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  • 1. The assessment of neuropsychiatric disorders during adolescence – the role of school psychologist Maria Taanila School Psychologist The Municipality of Kangasala, Finland 27th July 2007, ISPA Congress © Maria Taanila
  • 2. The content of the presentation
    • What are the neuropsychiatric disorders?
    • University Hospital of Tampere, Department of Adolescent Psychiatry – neuropsychiatric team for adolescents
      • What kind of issues did we work with
      • What we learned
    • Neuropsychiatric disorder or not?
      • School psychologist’s view
    • Discussion, questions
    © Maria Taanila
  • 3. Neuropsychiatric disorders
    • Medical disorders with internationally accepted diagnostic criteria (DSM-IV, ICD-10)
    • Broadest definition: disorders that include both neurological deficits and psychiatric symptoms (eg TBI, Parkinson, depression, schizophrenia)
    • Narrower definition: developmental language, learning and motoric disorders, attention deficit disorders (ADHD, ADD), autism spectrum disorders (eg Asperger’s syndrome), Tourette’s syndrome
    © Maria Taanila
  • 4. Neuropsychiatry and adolescents
    • Neuropsychiatric disorders are developmental: problems begin in childhood
    • Sometimes certain problems may become more obvious during adolescence when academic and social challenges increase
    • Growing publicity and awareness: nowadays problems tend to be more easily explained by a neuropsychiatric disorder
    • Prevalence of neuropsychiatric disorders is under debate…common or rare?
    © Maria Taanila
  • 5. Neuropsychiatry in Finland
    • Neuropsychiatric disorders have received a lot of attention in Finland during the last ten years
    • In the biggest hospitals there are teams specialized in neuropsychiatric disorders in children, some units can diagnose adults
    • First neuropsychiatric team specialized in adolescents began its work in University Hospital of Tampere in the Department of Adolescent Psychiatry in the autumn 2005
    © Maria Taanila
  • 6. Referrals to the neuropsychiatric examination
    • Age range 13-19 years, mean 15 years
    • 60 % males, 40 % females
    • Most often the suspected disorder was either ADHD or Asperger’s syndrome
    • The initiative to the referral was usually taken by parents or teachers
    © Maria Taanila
  • 7. Problems and symptoms in referred adolescents
    • School problems: poor performance, conduct problems
    • Emotional problems: depression, sudden changes of mood, irritability, anxiety
    • Affect control problems: aggression, violence, tantrums
    • Self-injurious behaviour, suicidal thoughts
    • Substance abuse
    • Lack of contemporary friends, loneliness
    • Bizarre behavior
    © Maria Taanila
  • 8. Examination protocol
    • Structured interviews of parents (3Di for autism spectrum disorders, ICD-10 diagnostic criteria for attention deficit disorders)
    • Structured observation (ADOS* for autism spectrum disorders)
    • Psychological assessment
    • Psychiatric assessment
    • Collection of case history from earlier assessments and interventions
    • *Autism Diagnostic Observation Schedule
    © Maria Taanila
  • 9. Psychological assessment
    • Was made when necessary in a needed extent
      • Cognitive level (WISC III, WAIS-R or WAIS-III)
      • Assessment of neuropsychological deficits (eg NEPSY, WMS-R, CPT-II, WCST, TMT)
      • Academic skills (Finnish reading, writing and calculation tests)
      • Personality assessment (usually interview, Ro-CS, MMPI, sometimes also questionnaires and projective tests)
    © Maria Taanila
  • 10.
    • WISC-III = Wechsler’s Intelligence Scale for Children –Third Edition
    • WAIS-R = Wechsler Adult Intelligence Scale – revised
    • WAIS-III = Wechsler Adult Intelligence Scale –Third Edition
    • NEPSY = An abbreviation of a neuropsychological instrument for children (made in Finland, also available in English)
    • WMS-R = Wechsler’s Memory Scale – revised
    • CPT-II = Conner’s Continuous Performance Test
    • WCST = Wisconsin Card Sorting Test
    • TMT = Trail Making Test (A and B)
    • Ro-CS = The Rorschach Comprehensive System (J. Exner)
    • MMPI = Minnesota Multiphasic Personality Inventory
    © Maria Taanila
  • 11. When ADHD/ADD was suspected
    • Attention deficit disorder was found only in about 20% of cases
    • Other explanations for difficulties:
      • Moderate/Severe developmental difficulties: maturation delay, distortions in identity development (eg psychopathic traits, narcissistic features) (about 50%)
      • Cognitive deficits such as learning disabilities, even mental retardation (about 15%)
      • Behavioral problems without significant attention deficits, such as conduct disorder, impulse control disorder (about 10%)
    © Maria Taanila
  • 12. When autism/Asperger’s syndrome was suspected
    • An autism spectrum disorder was found in about 60% of cases
    • Other explanations:
      • Moderate/Severe developmental difficulties: maturation delay, distortions in identity development (eg narcissistic features), high psychosis risk/psychosis in adolescence
      • Long-term bullying with its consequences
      • Dysphasia affecting on social relations
    © Maria Taanila
  • 13. Extreme examples
    • Bizarre behaviour and withdrawal from peers: Autism spectrum disorder?
      • Can result from poor social skills and lack of insight into social codes and rules: future professor?
      • Can be a serious sign of mental illness: future psychiatric patient?
    • Poor performance at school and conduct problems: ADHD?
      • Can result from excessive need for stimulation and difficulty to tolerate monotonous situations: future risk-taking executive manager?
      • Can be a serious sign of broader asocial development: future criminal?
    © Maria Taanila
  • 14. Some explanations for declining school performance and conduct problems
      • Learning can just become too demanding, resistance and lack of motivation can be adjustment to fear of failure
      • Depression is a common psychiatric condition and may among adolescents manifestate as conduct problems and affect control problems
      • Parental and other family related problems affect children and can be more serious than anyone might expect from school’s point of view
    © Maria Taanila
  • 15. Some explanations for withdrawal from peers
      • Bullying is common, can be chronic, invisible and only seemingly harmless, even serious bullying can be denied by the victim
      • Depression and anxiety are common during adolescence and affect both capability and willingness to social interaction
      • Social interaction becomes more complicated and challenging during adolescence, shyness and low self-esteem can lead to being left outside
    © Maria Taanila
  • 16. Difficulties from school psychologist’s perspective
    • It isn’t always easy to differentiate harmless and temporary adolescent behavior from serious developmental problems
    • One hasn’t got resources and expertise to evaluate every deviantly behaving adolescent thoroughly
    • One can’t refer all the problematic cases into psychiatric evaluation
    • Even getting a diagnosis does not solve all the problems at school
    © Maria Taanila
  • 17. School psychologist’s unique perspective: seeing different sides
    • What parents seem to think?
      • There’s nothing wrong with him, just like me in her age, somebody please do something, couldn’t care less?
    • What peers seem to think?
      • One of us, one of them or an outcast?
      • Admired, frightening, ridiculed, despised, bullied, disturbed?
    • What teachers seem to think?
      • The misunderstood, just one of many, the usual suspect, just like his brother, the root of all evil?
    © Maria Taanila
  • 18. Finally
    • Differential diagnostics of neuropsychiatric disorders during adolescence is complicated and difficult
    • Luckily, at least in Finland, diagnosis is made by a physician!
    © Maria Taanila
  • 19.
    • THANK YOU!
    © Maria Taanila