guardian ad litem of) v. British Columbia (Attorney general), the Supreme Court of Canada ruled that since the outcomes of ABA were unproven and the treatment itself is still experimental, it could not be considered a "core treatment" (one for which the province is required to pay). The decision quoted the original trial judge, noting that "the trial judge found only that in “some cases” it may produce 'significant results'" [1]
Language - ABA and discrete trials are seen as less effective for improving 'functional language', the ability to use language to communicate effectively. Best practices for language learning now involve 'naturalized' teaching, mimicking the functions of language - requesting (manding), labeling (tacting) and obeying commands (receptive language).[12]
Objection from the autism rights movement - Autism rights activists oppose ABA for multiple reasons, ranging from its early dependency on aversives (in the original experiments the aversive was a cattle prod) to its goals of "extinguishing" even harmless autistic behavior such as stimming and rendering the child "undistinguishable from peers". Michelle Dawson, an autistic woman, filed an intervener factum in the Auton case challenging ABA on ethical grounds. [2]

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Private SPED Schools | Public SPED Schools



Legends:

A -Autism CP -Cerebral Palsy MG/FL – Mentally Gifted and
Fast Learner
ADD -Attention Deficit
Disorder DS -Down Syndrome OH -Orthopedically
Handicapped
ADHD -Attention Deficit Hyperactivity Disorder HI – Hearing Impaired SD Speech Defective
BP -Behavior Problem LD -Learning Disabled SL -Slow Learner
CI -Chronically Ill MC/MR -Mentally
Challenged and
Metally Retarded VI -Visually Impaired
SCHOOL ADDRESS TELEPHONE SCHOOL HEAD CLIENTELE
A. Manila
Brother of Charity Ortho-Pedagogical Inst. 2002 Jesus St., Pandacan, City of Manila 564-01-97 / 338-54-99 Bro. Antonio L. Benito MC, A
Granada Educational Foundation Inc., School for the Hearing Impaired 1126 R. Hidalgo St., Quiapo, City of Manila 736-29-38 / 733-99-18 / FX734-31-74 Bro. Romanito N. Salada HI
Sergia G. Esguerra Memorial Foundation, Inc. Girls Scout Headquarters, Nagtahan Bridge, Pandacan, City of Manila 564-0156 / 26 Ms. Julie G.Esguerra HI, DS, SD
St. Teodora School and Tutorial Arts Center 1425 3rd & 4th Flrs., Sanchez Ext., Tondo, City of Manila 251-79-50 / 252-89-72 Ms. Katherine A. Chuabio MC, A, ADD, ADHD
B. Quezon City
Abiertas Radiance School 21 Santolan Rd., Quezon City 415-67-46 / 412-46-96 / 726-97-28fx Ms. Ma. Asuncion Jose MC, ADHD, BP, MC, ADD
Akademia Schools, Inc. 57 Maginhawa St., UP Village, Quezon City
Bridges Foundation, Inc. 22 Scout Limbaga St., Timog Ave., Quezon City 372-07-52 to 53 Ms. Barbra D. Paguia/Ms.Lea Reyes A, MC, ADHD
Center for Developmental Intervention Foundation, Inc. Special School Phil. Children’s Medical Center Compound, Quezon Blvd., Quezon City 924-66-01 to 25 Loc. 264; 929-79-07 Fax Ms. Evelyn B. Caja MC, A, ADHD
Center for Exceptional Children 30 Branches St., GSIS Village, Proj. 8, Quezon City 929-97-65 / 928-07-68 Ms. Amparo C. Magtoto MC, ADHD, ADD, BP, LD
Cupertino Center for Special Children Mangyan Rd., La Vista Subd. Loyola Heights, Quezon City 928-41-15 Fax Dr. Ma. Therese Macapagal MC, A, ADHD
Fairfield School, Inc. 15 Matiaga St., Brgy. Central, Quezon City 926-5911 Dr. Mercedez Adorio MC, A, ADHD
Gentle Minds Learning Center 4 H.I. Ruby St., Cypress Village, Balintawak, Quezon City MC, ADHD, LD, MC, BP
Headway School for Giftedness, Inc. 130 Matahimik St., UP Village, Diliman, Quezon City 926-91-74 / 426-77-39 Ms. Maria Luz B. Estudillo Gifted / Talented
Integrative School of Quezon City Foundation,Inc. 13 Maginhawa St., UP Village, Quezon City 925-51-96 Ms. Rose Imelda P. Garcia MG, MR, A, BP. LD, ADHD
Immaculate Conception Cathedral School, Inc. 39 Lantana St., Cubao, Quezon City 727-27-40 to 44 loc. 404 / 721-7078 Ms. Bienvenida Roxas MR, A, ADHD
Lord Jesus Our Redeemer Christian Acad., Inc. 380 Quirino Highway, Brgy. Talipapa, Sangangdaan, Nov. 455-91-59 MR, A, ADHD
Ma. Lena Buhay Memorial Foundation 25 Starline Rd., cor. Milkyway Drive, Blue Ridge, Quezon City 647-10-76 res. / 647-12-70 Ms. Leticia N. Buhay, MS HI
Miriam Col.- Southeast Asian Institute for the Deaf Miriam College Compound, Katipunan Rd., Loyola Hts, Quezon City 426-01-71Fx / 925-72-57 Ms. Carolyn C. Ui HI
Montessori Children’s House, Inc. Panay Ave., Diliman, Quezon City 372-4413 / 697-4644 Ms. Sylvia Lazo MR, BP
Multiple Intelligence International. School Found., Inc. 4 Escaler St., Loyola Heights, Quezon City 928-01-43 / 433-4949 / 433-4948 Ms. Mary Joy Canon Abaquin HI, A
New Era University St. Joseph St., Milton Hills Subd., Diliman, Quezon City 981-4221 / 981-4240 Loc. 3915 Mr. Orlando Cabigting, Jr. MR, A, ADHD
New Hope SPED Center 14 Kasing-kasing St., East Kamias, Quezon City 921-87-58 Erlinda R. Tejero A, ADHD, ADD
P-M Calamba Learning Center, Inc. 2 Balete Drive, cor. N. Domingo, Quezon City 726-15-49 / 725-99-70 / 413-05-01 Mr. Chares M. Calamba BP
Resources for the Blind, Inc. 3 FCOTI Bldg., 623 EDSA, Cubao, Quezon City Early Intervention
Saints & Angel School Inc. P. Dela Cruz, San Bartolome, Novaliches, Quezon City 419-4798 Ms. Candida Arceo-Corpuz
Siena College Del Monte Ave., Quezon City 414-11-55 / 731-7920 Sr. Estrella T. Tangan, O.P. Ph.D. MR, A, ADHD, MC, LD
St. Anne’s Special School 3 Faith St.,Teresa Village, Brgy. Bahay Toro, Quezon City 9278619 / 926-88-96 Ms. Aurora T. Apuada MC, ADHD, LD
St. Francis K Six-VSA-Arts Philippines , Inc. Balabac St., Kapiligan, North Araneta Subd.,Quezon City 712-3731 Ms. Rebecca Santos HI
St. John Ma. de Vianney Special Education Learning and Resource Center 252 Scout Chuatoco, Roxas District, Quezon City 371-49-13TF / 373-52-20 Ms. Teresita G. de Mesa,ED,D. SL, LD, MC, BP, A. ADHD
St. Joseph College 295 E. Rodriguez Sr. Blvd., Quezon City 723-02-21 Loc. 126 Sis Mercedes Salud MC, A, ADHD, ADD
Sto. Niño Special Education Center Foundation, Inc. 20 M. Cruz St., Brgy. Kaligayahan, Novaliches, Quezon City 939-60-16 / 939-89-23 TF Mrs. Remedios Agahan MC, A, HI, LD
Take the Nations For Jesus Christian Academy 771 Aurora Blvd., Brgy. Mariana, Quezon City 725-2779 / 725-3114 Mrs. Ida W. Matriano MC, A, LD
T. D. & S. Hope Christian Academy Iris St., cor. Dahlia Ave., West Fairview, Quezon City 428-30-23 / 930-8647Fx Mrs. Eleanor L. Pedro MR, A, ADHD, LD, MC
The Child’s World – A Growing Center 732 Amoranto Ave., Sta. Mesa Heights, Quezon City 712-47-22 / 712-48-55 / 783-7586 Ms. Evelina Tan CP, LD, A
Tumble N Touch Special Learning Center 16 P. Tuason St., Proj. 4 , Quezon City 438-83-27 / 438-88-22 / 437-18-39 Ms. Lourdes Lero MC, FL, ADHD, ADD
Wee Care Child Health Development 44 Malingap St., Teachers Village, Quezon City 433-73-70 Dr. Regina Cailao MC, A, DS, HI, CP, ADHD
Wordlab School, Inc. 28 7th St., New Manila, Quezon City 724-38-71 / 727-97-62 Ms. Faye Matea Casis LD, ADHD, ADD, MC
C. Pasay City
Capt. Wilijado P. Abuid- Escuela De La Vida 33 A. Arnaiz Ave.,Cor. Robert St., Libertad, Pasay City 831-15-25 / 551-51-57 Ms. Jenrose Franco MC, A, ADHD
D. Caloocan City
E.M. Castro Sped Learning Center Blk 5, Lot 30, Soldiers Hills III, Caloocan City 961-55-99 / 961-55-92 Dr. Ella M. Castro FL, LD, ADHD
Holy Rosary College Foundation 1427 Fr. Hofstee St., Tala, Caloocan City 962-84-18 Mrs. Dolora D. Loquinarioo A, SL, ADD,, ADHD
Secret of God’s Child Learning Center, Inc. 176 12th Ave. cor. Rosal St., Grace Park, Caloocan City 363-48-92 Mr. Noel L. Beriña II MC, A, ADD
E. Mandaluyong City
Angeli Dei School 449 Malaya St., Plainview, City of Mandaluyong 532-57-95 / 532-63-16TF Ms. Leticia U. Uy MC, HI, A, LD, ADHD
F. Marikina City
Eucharistiana Center for Special Children 5 Russet St.,SSS Village, Concepcion II, Marikina City 941-81-35 Mr. Peter F. Mallonga MC, A, ADHD
Majestic Math for Kids and Special Education Center 2 Diego Silang St., San Roque, Marikina City MC, A, ADHD, LD, ADD
Sta. Clara Learning Center of Marikina City 117 M.H. del Pilar St., Kalumpang, Marikina City 645-49-45 / 645-1232 Dr. Telly S. Cheng MC, A, ADHD, ADD, MD
G. Makati City
Carolina Learning Center 1128 E. Rodriguez Ave., Bangkal, Makati City 843-19-92 TF / 833-83-51 Ms. Ola Del Mundo MC, A, BP, LD, OH, ADHD
Little Kids of I.S.A.A.C. 2697 Rodriguez Ave., Corner Cailles St. Bangkal, Makati City 886-44-58 MR, BP, A, ADD, ADHD
REACH International School Inc. 67 Oaseo de Roxas St., Urd. Vill., Makati City 812-05-77/751-99-52 Ms. Martha Cynthia Tinsay Gonzalez MC, ADHD, LD, MD
Stepping Stone Learning & Resource Center MRTC Bldg., Camia St., Guadalupe Viejo, Makati City 896-02-69 / 899-83-83 Ms. Marissa Labajo MC, A, CP, DS, MH, ADHD
St. Colleta Special School 2118 – L Nuestra Señora cor. Antipolo St., Guadalupe Nuevo, Makati City 750-67-61 Ms. Remedios Mendez MC, ADHD, ADD, LD, SL
Skill Camp Learning Center Philippines, Inc. La Fuerza Plaza II, 2241 Chino Roces, cor. Sabio St., Makati 893-47-33 / 812-50-87 MC, A, ADHD, ADD, SL, MD
H. Pasig City
Guardian Angel Learning Center of Pasig Lot 2,Blk 1 Almon St., Northwest Vill.,Sta. Lucia, Pasig City 401=12-65 / 655-46-18 Dr. Lorenzo E. E. Gamos A, ADD, ADHD
Laro, Lapis at Libro Center for Learners 110 Amang Rodriguez Jr. Ave., De La Paz, Pasig City 915-52-65 / 475-3119 Dr. Rosario Margarita A. Aligada MR, A, ADHD
Mariam Claire Integrated School 106 Hawaii St., Greenpark, De La Paz, Pasig City 916-05-70 / 416-53-78 Ms. Mayumi Dino A, ADHD, MC
Our Lady of Salvation Educ’l. Integration Found. Ctr. 166 D.A. Luna St., Malinao, Pasig City 643-55-16 Ms. Salve S. Labrador A, MC, DS, ADHD, ADD
Shine Special Education Center, Inc. 33 San Rafael cor. San Roque, Brgy., Kapitolyo,Pasig City 635-59-60 Ms. Ma. Rosario G. Joaquin Autism, other related disorders
Westdrive Education Foundation, Inc. 20 West Capitol Drive, Kapitolyo, Pasig City 631-45-36TF Ms. Wilma Viña Luz D. De Leon A, BP, MC, HI
I. San Juan City
Donum Dei Academy 152 F. Blumenttrit Rd., Cor. R. Pascual, Batis, San Juan City 744-40-93 Miss Teresita G. Garica A, BP, CI, LD, ADHD, ADD
Kids World Integrated School, Inc. Johnson Clubhouse, North Greenhills, San Juan City 726-65-70 Ms. Ingrid Yap MR, A, ADHD, ADD, SL
Learning Partners School, Inc. 189 Pilar St., Addition Hills, San Juan City 725-76-10 Ms. Josephine V. Nepomoceno HI. MC
Resalest Educational Center 12 A Allenby St., Maytunas, San Juan City 705-18-42 Mrs. Alicia G. Rea BP, ADHD
Tabernacle of Faith Christian Academy 151 J. Ruiz St., Salapan, San Juan City 723-77-60 / 62, 727-07-50TF Rev. Domingo T. Taniegra, Jr. A, SL, MC, PDD, ADHD
J. Parañaque City
Ann Arbor Montessori Learning Center 390 El Grande Ave., BF Homes, Parañaque City 826-6972 / 826-6028 / 825-0591Fax Dr. Lourdes L. Carpio A, MC, ADHD
Blessed Luisa School 96 San Gabriel St.,San Antonio Valley, San Isidro, Parañaque City 825-27-36TF Mrs. Ma. Luisa E. Shiapno MC, A, ADHD
KC Pre School Tutorial & Review Center,Inc. 252 Aguirre Ave., BF Homes, Parañaque City 809-45-53 Marie Josephine C. Solano MR, A, ADHD, LD, SL
Stone Castle Learning Center 19 Britain St., Betterliving Subd., Parañaque City 823-01-77 Ms. Mary Ann A. Muñoz MR, A, ADHD, ADD
The Learning Center, Inc. 134 Carmelite St., Merville Subd., Parañaque City 824-99-62 / 824-99-64 Ms. Ma. Yolanda Michelle Bautista MC, BP, HI, OH, ADHD
Trust in God Learning School, Inc. 35 Germany St., Ethiopa Better Living, Parañaque City MR A, ADHD, SL, LD
K. Las Piñas City
Academy of Jesus, Inc. V. Guinto St., Manuel V. Pamplona, Las Piñas City 874-25-56 / 874-55-73 / 874-35-31 Ms. Brenda L. Gulapa MR A, ADHD, ADD
ALPHASTAR Educational Centre, Inc. Ph 3 L 4 B. A. Liwanag St. Classic I, BFRV, City of Las Piñas 875-28-36 Ms. Ophelia M. So MC, A, ADHD
Bright Morning Star School St. Joseph Subd., Pulang Lupa, City of Las Piñas 829-94-56 Ms. Marietta Bajamundi ADHD, LD, SL, MC, MR
Center for Autism &Related Disorders 898 Palace Rd., BF Homes, City of Las Piñas 820-8719 Ms. Rebecca S. Esguerra A, ADHD, ADD, MC, MD
De La arese Montessori School, Inc. St. Peter, Pulanlupa 1, Las Piñas City 871-7275 Dr. Nelia Sorvida MR, A, ADHD, BP
H.O.P.E. Development Center for Children, Inc. 41 Mariano Ponce cor. Tropical St., Ph V BF Homes Executive. Village, City of Las Piñas 801-07-94 / 801-79-01TF / 632-37-50 Mrs. Nida Socorro Gusto MC, ADD, A, ADHD
Integrated Movement Academy, Inc. 33 Gloria Diaz St., BF Resort Village, Pamplona, City of Las Piñas 871-21-23 Ms. Glecita Repia MC, A, ADHD
Joseph Gualandi School for Hearing Impaired, Inc. 66-A Periquet St., BF Homes Exec. Village, City of Las Piñas 829-64-50 / 829-6091 Sr. Elena Serafino HI
Kidzone Guided Development Centre Block 1 Lot 4, Garmet St., Manuela Homes, Talon V, LP MR, A, ADHD, ADD, LD, SL
Las Pinas Montessori School Gumamela St.cor. DamadeNoche, Vergonville Vill., City of Las Piñas 871-17-25 / 872-58-08 Ms. Rowena Lorenzo MC, A, OH, HI, LD, ADHD
Mary Immaculate Parish Special School Agro Homes I, Talon 5, City of Las Piñas 805-50-80TF / 806-40-46 Rev. Fr. Fidel G. Fabile MC, SL, HI, A, VI, BP, ADHD
PATUBAES Learning Center (DSWD) 21 Marigold St., Vergonville, Pulang-lupa 2, City of Las Piñas 871-97-40 Ms. Bibiana Q. Basa MC, HI, LD, DS, A, ADHD, CP
Silverdale Learning Resource Center Italia 500, BF Resort Village, Batican Drive 873-82-96 / 873-04-15 / 873-73-73 Dr. Leisa M. Gaviola MH
Skyword Southern Academy(Skyview Learning Center) L1, B5 Venezia cor. Ozaita Sts., BF Resort Vill., Talon 2, City of Las Piñas 871-70-58 / 871-10-14 Ms. Angelita Landrito A, MR, DD. ADHD
Southville International School Luxemburg, BF Homes 842-88-11 / 825-63-74 Dr. Genevie Tan Mentally Gifted
Special Care Development Center Blk 10, Lot 3, Catmon Rd., Pilar Village, City of Las Piñas 801-43-02 / 806-83-34 TF / 871-51-67 Ms. Lolita Serrano MC, HI,, ADHD, A, SD, LD, CP, MH
The Village Plygroup Foundation, Inc. 68 Lalaine Bennet St., BF Resort Village, Pamplona, LP
L. Valenzuela City
Bible Institute for the Deaf Gov. Ignacio Santiago St., Malinta, Valenzuela City 444-19-26 / 294-62-75TF Ms. Ellen Castillo HI
St. Mary’s Angels School of Valenzuela P. Gomez St., Fortune Village 7, Parada, Valenzuela City 291-11-36 / 37 Mrs. Susan C. Ramos A, DS, ADHD, GDD, LD, SD, ,ADHD, BP
M. Malabon and Navotas City
De La Salle – Araneta University Victoneta Ave., Salvador Araneta Campus, Malabon City 330-91-28 to 33 Loc. 118 Dr. Jidith D. Aldaba MR, ADD, ADHD, A, MC
Higher Ground Baptist Academy Foundation, Inc. 6 Maria Clara St.., Acacia, Malabon City
T.A.L.K. Learning Center, Inc. 83 Bronce St., Tugatog, Malabon City 287-18-16 Mrs. Josefina Valeriano HI
N. Taguig City and Pateros
St. Martha’s Development & Learning Center 42 M. Lozada St., Sto. Rosario, Silangan, Pateros 642-53-17TF Ms. Desi Villo OH, A, BP, ADHD, ADD, MC
O. Muntinlupa
Anima Christi for Learning and Human Development #5 St. Mark St., San Jose Village, Alabang, City of Muntinlupa 809-74-45TF / 807-41-69 / 842-64-63 Mrs. Rizalina G. Ochoa ADHD, LD, MC, A, SL, HI, BP
Colegio De Nuestra Señora de Guadalupe Umali Cpd. , Summitville Subd., Putatan Muntinlupa City 861-10-19 / 862-00-57 Ms. Ma. Noli M. Chua
St. Agustine School for the Deaf Blk 18 L-3, Gladiola, Doña Rosario, Bayview, Sucat 837-06-11 / 838-63-91 Ms. Rhodora Pamaran HI
The Birthright Educators Foundation 0348 Beverly St., Park Homes, Tunasan, City of Muntinlupa 850-19-87 Mrs. Miriam Del Rosario A, BP, HI, OH, SD, VI, MC, ADHD

What is ABA or Applied Behavior Analysis?
ABA
(Applied Behavior Analysis)

History

Applied behavior analysis is the applied side of the experimental analysis of behavior. Its origin can be traced back to Teodoro Ayllon & Jack Michael's 1959 article The psychiatric nurse as a behavioral engineer.[13] The research basis of ABA can be found in the theoretical work of behaviorism and radical behaviorism originating with the work of B. F. Skinner.

Applied Behavior Analysis now encompasses treatments in applied settings in things as varied as leisure skills development, improving sports performance, cigarette smoking cessation, increasing exercise, and other areas.

Definition: "[ABA is] the design, implementation, and evaluation of environmental modifications to produce socially significant improvement in human behavior. ABA includes the use of direct observation, measurement, and functional analysis of the relations between environment and behavior. ABA uses antecedent stimuli and consequences, based on the findings of descriptive and functional analysis, to produce practical changeThis definition places emphasis on socially significant changes, but ABA can be used to alter virtually any behavior irrespective of its social relevance.

The components of any behavior are as follows: A.B.C

Antecedent: a verbal or physical stimulus such as a command or request. This may come from the environment or from another person, or even internal to the subject.
Behavior: the student's response
Consequence: What happens conditional to the behavior. In controlled situations the consequence is that the student receives something motivational to him/her: commonly food, rewards, praise, a toy, etc. Consequence could also include correction (or punishment, but this is rarely used).


The key aspects of ABA are

Observation of current behavior for topography (what the movement looks like), frequency, antecedents and consequences
Breaking down desired skills into steps
Teaching the steps through repeated presentation of discrete trials
Data on performance is tracked to show changes over time


Facts about ABA

ABA is one of the most common, and the only proven, method used to treat autism
Applied Behavior Analysis has been shown to be an effective means of intervention for adults and children with pervasive developmental disorder and is one of the most widely used with this population.
The ABA approach teaches social, motor, and verbal behaviors as well as reasoning skills.
ABA therapy is especially useful in teaching behaviors to children with autism who do not otherwise "pick up" on these behaviors on their own as other children would.
ABA teaches these skills through use of careful behavioral observation and positive reinforcement or prompting to teach each step of a behavior.
Generally ABA involves intensive training of the therapists, extensive time spent in ABA therapy (20-40 hours per week) and weekly supervision by experienced clinical supervisors known as a certified behavior analyst.[10]



An increasing amount of research in the field of ABA is concerned with autism; and it is a common misconception that Behavior Analysts work almost exclusively with individuals with autism and that ABA is synonymous with Discrete Trials teaching. ABA principles can also be used with a range of typical or atypical individuals whose issues vary from demonstrating developmental delays, significant behavioral problems or undesirable habits.

ABA is often confused as a table-only therapy. Properly performed, ABA should be done in the table and natural environments, depending on the student's progress and needs. Once a student has mastered a skill at the table, the ABA team should move the student into a natural environment for further training and generalization of the skills just learned.

Frequently, the Assessment of Basic Language and Learning Skills (ABLLS) is used to create a baseline of the autistic (or otherwise diagnosed) learner's functional skill set. The ABLLS breaks down the learner's strengths and weaknesses to best tailor the ABA curriculum to them. By focusing on the exact skills that need help, the teacher does not waste time teaching a skill the student knows. This can also prevent student frustration at attempting a skill for which he or she is not ready.


Discrete trials

Discrete trials were originally used by B. F. Skinner in his experimental studies with rats and pigeons to demonstrate how learning was influenced by rates of reinforcement. The discrete trials method was adapted as a therapy for developmentally delayed children and children with autism. For example, Ivar Lovaas pioneered the use of discrete trials for autistic children to help them learn skills ranging from making eye contact and following simple instructions to advanced language and social skills. Discrete trials involve breaking a behavior into its most basic functional unit and presenting the units in a series.

A discrete trial usually consists of the following: The antecedent, possibly combined with a prompt (a non-essential element used to assist learning or correct responding), the behavior of the student, and a consequence. If the student's behavior is what is desired, the consequence is something positive: food, candy, a game, praise, etc. If the behavior was not correct, the teacher offers the correct answer, then repeats the trial, possibly with more prompting if needed.

There is usually an inter-trial interval that allows for a few seconds to separate each trial, to allow the student to process the information, teaches the student to wait, and makes the onset of the next trial more discrete. Discrete trials can be used to develop most skills, which includes cognitive, verbal communication, play, social and self-help skills.

Techniques used in Applied Behavior Analysis

1. Chaining

Main article: Chaining
The skill to be learned is broken down into the smallest units for easy learning. For example, a child learning to brush teeth independently may start with learning to unscrew the toothpaste cap. Once the child has learned this, the next step may be squeezing the tube, and so on.

2. Prompting

The parent or therapist provides assistance to encourage the desired response from the child. The aim is to use the least intrusive prompt possible that will still lead to the desired response. Prompts can include:

* Verbal cues ie. "Take the toothpaste cap off" (Used the least as they are the hardest to fade)
* Visual cues ie. pointing at the toothpaste
* Physical guidance ie. moving the child's hands to unscrew the lid
* Demonstration ie. taking the cap off to show the child how it is done.

3. Fading

The overall goal is for a child to eventually not need prompts. This is why the least intrusive prompts are used, so the child does not become overly dependent on them when learning a new behavior or skill. Prompts are gradually faded out as then new behavior is learned. Learning to unscrew the toothpaste lid may start with physically guiding the child's hands, to pointing at the toothpaste, then just a verbal request.

4. Generalization

Once a skill is learned in a controlled environment (usually table-time), the skill is taught in more general settings. Perhaps the skill will be taught in the natural environment. If the student has successfully mastered learning colors at the table, the teacher may take the student around the house or his school and then re-teach the skill in these more natural environments.

5. Shaping

Main article: Reinforcing successive approximations
Shaping involves gradually modifying the existing behavior of a child into the desired behavior. If a child engages with a dog by hitting it, the child could have their behavior shaped by reinforcing interactions in which the child touches the dog more gently. Over many interactions, successful shaping would replace the hitting behavior with patting or other gentler behavior.

6. Differential reinforcement

Reinforcement provides a response to a child’s behavior that will most likely increase that behavior. It is “differential” because the level of reinforcement varies depending on the child’s response. Difficult tasks may be reinforced heavily whereas easy tasks may be reinforced less heavily. We must systematically change our reinforcement so that the child eventually will respond appropriately under natural schedules of reinforcement (occasional) with natural types of reinforcers (social).

7. Video modeling

One teaching technique found to be effective with some children is the use of video modeling (the use of taped sequences as exemplars of behavior). It can be used by therapists to assist in the acquisition of both verbal and motor resoponses, in some cases for long chains of behavior.[11]




Maintaining parental and professional relationships in the ABA approach

An adequate communication and a supportive relationship between educational systems and families allow children to receive a beneficial education. This pertains to typical learners as well as to children who need additional services. It was not until the 1960s that researchers began exploring Applied Behavior Analysis as a method to educate those children who fall somewhere on the autism spectrum. Behavioral analysts agree that consistency in and out of the school classroom is key in order for autistic children to maintain proper standing in school and continue to develop to their greatest potential.

Applied behavior analysis involves an entire team working together to address a child's needs. This team includes professionals such as speech therapists as well as the children's primary caregivers, who are treated as key to the implementation of successful therapy in the ABA model. The ABA method relies on behavior principles and a recommended curriculum that reflects an individual child's needs and abilities. As such, regular meetings with professionals to discuss programming are one way to establish a successful working relationship between a child's family and their school. When a caregiver can be the outlet source for the generalization of skills outside of school, it helps the child's therapy process by catering to the child's individual needs. In the ABA framework, developing and maintaining a structured working relationship between parents and professionals is essential to ensure consistency of thought and practice of behavioral methods.

Criticisms of ABA

Applied behavioral analysis has been criticized for several perceived failings.

Outcomes - The long term outcomes of ABA therapy have not been established, and there have been no investigations of improved quality of life in adulthood, as measured by criteria like the ability to maintain meaningful employment or relationships.[citation needed]. In the case of Auton (Guardian ad litem of) v. British Columbia (Attorney general), the Supreme Court of Canada ruled that since the outcomes of ABA were unproven and the treatment itself is still experimental, it could not be considered a "core treatment" (one for which the province is required to pay). The decision quoted the original trial judge, noting that "the trial judge found only that in “some cases” it may produce 'significant results'" [1]
Language - ABA and discrete trials are seen as less effective for improving 'functional language', the ability to use language to communicate effectively. Best practices for language learning now involve 'naturalized' teaching, mimicking the functions of language - requesting (manding), labeling (tacting) and obeying commands (receptive language).[12]
Objection from the autism rights movement - Autism rights activists oppose ABA for multiple reasons, ranging from its early dependency on aversives (in the original experiments the aversive was a cattle prod) to its goals of "extinguishing" even harmless autistic behavior such as stimming and rendering the child "undistinguishable from peers". Michelle Dawson, an autistic woman, filed an intervener factum in the Auton case challenging ABA on ethical grounds. [2]

Your Full Name
Your Address
SUBURB STATE POSTCODE
Telephone/Mobile Number

DATE

Mr/Ms (Name of your Boss/Manager)
Job Title
Company Name
Address number and street name
SUBURB STATE POSTCODE


Dear (Name of contact person), (if you don’t know who to address it to, use ‘Dear Sir or Madam’)

RE: Notice of Resignation

I wish to inform you that I will be resigning from my job as a (your job title), on (date), and I will conclude my employment (?) weeks from this date.

I have accepted another position that will further develop my skills. (you can give your reason for leaving but this is optional)

Working with the company has allowed me to gain important knowledge over the last (?) years (or how long you were employed).

I would like to take this opportunity to thank you for letting me provide my services.


Yours sincerely
(your signature)
(your name printed)

SACKS’ SENTENCE COMPLETION TEST

NATURE OF THE TEST

Dr. Joseph M. Sacks and other psychologist of the New York Veterans Administrative Mental Hygiene Service developed a sentence completion test designed to obtain significant clinical material in four representative areas of adjustment namely: • family • sex • interpersonal relationship • self-concept

It has felt that items included in this test present sufficient opportunities for the subject to express his attitudes so that clinical psychologist may infer his dominant personality traits/trends. Such information is useful in screening patient for therapy, which gives clues to content and dynamics of patients’ attitudes and feelings.

NATURE OF THE SCALE FAMILY The family area included three sets of attitudes namely: a) those towards mother, b) father, and c) family unit. It is hoped that even when the subject becomes evasive or cautious, at least one of the four items in each area will reveal significant response.

SEX The sex area includes attitudes towards woman and heterosexual relationship. The 8 items in this area allows the subject to express himself with regards to woman, towards marriage, and with respect to sexual relationship.

INTERERSONAL RELATIONSHIP The area of interpersonal relationship includes attitudes towards friends and acquaintances, colleagues at work or school, superior at work or school, and people supervised. The 16 items in this area affords the subject to express his feelings towards those.

SELF-CONCEPT The area of self-concept includes fear, guilt feelings, goals and attitudes towards one’s own ability, concept of himself as he is, he was and as he hopes to be. There are 24 items included in this area.

SCORING AND INTERPRETATION A rating sheet has been advised for the SSCT which brings together under each attitude, the four stimulus item and the subject’s responses to them.

For example:

Attitude towards Father items: 1. I feel that my father seldom works. 16. If my father would do better. 31. I wish that my father is dead. 46. I feel that my father is no good. Those four responses are considered together and interpretative summary is made that crystallizes the clinician’s impression of the subjects’ attitude towards in this area. In this case, the summary stated: “Extreme hostility and contempt or overt death wishes” A rating is made of the subject’s degree of disturbance in this area according to the following scale:

2 - SEVERELY DISTURBED Appears to require the therapeutic aid in handling emotional conflicts in this area. 1 – MILDLY DISTURBED Has emotional conflict in this area but appears able to handle them without therapeutic aid. 0 – No Significant disturbance rated in this area X – Unknown, Insufficient evidence

Sacks and Levy feel that it is more desirable to point out areas of disturbance and determine these through a constellation of response. The validity of the rating is dependent of course upon the clinical background of the examiner as well as upon materials produced by the subject.

The following are the summaries and ratings of the individual attitudes and outlines presented for a general summary of the SSCT findings. This includes the following:

1. Statement of those areas in which subject shows the most disturbed attitudes. This may provide significant clues for therapist. 2. A description of the interrelationships between attitudes with respect to content. This often illuminates dynamic factors in the case.

Certain influences on the subject’s personality structure case be made on the basis of the SSCT, such as: 1. The subject’s manner of response to impulse from within or to stimuli from the environment. 2. The subject’s nature of response to stress –impulsive or well-controlled. 3. The subject’s thinking content: realistic, artistic, and fantastic.

Interpretation Guide

Attitude towards Mother (14, 29, 44, 59) 2 = Completely rejects and depreciates mother whom he considers over demanding. 1 = Sees mother’s fault but accepts and tolerates differences. 0 = express only positive feelings towards the mother.

Attitude towards Father (1, 16, 31, 46) 2 = feels extreme hostility and contempt with overt death wishes. 1 = admires father but wishes that their relationship were closer. 0 = expresses complete satisfaction with father’s personality.

Attitude towards Family Unit (2, 27, 42, 57) 2 = feels rejected by the family which lacks solidarity and which has constantly contended with difficulties. 1 = aware that the family does not recognize him as a mature person but has no difficulty in relating with them. 0 = instability of the family domicile has had little effect on his favorable feeling towards them.

Attitude towards Women ( 10, 25, 40, 55) 2 = extremely suspicious, possible homosexual tendency 1 = high ideas but ambivalent feelings. 0 = only minor or superficial criticisms

Attitude towards Heterosexual Relationship (11,26,41,56) 2 = appears to have given up achieving good sexual adjustment 1 = deserved sexual experiences but reservation about his ability to maintain marital relationship. 0 = indicates satisfaction towards this area

Attitude towards Friends and Acquaintances (8,23,38,53) 2 = suspicious and apparently seclusive 1= seems to wait approval of others before committing himself emotionally 0 = express mutual relationship with friends and self

Attitude towards People Supervised (4,19,34,58) 2 = feels he can handle or control hostility in handling others 1 = feels capable of doing good supervisory but has misgivings about assuming an authoritarian role. 0 = feels controllable and well accepted by subordinates.

Attitude towards Supervisors at work or School (6,21,36,51) 2 = resents or fear authority 1 = mild difficulty in accepting difficulty 0 =

Attitude towards Colleague at work/school (13,28,43,58) 2 = feels rejected by colleagues, and condemns them 1 = has some difficulty at work and depends on colleagues 0 = expresses good mutual feelings

Fear (7,22,37,52) 2 = disturbed by the apparent fear of loving, possibility to control his feelings 1 = fear of self-assertion which is fairly common and not pervasive. 0 = lack of fear

Guilt Feelings (15,30,45,60) 2 = concerned with spiritual feeling and physical sex drives 1 = has regret over past and seems mildly disturbed by his failure to control his trouble. 0 = does not seem to be aware of guilt feelings

Attitude towards Own Ability (2,7,32,47) 2 = feels completely incompetent and hopeless 1 = feels he has a specific ability but tends to fear difficulty 0 = confident on his ability to overcome obstacles

Attitude towards Past (9,24,39,54) 2 = feels rejected and isolated 1 = 0 = feels well adjusted, no significant disturbance in the past

Attitude towards the Future (5, 20, 35, 50) 2 = pessimistic, no hope in his own resources for happiness and success 1 = unsure of himself but tries to be optimistic 0 = seems confident in achieving his goals

Goals (3, 18,53,49) 2 = lack of motivation for achievement 1 = desires material things for family as well as for himself 0 =

History
Herman Von Ebbinghaus is generally credited with developing the first sentence completion test in 1897.[1] Ebbinghaus’s sentence completion test was used as part of an intelligence test.[2]

Carl Jung’s word association test may also have been a precursor to modern sentence completion tests.

In recent decades, sentence completion tests have increased in usage, in part because they are easy to develop and easy to administer. As of the 1980s, sentence completion tests were the seventh most widely used personality assessment instruments.[3]

Another reason for the increased usage of sentence completion tests is because of their superiority to other measures in uncovering conflicted attitudes.[4]

Some sentence completion tests were developed as a way to overcome the problems associated with thematic apperception measures of the same constructs.[2]

Uses
The uses of sentence completion tests include personality analysis, clinical applications, attitude assessment, achievement motivation, and measurement of other constructs. They are used in several disciplines, including psychology, management, education, and marketing.

Sentence completion measures have also been incorporated into non-projective applications, such as intelligence tests, language comprehension, and language and cognitive development tests.[5]

Examples of sentence completion tests
There are many sentence completion tests available for use by researchers. Some of the most widely used sentence completion tests include:

Rotter Incomplete Sentence Blank (assesses personality traits; perhaps the most widely used of all sentence completion tests).
Miner Sentence Completion Test (measures managerial motivations).
Washington University Sentence Completion Test (measures ego development).
Data analysis, validity and reliability
The data collected from sentence completion tests can usually be analyzed either quantitatively or qualitatively.[6]

Sentence completion tests usually include some formal coding procedure or manual. The validity of each sentence completion test must be determined independently and this depends on the instructions laid out in the scoring manual.

Compared to positivist instruments, such as Likert-type scales, sentence completion tests tend to have high face validity (i.e., the extent to which measurement items accurately reflect the concept being measured). This is to be expected, because in many cases the sentence stems name or refer to specific objects and the respondent is provides responses specifically focused on such objects.

References
^ Rhode, A.R. (1957) The Sentence Completion Method. New York: The Ronald Press 1957; Lah, M.I. (1989). Sentence Completion Tests. In C.S. Newmark (Ed.), Major psychological assessment instruments, Vol II (pp 133-163). Boston: Allyn and Bacon.
^ a b Ibid.
^ Holaday, M., Smith, D.A. & Sherry, A. (2000). Sentence completion tests: A review of the literature and results of a survey of members of the society for personality assessment. Journal of Personality Assessment, 74, 371-383.; Lubin, B., Larsen, R.M. & Matarazzo, J.D. (1984). Patterns of psychological test usage in United States: 1935-1982. American Psychologist, 39, 451-454.
^ Lawrence C. Soley & Aaron Lee Smith (2008). Projective Techniques for Social Science and Business Research. Milwaukee: The Southshore Press.
^ Ibid.
^ Ibid.

Sentence completion tests are a class of semi-structured projective techniques. Sentence completion tests typically provide respondents with beginnings of sentences, referred to as “stems,” and respondents then complete the sentences in ways that are meaningful to them. The responses are believed to provide indications of attitudes, beliefs, motivations, or other mental states. There is debate over whether or not sentence completion tests elicit responses from conscious thought rather than unconscious states. This debate would affect whether sentence completion tests can be strictly categorized as projective tests.

A sentence completion test form may be relatively short, such as those used to assess responses to advertisements, or much longer, such as those used to assess personality. A long sentence completion test is the Forer Sentence Completion Test, which has 100 stems. The tests are usually administered in booklet form where respondents complete the stems by writing words on paper.

The structures of sentence completion tests vary according to the length and relative generality and wording of the sentence stems. Structured tests have longer stems that lead respondents to more specific types of responses; less structured tests provide shorter stems, which produce a wider variety of responses.

Introduction: Bipolar Disorder

This booklet discusses bipolar disorder in adults. For information on bipolar disorder in children and adolescents, see the NIMH booklet, “Bipolar Disorder in Children and Teens: A Parent’s Guide.”

What is bipolar disorder?

Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. Symptoms of bipolar disorder are severe. They are different from the normal ups and downs that everyone goes through from time to time. Bipolar disorder symptoms can result in damaged relationships, poor job or school performance, and even suicide. But bipolar disorder can be treated, and people with this illness can lead full and productive lives.

Bipolar disorder often develops in a person's late teens or early adult years. At least half of all cases start before age 25.1 Some people have their first symptoms during childhood, while others may develop symptoms late in life.

Bipolar disorder is not easy to spot when it starts. The symptoms may seem like separate problems, not recognized as parts of a larger problem. Some people suffer for years before they are properly diagnosed and treated. Like diabetes or heart disease, bipolar disorder is a long-term illness that must be carefully managed throughout a person's life.

What are the symptoms of bipolar disorder?

People with bipolar disorder experience unusually intense emotional states that occur in distinct periods called "mood episodes." An overly joyful or overexcited state is called a manic episode, and an extremely sad or hopeless state is called a depressive episode. Sometimes, a mood episode includes symptoms of both mania and depression. This is called a mixed state. People with bipolar disorder also may be explosive and irritable during a mood episode.

Extreme changes in energy, activity, sleep, and behavior go along with these changes in mood. It is possible for someone with bipolar disorder to experience a long-lasting period of unstable moods rather than discrete episodes of depression or mania.

A person may be having an episode of bipolar disorder if he or she has a number of manic or depressive symptoms for most of the day, nearly every day, for at least one or two weeks. Sometimes symptoms are so severe that the person cannot function normally at work, school, or home.

Symptoms of bipolar disorder are described below.

Symptoms of mania or a manic episode include: Symptoms of depression or a depressive episode include:
Mood Changes
A long period of feeling "high," or an overly happy or outgoing mood
Extremely irritable mood, agitation, feeling "jumpy" or "wired."
Behavioral Changes
Talking very fast, jumping from one idea to another, having racing thoughts
Being easily distracted
Increasing goal-directed activities, such as taking on new projects
Being restless
Sleeping little
Having an unrealistic belief in one's abilities
Behaving impulsively and taking part in a lot of pleasurable,
high-risk behaviors, such as spending sprees, impulsive sex, and impulsive business investments.
Mood Changes
A long period of feeling worried or empty
Loss of interest in activities once enjoyed, including sex.
Behavioral Changes
Feeling tired or "slowed down"
Having problems concentrating, remembering, and making decisions
Being restless or irritable
Changing eating, sleeping, or other habits
Thinking of death or suicide, or attempting suicide.
In addition to mania and depression, bipolar disorder can cause a range of moods, as shown on the scale.



One side of the scale includes severe depression, moderate depression, and mild low mood. Moderate depression may cause less extreme symptoms, and mild low mood is called dysthymia when it is chronic or long-term. In the middle of the scale is normal or balanced mood.

At the other end of the scale are hypomania and severe mania. Some people with bipolar disorder experience hypomania. During hypomanic episodes, a person may have increased energy and activity levels that are not as severe as typical mania, or he or she may have episodes that last less than a week and do not require emergency care. A person having a hypomanic episode may feel very good, be highly productive, and function well. This person may not feel that anything is wrong even as family and friends recognize the mood swings as possible bipolar disorder. Without proper treatment, however, people with hypomania may develop severe mania or depression.

During a mixed state, symptoms often include agitation, trouble sleeping, major changes in appetite, and suicidal thinking. People in a mixed state may feel very sad or hopeless while feeling extremely energized.

Sometimes, a person with severe episodes of mania or depression has psychotic symptoms too, such as hallucinations or delusions. The psychotic symptoms tend to reflect the person's extreme mood. For example, psychotic symptoms for a person having a manic episode may include believing he or she is famous, has a lot of money, or has special powers. In the same way, a person having a depressive episode may believe he or she is ruined and penniless, or has committed a crime. As a result, people with bipolar disorder who have psychotic symptoms are sometimes wrongly diagnosed as having schizophrenia, another severe mental illness that is linked with hallucinations and delusions.

People with bipolar disorder may also have behavioral problems. They may abuse alcohol or substances, have relationship problems, or perform poorly in school or at work. At first, it's not easy to recognize these problems as signs of a major mental illness.

How does bipolar disorder affect someone over time?

Bipolar disorder usually lasts a lifetime. Episodes of mania and depression typically come back over time. Between episodes, many people with bipolar disorder are free of symptoms, but some people may have lingering symptoms.

Doctors usually diagnose mental disorders using guidelines from the Diagnostic and Statistical Manual of Mental Disorders, or DSM. According to the DSM, there are four basic types of bipolar disorder:

Bipolar I Disorder is mainly defined by manic or mixed episodes that last at least seven days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, the person also has depressive episodes, typically lasting at least two weeks. The symptoms of mania or depression must be a major change from the person's normal behavior.
Bipolar II Disorder is defined by a pattern of depressive episodes shifting back and forth with hypomanic episodes, but no full-blown manic or mixed episodes.
Bipolar Disorder Not Otherwise Specified (BP-NOS) is diagnosed when a person has symptoms of the illness that do not meet diagnostic criteria for either bipolar I or II. The symptoms may not last long enough, or the person may have too few symptoms, to be diagnosed with bipolar I or II. However, the symptoms are clearly out of the person's normal range of behavior.
Cyclothymic Disorder, or Cyclothymia, is a mild form of bipolar disorder. People who have cyclothymia have episodes of hypomania that shift back and forth with mild depression for at least two years. However, the symptoms do not meet the diagnostic requirements for any other type of bipolar disorder.
Some people may be diagnosed with rapid-cycling bipolar disorder. This is when a person has four or more episodes of major depression, mania, hypomania, or mixed symptoms within a year.2 Some people experience more than one episode in a week, or even within one day. Rapid cycling seems to be more common in people who have severe bipolar disorder and may be more common in people who have their first episode at a younger age. One study found that people with rapid cycling had their first episode about four years earlier, during mid to late teen years, than people without rapid cycling bipolar disorder.3 Rapid cycling affects more women than men.4

Bipolar disorder tends to worsen if it is not treated. Over time, a person may suffer more frequent and more severe episodes than when the illness first appeared.5 Also, delays in getting the correct diagnosis and treatment make a person more likely to experience personal, social, and work-related problems.6

Proper diagnosis and treatment helps people with bipolar disorder lead healthy and productive lives. In most cases, treatment can help reduce the frequency and severity of episodes.

What illnesses often co-exist with bipolar disorder?

Substance abuse is very common among people with bipolar disorder, but the reasons for this link are unclear.7 Some people with bipolar disorder may try to treat their symptoms with alcohol or drugs. However, substance abuse may trigger or prolong bipolar symptoms, and the behavioral control problems associated with mania can result in a person drinking too much.

Anxiety disorders, such as post-traumatic stress disorder (PTSD) and social phobia, also co-occur often among people with bipolar disorder.8-10 Bipolar disorder also co-occurs with attention deficit hyperactivity disorder (ADHD), which has some symptoms that overlap with bipolar disorder, such as restlessness and being easily distracted.

People with bipolar disorder are also at higher risk for thyroid disease, migraine headaches, heart disease, diabetes, obesity, and other physical illnesses.10, 11 These illnesses may cause symptoms of mania or depression. They may also result from treatment for bipolar disorder.

Other illnesses can make it hard to diagnose and treat bipolar disorder. People with bipolar disorder should monitor their physical and mental health. If a symptom does not get better with treatment, they should tell their doctor.

What are the risk factors for bipolar disorder?

Scientists are learning about the possible causes of bipolar disorder. Most scientists agree that there is no single cause. Rather, many factors likely act together to produce the illness or increase risk.

Genetics

Bipolar disorder tends to run in families, so researchers are looking for genes that may increase a person's chance of developing the illness. Genes are the "building blocks" of heredity. They help control how the body and brain work and grow. Genes are contained inside a person's cells that are passed down from parents to children.

Children with a parent or sibling who has bipolar disorder are four to six times more likely to develop the illness, compared with children who do not have a family history of bipolar disorder.12 However, most children with a family history of bipolar disorder will not develop the illness.

Genetic research on bipolar disorder is being helped by advances in technology. This type of research is now much quicker and more far-reaching than in the past. One example is the launch of the Bipolar Disorder Phenome Database, funded in part by NIMH. Using the database, scientists will be able to link visible signs of the disorder with the genes that may influence them. So far, researchers using this database found that most people with bipolar disorder had:13

Missed work because of their illness
Other illnesses at the same time, especially alcohol and/or substance abuse and panic disorders
Been treated or hospitalized for bipolar disorder.
The researchers also identified certain traits that appeared to run in families, including:

History of psychiatric hospitalization
Co-occurring obsessive-compulsive disorder (OCD)
Age at first manic episode
Number and frequency of manic episodes.
Scientists continue to study these traits, which may help them find the genes that cause bipolar disorder some day.

But genes are not the only risk factor for bipolar disorder. Studies of identical twins have shown that the twin of a person with bipolar illness does not always develop the disorder. This is important because identical twins share all of the same genes. The study results suggest factors besides genes are also at work. Rather, it is likely that many different genes and a person's environment are involved. However, scientists do not yet fully understand how these factors interact to cause bipolar disorder.

Brain structure and functioning

Brain-imaging studies are helping scientists learn what happens in the brain of a person with bipolar disorder.14, 15 Newer brain-imaging tools, such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET), allow researchers to take pictures of the living brain at work. These tools help scientists study the brain's structure and activity.

Some imaging studies show how the brains of people with bipolar disorder may differ from the brains of healthy people or people with other mental disorders. For example, one study using MRI found that the pattern of brain development in children with bipolar disorder was similar to that in children with "multi-dimensional impairment," a disorder that causes symptoms that overlap somewhat with bipolar disorder and schizophrenia.16 This suggests that the common pattern of brain development may be linked to general risk for unstable moods.

Learning more about these differences, along with information gained from genetic studies, helps scientists better understand bipolar disorder. Someday scientists may be able to predict which types of treatment will work most effectively. They may even find ways to prevent bipolar disorder.

How is bipolar disorder diagnosed?

The first step in getting a proper diagnosis is to talk to a doctor, who may conduct a physical examination, an interview, and lab tests. Bipolar disorder cannot currently be identified through a blood test or a brain scan, but these tests can help rule out other contributing factors, such as a stroke or brain tumor. If the problems are not caused by other illnesses, the doctor may conduct a mental health evaluation. The doctor may also provide a referral to a trained mental health professional, such as a psychiatrist, who is experienced in diagnosing and treating bipolar disorder.

The doctor or mental health professional should conduct a complete diagnostic evaluation. He or she should discuss any family history of bipolar disorder or other mental illnesses and get a complete history of symptoms. The doctor or mental health professionals should also talk to the person's close relatives or spouse and note how they describe the person's symptoms and family medical history.

People with bipolar disorder are more likely to seek help when they are depressed than when experiencing mania or hypomania.17 Therefore, a careful medical history is needed to assure that bipolar disorder is not mistakenly diagnosed as major depressive disorder, which is also called unipolar depression. Unlike people with bipolar disorder, people who have unipolar depression do not experience mania. Whenever possible, previous records and input from family and friends should also be included in the medical history.

How is bipolar disorder treated?

To date, there is no cure for bipolar disorder. But proper treatment helps most people with bipolar disorder gain better control of their mood swings and related symptoms.18-20 This is also true for people with the most severe forms of the illness.

Because bipolar disorder is a lifelong and recurrent illness, people with the disorder need long-term treatment to maintain control of bipolar symptoms. An effective maintenance treatment plan includes medication and psychotherapy for preventing relapse and reducing symptom severity.21

Medications

Bipolar disorder can be diagnosed and medications prescribed by people with an M.D. (doctor of medicine). Usually, bipolar medications are prescribed by a psychiatrist. In some states, clinical psychologists, psychiatric nurse practitioners, and advanced psychiatric nurse specialists can also prescribe medications. Check with your state's licensing agency to find out more.

Not everyone responds to medications in the same way. Several different medications may need to be tried before the best course of treatment is found.

Keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events can help the doctor track and treat the illness most effectively. Sometimes this is called a daily life chart. If a person's symptoms change or if side effects become serious, the doctor may switch or add medications.

Some of the types of medications generally used to treat bipolar disorder are listed on the next page. Information on medications can change. For the most up to date information on use and side effects contact the U.S. Food and Drug Administration (FDA).

Mood stabilizing medications are usually the first choice to treat bipolar disorder. In general, people with bipolar disorder continue treatment with mood stabilizers for years. Except for lithium, many of these medications are anticonvulsants. Anticonvulsant medications are usually used to treat seizures, but they also help control moods. These medications are commonly used as mood stabilizers in bipolar disorder:
Lithium (sometimes known as Eskalith or Lithobid) was the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) in the 1970s for treatment of mania. It is often very effective in controlling symptoms of mania and preventing the recurrence of manic and depressive episodes.
Valproic acid or divalproex sodium (Depakote), approved by the FDA in 1995 for treating mania, is a popular alternative to lithium for bipolar disorder. It is generally as effective as lithium for treating bipolar disorder.23, 24 Also see the section in this booklet, "Should young women take valproic acid?"
More recently, the anticonvulsant lamotrigine (Lamictal) received FDA approval for maintenance treatment of bipolar disorder.
Other anticonvulsant medications, including gabapentin (Neurontin), topiramate (Topamax), and oxcarbazepine (Trileptal) are sometimes prescribed. No large studies have shown that these medications are more effective than mood stabilizers.
Valproic acid, lamotrigine, and other anticonvulsant medications have an FDA warning. The warning states that their use may increase the risk of suicidal thoughts and behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be closely monitored for new or worsening symptoms of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. People taking these medications should not make any changes without talking to their health care professional.

Lithium and Thyroid Function

People with bipolar disorder often have thyroid gland problems. Lithium treatment may also cause low thyroid levels in some people.22 Low thyroid function, called hypothyroidism, has been associated with rapid cycling in some people with bipolar disorder, especially women.

Because too much or too little thyroid hormone can lead to mood and energy changes, it is important to have a doctor check thyroid levels carefully. A person with bipolar disorder may need to take thyroid medication, in addition to medications for bipolar disorder, to keep thyroid levels balanced.

Should young women take valproic acid?

Valproic acid may increase levels of testosterone (a male hormone) in teenage girls and lead to polycystic ovary syndrome (PCOS) in women who begin taking the medication before age 20.25, 26 PCOS causes a woman's eggs to develop into cysts, or fluid filled sacs that collect in the ovaries instead of being released by monthly periods. This condition can cause obesity, excess body hair, disruptions in the menstrual cycle, and other serious symptoms. Most of these symptoms will improve after stopping treatment with valproic acid.27 Young girls and women taking valproic acid should be monitored carefully by a doctor.

Atypical antipsychotic medications are sometimes used to treat symptoms of bipolar disorder. Often, these medications are taken with other medications. Atypical antipsychotic medications are called "atypical" to set them apart from earlier medications, which are called "conventional" or "first-generation" antipsychotics.
Olanzapine (Zyprexa), when given with an antidepressant medication, may help relieve symptoms of severe mania or psychosis.28 Olanzapine is also available in an injectable form, which quickly treats agitation associated with a manic or mixed episode. Olanzapine can be used for maintenance treatment of bipolar disorder as well, even when a person does not have psychotic symptoms. However, some studies show that people taking olanzapine may gain weight and have other side effects that can increase their risk for diabetes and heart disease. These side effects are more likely in people taking olanzapine when compared with people prescribed other atypical antipsychotics.
Aripiprazole (Abilify), like olanzapine, is approved for treatment of a manic or mixed episode. Aripiprazole is also used for maintenance treatment after a severe or sudden episode. As with olanzapine, aripiprazole also can be injected for urgent treatment of symptoms of manic or mixed episodes of bipolar disorder.
Quetiapine (Seroquel) relieves the symptoms of severe and sudden manic episodes. In that way, quetiapine is like almost all antipsychotics. In 2006, it became the first atypical antipsychotic to also receive FDA approval for the treatment of bipolar depressive episodes.
Risperidone (Risperdal) and ziprasidone (Geodon) are other atypical antipsychotics that may also be prescribed for controlling manic or mixed episodes.
Antidepressant medications are sometimes used to treat symptoms of depression in bipolar disorder. People with bipolar disorder who take antidepressants often take a mood stabilizer too. Doctors usually require this because taking only an antidepressant can increase a person's risk of switching to mania or hypomania, or of developing rapid cycling symptoms.29 To prevent this switch, doctors who prescribe antidepressants for treating bipolar disorder also usually require the person to take a mood-stabilizing medication at the same time.
Recently, a large-scale, NIMH-funded study showed that for many people, adding an antidepressant to a mood stabilizer is no more effective in treating the depression than using only a mood stabilizer.30

Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and bupropion (Wellbutrin) are examples of antidepressants that may be prescribed to treat symptoms of bipolar depression.
Some medications are better at treating one type of bipolar symptoms than another. For example, lamotrigine (Lamictal) seems to be helpful in controlling depressive symptoms of bipolar disorder.

What are the side effects of these medications?
Before starting a new medication, people with bipolar disorder should talk to their doctor about the possible risks and benefits.

The psychiatrist prescribing the medication or pharmacist can also answer questions about side effects. Over the last decade, treatments have improved, and some medications now have fewer or more tolerable side effects than earlier treatments. However, everyone responds differently to medications. In some cases, side effects may not appear until a person has taken a medication for some time.

If the person with bipolar disorder develops any severe side effects from a medication, he or she should talk to the doctor who prescribed it as soon as possible. The doctor may change the dose or prescribe a different medication. People being treated for bipolar disorder should not stop taking a medication without talking to a doctor first. Suddenly stopping a medication may lead to "rebound," or worsening of bipolar disorder symptoms. Other uncomfortable or potentially dangerous withdrawal effects are also possible.

FDA Warning on Antidepressants

Antidepressants are safe and popular, but some studies have suggested that they may have unintentional effects on some people, especially in adolescents and young adults. The FDA warning says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation, or withdrawal from normal social situations. Families and caregivers should report any changes to the doctor. For the latest information visit the FDA website.

The following sections describe some common side effects of the different types of medications used to treat bipolar disorder.

1. Mood Stabilizers

In some cases, lithium can cause side effects such as:

Restlessness
Dry mouth
Bloating or indigestion
Acne
Unusual discomfort to cold temperatures
Joint or muscle pain
Brittle nails or hair.31
Lithium also causes side effects not listed here. If extremely bothersome or unusual side effects occur, tell your doctor as soon as possible.

If a person with bipolar disorder is being treated with lithium, it is important to make regular visits to the treating doctor. The doctor needs to check the levels of lithium in the person's blood, as well as kidney and thyroid function.

These medications may also be linked with rare but serious side effects. Talk with the treating doctor or a pharmacist to make sure you understand signs of serious side effects for the medications you're taking.

Common side effects of other mood stabilizing medications include:

Drowsiness
Dizziness
Headache
Diarrhea
Constipation
Heartburn
Mood swings
Stuffed or runny nose, or other cold-like symptoms.32-37
2. Atypical Antipsychotics

Some people have side effects when they start taking atypical antipsychotics. Most side effects go away after a few days and often can be managed successfully. People who are taking antipsychotics should not drive until they adjust to their new medication. Side effects of many antipsychotics include:

Drowsiness
Dizziness when changing positions
Blurred vision
Rapid heartbeat
Sensitivity to the sun
Skin rashes
Menstrual problems for women.
Atypical antipsychotic medications can cause major weight gain and changes in a person's metabolism. This may increase a person's risk of getting diabetes and high cholesterol.38 A person's weight, glucose levels, and lipid levels should be monitored regularly by a doctor while taking these medications.

In rare cases, long-term use of atypical antipsychotic drugs may lead to a condition called tardive dyskinesia (TD). The condition causes muscle movements that commonly occur around the mouth. A person with TD cannot control these moments. TD can range from mild to severe, and it cannot always be cured. Some people with TD recover partially or fully after they stop taking the drug.

3. Antidepressants

The antidepressants most commonly prescribed for treating symptoms of bipolar disorder can also cause mild side effects that usually do not last long. These can include:

Headache, which usually goes away within a few days.
Nausea (feeling sick to your stomach), which usually goes away within a few days.
Sleep problems, such as sleeplessness or drowsiness. This may happen during the first few weeks but then go away. To help lessen these effects, sometimes the medication dose can be reduced, or the time of day it is taken can be changed.
Agitation (feeling jittery).
Sexual problems, which can affect both men and women. These include reduced sex drive and problems having and enjoying sex.
Some antidepressants are more likely to cause certain side effects than other types. Your doctor or pharmacist can answer questions about these medications. Any unusual reactions or side effects should be reported to a doctor immediately.

For the most up-to-date information on medications for treating bipolar disorder and their side effects, please see the online NIMH Medications booklet.

Should women who are pregnant or may become pregnant take medication for bipolar disorder?

Women with bipolar disorder who are pregnant or may become pregnant face special challenges. The mood stabilizing medications in use today can harm a developing fetus or nursing infant.39 But stopping medications, either suddenly or gradually, greatly increases the risk that bipolar symptoms will recur during pregnancy.40

Scientists are not sure yet, but lithium is likely the preferred mood-stabilizing medication for pregnant women with bipolar disorder.40, 41 However, lithium can lead to heart problems in the fetus. Women need to know that most bipolar medications are passed on through breast milk.41 Pregnant women and nursing mothers should talk to their doctors about the benefits and risks of all available treatments.

Psychotherapy
In addition to medication, psychotherapy, or "talk" therapy, can be an effective treatment for bipolar disorder. It can provide support, education, and guidance to people with bipolar disorder and their families. Some psychotherapy treatments used to treat bipolar disorder include:

Cognitive behavioral therapy (CBT) helps people with bipolar disorder learn to change harmful or negative thought patterns and behaviors.
Family-focused therapy includes family members. It helps enhance family coping strategies, such as recognizing new episodes early and helping their loved one. This therapy also improves communication and problem-solving.
Interpersonal and social rhythm therapy helps people with bipolar disorder improve their relationships with others and manage their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.
Psychoeducation teaches people with bipolar disorder about the illness and its treatment. This treatment helps people recognize signs of relapse so they can seek treatment early, before a full-blown episode occurs. Usually done in a group, psychoeducation may also be helpful for family members and caregivers.
A licensed psychologist, social worker, or counselor typically provides these therapies. This mental health professional often works with the psychiatrist to track progress. The number, frequency, and type of sessions should be based on the treatment needs of each person. As with medication, following the doctor's instructions for any psychotherapy will provide the greatest benefit.

For more information, see the Substance Abuse and Mental Health Services Administration web page on choosing a mental health therapist.

Recently, NIMH funded a clinical trial called the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). This was the largest treatment study ever conducted for bipolar disorder. In a study on psychotherapies, STEP-BD researchers compared people in two groups. The first group was treated with collaborative care (three sessions of psychoeducation over six weeks). The second group was treated with medication and intensive psychotherapy (30 sessions over nine months of CBT, interpersonal and social rhythm therapy, or family-focused therapy). Researchers found that the second group had fewer relapses, lower hospitalization rates, and were better able to stick with their treatment plans.42 They were also more likely to get well faster and stay well longer.

NIMH is supporting more research on which combinations of psychotherapy and medication work best. The goal is to help people with bipolar disorder live symptom-free for longer periods and to recover from episodes more quickly. Researchers also hope to determine whether psychotherapy helps delay the start of bipolar disorder in children at high risk for the illness.

Visit the NIMH Web site for more information on psychotherapy.

Other treatments

Electroconvulsive Therapy (ECT)—For cases in which medication and/or psychotherapy does not work, electroconvulsive therapy (ECT) may be useful. ECT, formerly known as "shock therapy," once had a bad reputation. But in recent years, it has greatly improved and can provide relief for people with severe bipolar disorder who have not been able to feel better with other treatments.
Before ECT is administered, a patient takes a muscle relaxant and is put under brief anesthesia. He or she does not consciously feel the electrical impulse administered in ECT. On average, ECT treatments last from 30–90 seconds. People who have ECT usually recover after 5–15 minutes and are able to go home the same day.43

Sometimes ECT is used for bipolar symptoms when other medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severely depressive, manic, or mixed episodes, but is generally not a first-line treatment.

ECT may cause some short-term side effects, including confusion, disorientation, and memory loss. But these side effects typically clear soon after treatment. People with bipolar disorder should discuss possible benefits and risks of ECT with an experienced doctor.44

Sleep Medications—People with bipolar disorder who have trouble sleeping usually sleep better after getting treatment for bipolar disorder. However, if sleeplessness does not improve, the doctor may suggest a change in medications. If the problems still continue, the doctor may prescribe sedatives or other sleep medications.
People with bipolar disorder should tell their doctor about all prescription drugs, over-the-counter medications, or supplements they are taking. Certain medications and supplements taken together may cause unwanted or dangerous effects.

Herbal Supplements

In general, there is not much research about herbal or natural supplements. Little is known about their effects on bipolar disorder. An herb called St. John's wort (Hypericum perforatum), often marketed as a natural antidepressant, may cause a switch to mania in some people with bipolar disorder.45 St. John's wort can also make other medications less effective, including some antidepressant and anticonvulsant medications.46 Scientists are also researching omega-3 fatty acids (most commonly found in fish oil) to measure their usefulness for long-term treatment of bipolar disorder.47 Study results have been mixed.48 It is important to talk with a doctor before taking any herbal or natural supplements because of the serious risk of interactions with other medications.

What can people with bipolar disorder expect from treatment?

Bipolar disorder has no cure, but can be effectively treated over the long-term. It is best controlled when treatment is continuous, rather than on and off. In the STEP-BD study, a little more than half of the people treated for bipolar disorder recovered over one year's time. For this study, recovery meant having two or fewer symptoms of the disorder for at least eight weeks.

However, even with proper treatment, mood changes can occur. In the STEP-BD study, almost half of those who recovered still had lingering symptoms. These people experienced a relapse or recurrence that was usually a return to a depressive state.49 If a person had a mental illness in addition to bipolar disorder, he or she was more likely to experience a relapse.49 Scientists are unsure, however, how these other illnesses or lingering symptoms increase the chance of relapse. For some people, combining psychotherapy with medication may help to prevent or delay relapse.42

Treatment may be more effective when people work closely with a doctor and talk openly about their concerns and choices. Keeping track of mood changes and symptoms with a daily life chart can help a doctor assess a person's response to treatments. Sometimes the doctor needs to change a treatment plan to make sure symptoms are controlled most effectively. A psychiatrist should guide any changes in type or dose of medication.

How can I help a friend or relative who has bipolar disorder?

If you know someone who has bipolar disorder, it affects you too. The first and most important thing you can do is help him or her get the right diagnosis and treatment. You may need to make the appointment and go with him or her to see the doctor. Encourage your loved one to stay in treatment.

To help a friend or relative, you can:

Offer emotional support, understanding, patience, and encouragement
Learn about bipolar disorder so you can understand what your friend or relative is experiencing
Talk to your friend or relative and listen carefully
Listen to feelings your friend or relative expresses-be understanding about situations that may trigger bipolar symptoms
Invite your friend or relative out for positive distractions, such as walks, outings, and other activities
Remind your friend or relative that, with time and treatment, he or she can get better.
Never ignore comments about your friend or relative harming himself or herself. Always report such comments to his or her therapist or doctor.

Support for caregivers

Like other serious illnesses, bipolar disorder can be difficult for spouses, family members, friends, and other caregivers. Relatives and friends often have to cope with the person's serious behavioral problems, such as wild spending sprees during mania, extreme withdrawal during depression, poor work or school performance. These behaviors can have lasting consequences.

Caregivers usually take care of the medical needs of their loved ones. The caregivers have to deal with how this affects their own health. The stress that caregivers are under may lead to missed work or lost free time, strained relationships with people who may not understand the situation, and physical and mental exhaustion.

Stress from caregiving can make it hard to cope with a loved one's bipolar symptoms. One study shows that if a caregiver is under a lot of stress, his or her loved one has more trouble following the treatment plan, which increases the chance for a major bipolar episode.50 It is important that people caring for those with bipolar disorder also take care of themselves.

How can I help myself if I have bipolar disorder?

It may be very hard to take that first step to help yourself. It may take time, but you can get better with treatment.

To help yourself:

Talk to your doctor about treatment options and progress
Keep a regular routine, such as eating meals at the same time every day and going to sleep at the same time every night
Try to get enough sleep
Stay on your medication
Learn about warning signs signaling a shift into depression or mania
Expect your symptoms to improve gradually, not immediately.
Where can I go for help?

If you are unsure where to go for help, ask your family doctor. Others who can help are listed below.

Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors
Health maintenance organizations
Community mental health centers
Hospital psychiatry departments and outpatient clinics
Mental health programs at universities or medical schools
State hospital outpatient clinics
Family services, social agencies, or clergy
Peer support groups
Private clinics and facilities
Employee assistance programs
Local medical and/or psychiatric societies.
You can also check the phone book under "mental health," "health," "social services," "hotlines," or "physicians" for phone numbers and addresses. An emergency room doctor can also provide temporary help and can tell you where and how to get further help.

What if I or someone I know is in crisis?

If you are thinking about harming yourself, or know someone who is, tell someone who can help immediately.

Call your doctor.
Call 911 or go to a hospital emergency room to get immediate help or ask a friend or family member to help you do these things.
Call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255); TTY: 1-800-799-4TTY (4889) to talk to a trained counselor.
Make sure you or the suicidal person is not left alone.

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For more information on bipolar disorder

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication 08-3679
Revised 2008

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