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Conditions That Complicate Management

Attention deficit/hyperactivity disorder is a specific developmental condition with a defined set of characteristics. Although a varied spectrum of severity exists, children with ADHD demonstrate a consistent and typical pattern of behavior and neurological function.

 
However, this “pure”@ picture is often complicated by the presence of other developmental or emotional dysfunctions. Several co-morbid conditions are described by professionals working with A DHD children.

 
Common Co-Morbid Conditions
Let’s look at some of the more common co-morbid conditions which may exist with ADHD:

 
Language-based learning disabilities. Central language processing disorders can mimic, and certainly complicate, the expression of attention disorders. For decades clinicians and educators have observed a significant overlap between children with ADHD and various language-based learning disabilities. As recently as two decades ago, professionals in the field tended to lump children with these related developmental disabilities together into the diagnostic category of minimal brain dysfunction. Attention, hyperactivity, and language-processing disorders were thought to be different ends of the continuum within this diagnosis. Recently the trend is to define the various diagnostic categories more precisely.

 
While many children with ADHD have no evidence of language-based learning disability, there are many children in which ADHD and a learning disability co-exist. I have seen children who have gone for years without treatment for their ADHD because all their academic problems were blamed on their language dysfunction. The attention problems and poor organization were thought to be secondary. On the other hand, I know of children who have not received serious evaluation of their reading and spelling under-achievement because their poor grades were blamed on their attention deficit disorder. When a child has been diagnosed with either ADHD or language processing dysfunction, the child should be carefully observe for evidence of the other condition.

 
Oppositional Defiant Disorder. While children with ADHD may disobey and at times seems to resist discipline, they are not typically defiant. Their lack of compliance is most likely due to impulsiveness and failure to think before they act. They also have difficulty associating their behaviors with consequences. But they want to please and tend to be unhappy with their failure to live up to expectations.

 
Oppositional defiant disorder (ODD) is characterized by a pattern of negative, hostile, and defiant behavior. Children with this disorder easily lose their temper, purposely annoy others, openly defy authority, refuse to comply with rules, and argue often. They may be resentful, angry, spiteful, and vindictive. ODD is defined by a pattern of such behavior over a long period which is not due to temporary stresses or provocations. Oppositional defiant disorder is more common in males. Over time ODD is likely to be associated with low self-esteem, low frustration tolerance, temper outbursts, poor peer relationships, and school underachievement.

 
Conduct Disorder. Children with conduct disorder exhibit a basic disregard for the rights of others and ignore age-appropriate norms of behavior. They may be cruel to other people and animals, fail to respect others rights (i.e., steal, misuse property), and ignore common rules of conduct. This pattern of behavior exists over a long period of time. It significantly disrupts the child’s relationships and adjustments to common life situations such as home and school.

 
Poor school performance, a greater frequency of school suspensions, and incidence of substance abuse are seen in children and adolescents with conduct disorders. These dysfunctional behaviors may begin in middle childhood but become more prominent in adolescence.

 
! Tourette’s Syndrome. Tourette’s syndrome (or Tourette’s disorder as it is sometimes called today) is characterized by the onset during childhood of multiple tics of various kinds (both motor tics and vocal tics) which may fluctuate in severity. The currently accepted essential diagnostic criteria include onset before the age of 21 years, multiple involuntary motor tics, one or more vocal tics, the waxing and waning of the tics, the gradual replacement of old tics with new ones, the absence of other medical explanations for the tics, and the presence of tics for more than one year.

 
Along with the tics, there may be obsessive compulsive tendencies, excessive anxiety, sleep disorders, learning difficulties, and impulsive behaviors. A variety of behavior/emotional problems have been identified in children with Tourette’s syndrome. Whether these behavioral problems are related to tic severity, a direct consequence of having a stigmatizing condition or an underlying part of the developmental condition is not clearly delineated.
ADHD has been reported to occur in 35% to 65% of children with Tourette’s syndrome. The treatment of children with attention deficit/hyperactivity disorder with co-morbid Tourette’s syndrome is controversial. The major confounding factor is that stimulant medications may provoke or intensify the tics. The stimulants do not cause the tics but if a child is predisposed to tics, the use of the stimulants may hasten the expression of tics, or aggravate them when they are present. While the stimulants may help the child with ADHD and Tourette’s, they should be used with caution.

 
If behavior and educational approaches are not successful for the child with Tourette’s and ADHD, then a trial with other types of medication should be considered.

 
Depression. It is well know that psychological depression is the most common emotional disorder affecting adults. The fact that depression is also very common in children and adolescents is less well known. Pre-teens and adolescents are particularly vulnerable to some degree of depression even under the best of circumstances. The child living with the stresses of ADHD are even more vulnerable. The frustration due to having to work harder to keep up academically, the constant negative feedback that is all too common and the difficulty getting along with peers sets the child up for depression. The usual low self-esteem experienced by many children with ADHD underlies their vulnerability.

 
Signs that suggest depression are a sudden drop in grades and performance in other activities such as sports or music. The depressed child or adolescent will tend to be moody and easily frustrated. They seem sad and have more trouble enjoying things they have enjoyed in the past. They often will withdraw and be less able to cope socially.

 
Depression in children and adolescents is likely to be a reaction to circumstances and come on over a short period of time. Chronic, long-term depression is less common.

 
This reactive depression is probably the most common co-morbid condition seen in children with ADHD. Fortunately, depression is also the most effectively treated of all the co-morbid conditions. Recognition, counseling, and sometimes short-term antidepressant medication will usually overcome the depression fairly quickly.

 
These are some of the more common co-morbid disorders. If is important to look for such conditions as a child is evaluated for ADHD. When they exist, success depends on managing the ADHD and co-morbid condition together.

ADHD and Prevalence of Depression

Attention Deficit in early childhood predisposes to adolescent depression according to research published  October 2010  in the Archives of General Psychiatry. This risk of depression in young children with ADHD is greater in girls, in those with associated conduct disorder, and in those whose mothers were depressed according to the study.

The Researchers evaluated 125 children age 4 to 6 who met the criteria for ADHD and 123 matched controls without any sign of ADHD. These subjects were followed for up to 14 years. All of the children in the study lived with their biological mothers.

ADHD at 4 to 6 years resulted in increased risk of major depression during the teen years by more than 15 times. Girls with ADHD had twice the risk of later depression than boys. Maternal depression increased the chance of depression in the children with ADHD by more than 7 times.

Comment: This study documents what many clinicians working with children and families have observed informally. The reasons for this increased risk of depression and mood disorders in teens who are diagnosed with ADHD are not yet clear. There may be biological factors common to both disorders. It is also likely that the stress of trying to live with the symptoms of ADHD would predispose one to depression. The very fact that the person with ADHD experiences the frustration of not being able to perform at the level they know they are capable of is, in itself, a significant stress.

Proper management of the ADHD as outlined in the book, ADHD Strategies for Success, will help minimize the stresses of living and learning for children with ADHD.

Certainly, parents and professionals working with children with ADHD, especially adolescents, should be diligent is watching for signs of depression and follow up on such signs when noted.

ADHD Can Persist Into Adulthood

Investigators in Rochester, Minnesota studied a large group of children born between 1976 and 1982. This group was followed from early childhood into adulthood (mean age 27 years at time of study). In this group, 232 subjects had been diagnosed with childhood ADHD. These 232 children were compared with 335 children without ADHD who served as controls. At the time of the study, the now adults were administered a variety of standardized neuro-psychiatric tests and interviews.

It was observed that ADHD persisted into adulthood in 29.3% of the individuals who had been diagnosed with childhood ADHD.

The participants who had childhood ADHD were more likely than controls (56% compared to 29%) to have one or more psychiatric disorders as adults. The most common co-morbid condition was alcohol dependence/abuse (26%). Additional diagnoses were other substance dependence/abuse conditions, anxiety disorders, mood disorders, and major depression. Those with ADHD persisting into adulthood were much more likely to have one or more psychiatric disorder (80% vs. 47%).

Several take home lesions from this study:

First of all, most children with ADHD will have resolution by adulthood.

However, ADHD does persist in a significant number of individuals (30%).

ADHD does leave significant emotional scars in a high percentage of individuals who were diagnosed with childhood ADHD. This points out the need for those diagnosed with ADHD to have ongoing mental health care into adulthood with special attention paid to potential psychiatric disorders.

Those adults with persistent ADHD (30% of those with childhood ADHD) will need to have ongoing ADHD treatment and monitoring as adults for other mental health needs.