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Attention deficit hyperactivity disorder (ADHD)

ADHD is a complex neurodevelopmental disorder that can affect a child's success at school, as well as their relationships. This disorder is a problem of not being able to focus, being overactive, not being able to control behavior, or a combination of these. Generally moderate ADHD is diagnosed in children by the time they're teenagers with the average age being 7 years old. ADHD is treatable. A diagnosis of ADHD is made when an individual displays at least six symptoms from the list below with some symptoms starting before the age of 7. If your child is diagnosed with ADHD, you should review all treatment options available. Then, set up a time to meet with a doctor or psychologist to determine the best course of action.

​ADHD affects an estimated two million American children, an average of at least one child in every U.S. classroom. In general, boys with ADHD have been shown to outnumber girls with the disorder by a rate of about three to one. There is no specific data on the rates of ADHD in adults, and sometimes the disorder is not diagnosed until adolescence or adulthood. Half of the children with ADHD retain symptoms of the disorder throughout their adult lives.

​There are 14 common signs of ADHD in children, which are:

1. Self-focused behavior
2. Interrupting
3. Trouble waiting their turn
4. Emotional turmoil
5. Fidgeting
6. Lack of focus
7. Problems playing quietly
8. Unfinished tasks
9. Mistakes
10. Daydreaming
11. Avoidance of task needing extended mental effort
12. Forgetfulness
13. Trouble getting organized
14. Symptoms in multiple settings

Some daily tasks that adolescents with ADHD may have trouble with include:

• focusing on schoolwork and assignments
• compromising with peers
• reading social cues
• time management
• maintaining personal hygiene
• driving safely
• helping out with chores at home

Anxiety 

Anxiety is a normal reaction to stress and can be beneficial in some situations by alerting us to danger and helping us prepare and pay attention.

​Anxiety disorders differ from normal feelings of nervousness or anxiousness and involve excessive fear or anxiety. Anxiety is the most common of mental disorders and affects more than 25 million Americans. Anxiety disorders are treatable and a number of effective treatments are available. Most people lead normal productive lives with treatment.

​There are several types of anxiety disorders which include generalized anxiety disorder (GAD), panic disorder, and various phobia-related disorders.

​Generalized Anxiety Disorder

Those with GAD display excessive anxiety or worry, most days for at least six months, about a number of things such as personal health, work, social interactions, and everyday routine life circumstances. Fear and anxiety can cause significant problems in areas of their life, such as social interactions, school, and work.

​Symptoms include:

• feeling restless, wound-up, or on-edge
• being easily fatigued
• difficulty concentrating
• irritability
• muscle tension
• difficulty controlling feelings of worry
• sleep problems (difficulty falling or staying asleep, restlessness, or unsatisfying sleep)

Panic Disorder

People with panic disorder have recurrent unexpected panic attacks. The attacks are sudden periods of intense fear that come on quickly and reach their peak within minutes. Attacks can be brought on by a trigger and can occur unexpectedly.

​During a panic attack, people may experience:

• heart palpitations (pounding heartbeat or accelerated heart rate)
• sweating
• feelings of impending doom
• sensations of shortness of breath, smothering, or choking
• trembling or shaking
• feelings of being out of control​

Phobia-related disorders

A phobia is an intense fear of - or aversion to - specific objects or situations. The fear people with phobias feel is out of proportion to the actual danger caused by the object or situation.

​People with a phobia:

• may have an irrational or excessive worry about encountering the feared object/situation
• experience immediate intense anxiety upon encountering the feared object/situation
• take active steps to avoid the feared object/situation
• endure unavoidable objects/situations with intense anxiety

​Other phobias include:

• Social anxiety disorder
• Agoraphobia
• Separation anxiety disorder

Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a developmental disorder that affects communication and behavior. Although autism can be diagnosed at any age, it is said to be a “developmental disorder” because symptoms generally appear in the first two years of life. People with ASD have:

• Difficulty with communication and interaction with other people
• Restricted interest and repetitive behaviors
• Symptoms that hurt the person's ability to function properly in school, work, and other areas of life

​Autism is known as a spectrum disorder because there is a wide variation in the type and severity of symptoms people experience. ASD occurs in all ethnic, racial, and economic groups. Although ASD can be a lifelong disorder, treatments and services can improve a person's symptoms and ability to function.

​Signs and Symptoms of ASD

People with ASD have difficulty with social communication and interaction, restricted interests, and repetitive behaviors. The list below gives some examples of the types of behaviors that are seen in people diagnosed with ASD. Not all people with ASD will show all behaviors, but most will show several.

​Social communication / interaction behaviors may include:

• Making little or inconsistent eye contact
• Tending not to look at or listen to people
• Rarely sharing enjoyment of objects or activities by pointing or showing things to others
• Failing to, or being slow to, respond to someone calling their name or to other verbal attempts to gain attention
• Having difficulties with the back and forth of conversation
• Often talking at length about a favorite subject without noticing that others are not interested or without giving others a chance to respond
• Having facial expressions, movements, and gestures that do not match what is being said
• Having an unusual tone of voice that may sound sing-song or flat and robot-like
• Having trouble understanding another person’s point of view or being unable to predict or understand other people’s actions

Restrictive/repetitive behaviors may include:

• Repeating certain behaviors or having unusual behaviors. 
• Having a lasting intense interest in certain topics, such as numbers, details, or facts
• Having overly focused interests, such as with moving objects or parts of objects
• Getting upset by slight changes in a routine
• Being more or less sensitive than other people to sensory input, such as light, noise, clothing, or temperature

People with ASD may also experience sleep problems and irritability. Although people with ASD experience many challenges, they may also have many strengths, including:

• Being able to learn things in detail and remember information for long periods of time
• Being strong visual and auditory learners
• Excelling in math, science, music, or art

​Causes and Risk Factors

While scientists don’t know the exact causes of ASD, research suggests that genes can act together with influences from the environment to affect development in ways that lead to ASD. Although scientists are still trying to understand why some people develop ASD and others don’t, some risk factors include:

• Having a sibling with ASD
• Having older parents
• Having certain genetic conditions—people with conditions such as Down syndrome, fragile X syndrome, and Rett syndrome are more likely than others to have ASD
• Very low birth weight

​​Diagnosing ASD

Doctors diagnose ASD by looking at a person’s behavior and development. ASD can usually be reliably diagnosed by the age of two. It is important for those with concerns to seek out assessment as soon as possible so that a diagnosis can be made, and treatment can begin.

​Diagnosis in Young Children

Diagnosis in young children is often a two-stage process.

​Stage 1: General Developmental Screening During Well-Child Checkups

Every child should receive well-child check-ups with a pediatrician or an early childhood health care provider. The American Academy of Pediatrics recommends that all children be screened for developmental delays at their 9-, 18-, and 24- or 30-month well-child visits and specifically for autism at their 18- and 24-month well-child visits.

Additional screening might be needed if a child is at high risk for ASD or developmental problems. Those at high risk include children who have a family member with ASD, have some ASD behaviors, have older parents, have certain genetic conditions, or who were born at a very low birth weight.

​Parents’ experiences and concerns are very important in the screening process for young children. Sometimes the doctor will ask parents questions about the child’s behaviors and combine those answers with information from ASD screening tools, and with his or her observations of the child. Read more about screening instruments on the Centers for Disease Control and Prevention (CDC) website.

​Children who show developmental problems during this screening process will be referred for a second stage of evaluation.

​Stage 2: Additional Evaluation

This second evaluation is with a team of doctors and other health professionals who are
experienced in diagnosing ASD.

This team may include:

• A developmental pediatrician—a doctor who has special training in child development
• A child psychologist and/or child psychiatrist—a doctor who has specialized training in
• brain development and behavior
• A neuropsychologist—a doctor who focuses on evaluating, diagnosing, and treating neurological,
• medical, and neurodevelopmental disorders
• A speech-language pathologist—a health professional who has special training in communication difficulties

The evaluation may assess:

• Cognitive level or thinking skills
• Language abilities
• Age-appropriate skills needed to complete daily activities independently, such as eating, dressing, and toileting

Because ASD is a complex disorder that sometimes occurs along with other illnesses or learning disorders, the comprehensive evaluation may include:

• Blood tests
• Hearing test

The outcome of the evaluation will result in a formal diagnosis and recommendations for treatment.

​Diagnosis in older children and adolescents

ASD symptoms in older children and adolescents who attend school are often first recognized by parents and teachers and then evaluated by the school’s special education team. The school’s team may perform an initial evaluation and then recommend these children visit their primary health care doctor or doctors who specialize in ASD for additional testing.

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Parents may talk with these specialists about their child’s social difficulties including problems with subtle communication. These subtle communication issues may include problems understanding tone of voice, facial expressions, or body language. Older children and adolescents may have trouble understanding figures of speech, humor, or sarcasm. Parents may also find that their child has trouble forming friendships with peers.

​Diagnosis in adults

Diagnosing ASD in adults is often more difficult than diagnosing ASD in children. In adults, some ASD symptoms can overlap with symptoms of other mental-health disorders, such as anxiety or attention-deficit/hyperactivity disorder (ADHD).

​Adults who notice the signs and symptoms of ASD should talk with a doctor and ask for a referral for an ASD evaluation. While testing for ASD in adults is still being refined, adults can be referred to a neuropsychologist, psychologist, or psychiatrist who has experience with ASD.

The expert will ask about concerns, such as:

• Social interaction and communication challenges
• Sensory issues
• Repetitive behaviors
• Restricted interests

Information about the adult’s developmental history will help in making an accurate diagnosis, so an ASD evaluation may include talking with parents or other family members.

Getting a correct diagnosis of ASD as an adult can help a person understand past difficulties, identify his or her strengths, and obtain the right kind of help. Studies are now underway to determine the types of services and supports that are most helpful for improving the functioning and community integration of transition-age youth and adults with ASD.

​Changes to the ASD Diagnosis

In 2013, a revised version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was released. The revision changed the away autism is classified and diagnosed. Using the previous version of the DSM, people could be diagnosed with one of several separate conditions:

• Autism disorder
• Asperger's syndrome
• Pervasive developmental disorder not otherwise specified (PDD-NOS)

​In the current revised version of the DSM these separate conditions have been combined into one diagnosis called "autism spectrum disorder."

​Treatments and Therapies

Treatment for ASD should begin as soon as possible after diagnosis. Early treatment for ASD is important as proper care can reduce individuals’ difficulties while helping them learn new skills and make the most of their strengths.

​The wide range of issues facing people with ASD means that there is no single best treatment for ASD. Working closely with a doctor or health care professional is an important part of finding the right treatment program.

​Medication

A doctor may use medication to treat some symptoms that are common with ASD. With medication, a person with ASD may have fewer problems with:

• Irritability
• Aggression
• Repetitive behavior
• Hyperactivity
• Attention problems
• Anxiety and depression

​Behavioral, psychological, and Educational therapy

People with ASD may be referred to doctors who specialize in providing behavioral, psychological, educational, or skill-building interventions. These programs are typically highly structured and intensive and may involve parents, siblings, and other family members. Programs may help people with ASD:

• Learn life-skills necessary to live independently
• Reduce challenging behaviors
• Increase or build upon strengths
• Learn social, communication, and language skills

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Depression

Depression is more than just feeling sad or going through a rough patch. It’s a serious mental health condition that requires understanding and medical care. Depression can be devastating for the people who have it and for their families if left untreated. With early detection, diagnosis and a treatment plan consisting of medication, psychotherapy and lifestyle choices, many people get better. Some only have one episode in a lifetime, but for most depression recurs. Episodes may last a few months to several years, if left untreated. Those with severe depression can become so hopeless and are a high risk for suicide.

Depression affects people of all ages and all racial, ethnic and socioeconomic groups. Different groups of people experience depression in different ways. Men may feel more shame about their depression and simply try to tough it out or use alcohol or drugs to self-medicate. Untreated depression in men can be devastating and men are about four times more likely to die by suicide than woman. With woman, many factors play a role in whether they develop depression, including genetics, biology, reproduction, hormonal changes, and interpersonal relationships.

Depression in elderly people often goes untreated because many people think that depression is a normal part of aging and a natural reaction to chronic illness, loss and social transition. The symptoms in older people may differ from younger people. Depression is characterized by memory problems, vague complaints of pain, and delusions and depression can be a side effect of many medications commonly prescribed to older people.

Gay, lesbian, bisexual, transgender and question (GLBTQ) people are at higher risk for depression because they regularly face discrimination from society at large and sometimes from family, co-workers or classmates. The GBVTQ stigma can make them more vulnerable to mental illnesses like depression.

Children with depression are more likely to complain of aches and pains than to say they are depressed. Teens with depression may become aggressive, engage in risky behavior, abuse drugs or alcohol, do poorly in school or run away. When teens experience an episode they have an increased risk for suicide. The third-leading cause of death from suicide is among children aged 15-19.

Symptoms

• Changes in sleep
• Changes in appetite
• Lack of concentration
• Loss of energy
• Lack of interest
• Low self-esteem
• Hopelessness
• Changes in movement
• Physical aches and pains

Causes

Depression does not have a single cause. It can be triggered, or it may occur spontaneously without being associated with a life crisis, physical illness or other risk. Scientist believe several factors contribute to cause depression:

• Trauma
• Genetics
• Life circumstances
• Brain structure
• Drug and alcohol abuse
• Other medical conditions

Diagnosis

To be diagnosed with depression, a person must have experienced a major depressive episode that has lasted longer than two weeks. Symptoms of a major depressive episode include:

• Loss of interest or loss of pleasure in all activities
• Change in appetite or weight
• Sleep disturbances
• Feeling agitated or fatigue
• Feelings of low self-worth
• Guilt of shortcomings
• Difficulty concentrating or making decisions
• Suicidal thoughts or intentions

Depression can be part of bipolar disorder or another mental illness making the diagnosis complicated. Research has shown that African Americans and Latinos are more likely to be misdiagnosed, so people who have been diagnosed with depression should look for a health care professional who understand their background and shares their expectations for treatment.

Treatment

Depression often responds to treatment, although it can be a devastating illness. The key is to get a specific evaluation and treatment plan. There are a variety of treatment options available for people with depression today, including:

• Medications
• Psychotherapy
• Brain stimulation therapies
• Light therapy
• Exercise
• Alternative therapies
• Self-management strategies in education
• Mind/body/spirit approaches

A person with depression may have additional conditions, which make it difficult to treat. The additional conditions may include substance abuse, ADHD, and/or anxiety disorders, including post-traumatic stress disorder (PTSD). Successful treatment of PTSD, ADHD or substance abuse usually improves the symptoms of depression.

Dissociative Disorders

Dissociation is a disconnection between a person's thoughts, memories, feelings, actions or sense of who her or she is. This is a normal process that everyone has experienced. Examples of mild, common dissociation include daydreaming, highway hypnosis or "getting lost" in a book or movie, all of which involve "losing touch" with awareness of one's immediate surroundings. All dissociative disorders are thought to stem from trauma experienced by the individual with this disorder. This aspect is thought to be a coping mechanism -- the person literally dissociates himself from a situation or experience that is too traumatic to integrate with their conscious self. Symptoms of these disorders are also seen in a number of other mental illnesses, including post-traumatic stress disorder, panic disorder, and obsessive compulsive disorder.

​Dissociative disorders come in many forms, the most famous of which is dissociative identity disorder (DID), formerly known as multiple personality disorder. Some of these disorders are listed below:

• Dissociative amnesia - characterized by blocking of critical personal information (amnesia)
• Dissociative fugue - an individual suddenly and unexpectedly takes physical leave of their surroundings and sets off on a journey of some kind
• Dissociative identity disorder (DID) - an individual suffering from DID has more than one distinct identity or personality state that surfaces in the individual on a recurring basis
• Depersonalization disorder - the feeling of detachment or distance from one's own experience, body, or self

Eating Disorders

Illnesses that are characterized by irregular eating habits and severe distress or concern about body weight or shape. The eating disturbances may include inadequate or excessive food intake which can ultimately damage an individual's well-being. There are three main types of eating disorders: anorexia nervosa, bulimia nervosa, and binge eating disorder. Each condition involves extreme food and weight issues; however, each disorder has unique symptoms that separate it from the others.

​People with anorexia nervosa and bulimia nervosa tend to be perfectionists with low self-esteem and are extremely critical of themselves and their bodies.

​Anorexia Nervosa

A person with anorexia will deny themselves food to the point of self-starvation as weight loss is an obsession. A person will deny hunger and refuse to eat, practice binge eating and purging behaviors or exercise to the point of exhaustion as an attempt to limit, eliminate or "burn" calories.

​Bulimia Nervosa

Someone living with bulimia will feel out of control when binging on very large amounts of food during short periods of time, and then desperately try to get rid of the extra calories using forced vomiting, abusing laxatives or excessive exercise. The individual will repeat the cycle that controls many aspects of the person's life. This has a very negative effect emotionally and physically. Those living with bulimia are usually normal weight or even a bit overweight.

​The individual with bulimia has emotional symptoms which include low self-esteem overly linked to body image, feelings of being out of control, feeling guilty or shameful about eating and will withdraw from friends and family.

​Binge Eating Disorder (BED)

Those with binge eating disorder have episodes of binge eating in which they consume extremely large quantities of food in a brief period and feel out of control during the binge. These individuals will try to get rid of the food by inducing vomiting or by using other unsafe practices such as fasting or laxative abuse. Binge eating is chronic and can lead to serious health complications such as obesity, diabetes, hypertension, and cardiovascular diseases.

​Diagnosis

If an eating disorder is believed to be an issue, a doctor will usually perform a physical examination, conduct an interview and order lab tests which will help form the diagnosis and check for related medical issues and complications. A mental health professional will conduct a psychological evaluation asking questions about eating habits, behaviors and beliefs. Types of questions asked may be about the patient's history of dieting, exercise, binging and purging.

​Treatment

Eating disorders are managed using a variety of techniques and vary depending on the type of disorder. The treatments generally include:

• Psychotherapy - talk or behavioral  therapy
• Medicine - such as antidepressants and anti-anxiety drugs. Many people living with eating disorders often have a co-occurring illness like depression or anxiety. There are no medications available to treat eating disorders themselves, but many patients find that these medications help with underlying issues.
• Nutritional counseling and weight restoration monitoring are crucial.

Obsessive-Compulsive Disorder (OCD)

Obsessive-Compulsive Disorder (OCD) is an anxiety disorder in which people have recurring, unwanted thoughts, ideas or sensations that make them feel driven to do something repetitively. Many people have focused thoughts or repeated behaviors, but these do not disrupt daily life and may add structure or may make tasks easier. Those with OCD have persistent and unwanted routines and behaviors that are rigid and not completing the task causes great distress. Many with OCD suspect their obsessions are not true and others may have poor insight and think they could be true. People with OCD, even if they know their obsessions are not true, have a difficult time keeping their focus off the obsessions or stopping the compulsive actions. OCD is often described as "a disease of doubt" as the sufferers experience "pathological doubt" because they are unable to distinguish between what is possible, what is probable, and what is unlikely to happen.

​Obsessions are intrusive, irrational thoughts - unwanted ideas or impulses that repeatedly fill a person's mind. Trying to avoid such thoughts creates great anxiety.

​Compulsions are repetitive rituals (hand washing, counting, checking, hoarding, or arranging). An individual repeats these actions without feeling satisfaction or a sense of completion. These individuals fear something bad will happen if they do not complete the ritual.

​Treatment

OCD does not go away on its own and there is no cure. The first step is to see your doctor. An exam will show if your symptoms are the result of a physical issue. If the symptoms are not, your doctor can recommend a mental illness specialist (psychologist, psychiatrist, mental health counselor or social worker). Many suffering from OCD find that combining talk therapy and medication works best.

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Oppositional Defiant Disorder (ODD)

All children are oppositional from time to time, particularly when tired, hungry, stressed, or upset. They may argue, talk back, disobey, and defy parents, teachers, and other adults. Oppositional behavior is a normal part of development for two to three year olds and early adolescents. However, openly uncooperative and hostile behavior becomes a serious concern when it is so frequent and consistent that it stands out when compared with other children of the same age and developmental level and when it affects the child's social, family, and academic life.

​ODD is a condition in which a child displays an ongoing pattern of an angry or irritable mood, defiant or argumentative behavior, and vindictiveness toward people in authority. The child's behavior often disrupts the child's normal daily activities, including activities within the family and at school.

ODD is typically diagnosed around early elementary school ages and stops being diagnosed around adolescence. Children who have ODD have a well-established pattern of behavior problems. Symptoms can include:

• Being unusually angry and irritable
• Frequently anger and resentment
• Being easily annoyed
• Arguing with authority figures
• Refusing to follow rules and questioning the rules
• Deliberately annoying o upset people
• Blaming others for mistakes or misbehavior
• Being vindictive
• Spiteful attitude and revenge seeking
• Mean or hateful talking to others
• Touchy and easily annoyed by others

All children can have these symptoms from time to time. What distinguishes ODD from normal oppositional behavior is how severe it is, and how long it has been going on for. A child with ODD will have had extreme behavior issues for at least six months.

Children with ODD are a regular daily frustration with ignored commands, arguments, explosive outbursts (build up over time) and these negative interactions damage the parent-child bond and reinforce hostile patterns of behavior.

The symptoms are usually seen in multiple settings but may be more noticeable at home or at school. One to sixteen percent of all school-age children and adolescents have ODD. The causes of ODD are unknown, but many parents report that their child with ODD was more rigid and demanding than the child's siblings from an early age.

​What Causes Oppositional Defiant Disorder?

The exact cause of ODD is not known, but it is believed that a combination of biological, genetic, and environmental factors may contribute to the condition.

• Biological: Some studies suggest that defects in or injuries to certain areas of the brain can lead to serious behavioral problems in children. In addition, ODD has been linked to abnormal functioning of certain types of brain chemicals, or neurotransmitters. Neurotransmitters help nerve cells in the brain communicate with each other. If these chemicals are not working properly, messages may not make it through the brain correctly, leading to symptoms of ODD, and other mental illnesses. Further, many children and teens with ODD also have other mental illnesses, such as ADHD, learning disorders, depression, or an anxiety disorder, which may contribute to their behavior problems.
• Genetics: Many children and teens with ODD have close family members with mental illnesses, including mood disorders, anxiety disorders, and personality disorders. This suggests that a vulnerability to develop ODD may be inherited.
• Environmental: Factors such as a dysfunctional family life, a family history of mental illnesses and/or substance abuse, and inconsistent discipline by parents may contribute to the development of behavior disorders.

How Is Oppositional Defiant Disorder Diagnosed?

As with adults, mental illnesses in children are diagnosed based on signs and symptoms that suggest a particular illness like ODD. If symptoms are present, the doctor will begin an evaluation by performing a complete medical history and physical exam. Although there are no lab tests to specifically diagnose ODD, the doctor may sometimes use tests such as neuroimaging studies or blood tests if they suspect that there may be a medical explanation for the behavior problems that occur. The doctor also will look for signs of other conditions that often occur along with ODD, such as ADHD and depression.

If the doctor cannot find a physical cause for the symptoms, he or she will likely refer the child to a child and adolescent psychiatrist or psychologist, mental health professionals who are specially trained to diagnose and treat mental illnesses in children and teens. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a child for a mental illness. The doctor bases his or her diagnosis on reports of the child's symptoms and his or her observation of the child's attitude and behavior. The doctor often must rely on reports from the child's parents, teachers, and other adults because children often have trouble explaining their problems or understanding their symptoms.

Treatment of ODD may include:
 

• Parent Management Training to help parents and others manage the child's behavior
• Individual Psychotherapy to develop more effective anger management
• Family Psychotherapy to improve communication and mutual understanding
• Cognitive Problem-Solving Skills Training and Therapies to decrease negativity
• Social Skills Training to increase flexibility and improve social skills and frustration tolerance with peers

Medications may be helpful in controlling some of the more distressing symptoms of ODD as well as the symptoms related to coexistent conditions such as ADHD, anxiety, and mood disorders.

A child with ODD can be very difficult for parents. These parents need support and understanding. Parents can help their child with ODD in the following ways:

• Always build on the positives, give the child praise and positive reinforcement when s/he shows flexibility or cooperation.
• Take a time-out or break if you are about to make the conflict with your child worse, not better. This is good modeling for your child. Support your child if s/he decides to take a time-out to prevent overreacting.
• Pick your battles. Since the child with ODD has trouble avoiding power struggles, prioritize the things you want your child to do. If you give your child a time-out in his room for misbehavior, don't add time for arguing. Say “your time will start when you go to your room."
• Set reasonable, age appropriate limits with consequences that can be enforced consistently.
• Maintain interests other than your child with ODD, so that managing your child doesn't take all your time and energy. Try to work with and obtain support from the other adults (teachers, coaches, and spouse) dealing with your child.
• Manage your own stress with healthy life choices such as exercise and relaxation. Use respite care and other breaks as needed.

Many children with ODD will respond to the positive parenting techniques. Parents may ask their pediatrician or family physician to refer them to a child and adolescent psychiatrist or other qualified mental health professional who can help diagnose and treat ODD and any coexisting psychiatric condition.

How Common Is Oppositional Defiant Disorder?

Estimates suggest that 2%-16% of children and teens have ODD. In younger children, ODD is more common in boys. In older children, it occurs about equally in boys and in girls. It typically begins by age 8.

What Is the Outlook for Children With Oppositional Defiant Disorder?

If your child is showing signs of ODD, it is very important that you seek care from a qualified mental health professional immediately. Without treatment, children with ODD may experience rejection by classmates and other peers because of their poor social skills and aggressive and annoying behavior. In addition, a child with ODD has a greater chance of developing a more serious behavioral disorder called conduct disorder. When started early, treatment is usually very effective.

Can Oppositional Defiant Disorder Be Prevented?

Although it may not be possible to prevent ODD, recognizing and acting on symptoms when they first appear can minimize distress to the child and family, and prevent many of the problems associated with the illness. Family members also can learn steps to take if signs of relapse (return of symptoms) appear. In addition, providing a nurturing, supportive, and consistent home environment with a balance of love and discipline may help reduce symptoms and prevent episodes of defiant behavior.

Symptoms

Sometimes it's difficult to recognize the difference between a strong-willed or emotional child and one with oppositional defiant disorder. It's normal to exhibit oppositional behavior at certain stages of a child's development.

Signs of ODD generally begin during preschool years. Sometimes ODD may develop later, but almost always before the early teen years. These behaviors cause significant impairment with family, social activities, school and work. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists criteria for diagnosing ODD. The DSM-5 criteria include emotional and behavioral symptoms that last at least six months.

Angry and irritable mood:

• Often and easily loses temper
• Is frequently touchy and easily annoyed by others
• Is often angry and resentful

Argumentative and defiant behavior:

• Often argues with adults or people in authority
• Often actively defies or refuses to comply with adults' requests or rules
• Often deliberately annoys or upsets people
• Often blames others for his or her mistakes or misbehavior

Vindictiveness:

• Is often spiteful or vindictive
• Has shown spiteful or vindictive behavior at least twice in the past six months

ODD can vary in severity:

• Mild. Symptoms occur only in one setting, such as only at home, school, work or with peers.
• Moderate. Some symptoms occur in at least two settings.
• Severe. Some symptoms occur in three or more settings.

For some children, symptoms may first be seen only at home, but with time extend to other settings, such as school and with friends.

When to see a doctor

Your child isn't likely to see his or her behavior as a problem. Instead, he or she will probably complain about unreasonable demands or blame others for problems. If your child shows signs that may indicate ODD or other disruptive behavior, or you're concerned about your ability to parent a challenging child, seek help from a child psychologist or a child psychiatrist with expertise in disruptive behavior problems.

Ask your primary care doctor or your child's pediatrician to refer you to the appropriate professional.

Causes

There's no known clear cause of oppositional defiant disorder. Contributing causes may be a combination of inherited and environmental factors, including:

• Genetics — a child's natural disposition or temperament and possibly neurobiological differences in the way nerves and the brain function
• Environment — problems with parenting that may involve a lack of supervision, inconsistent or harsh discipline, or abuse or neglect

Risk factors

Oppositional defiant disorder is a complex problem. Possible risk factors for ODD include:

• Temperament — a child who has a temperament that includes difficulty regulating emotions, such as being highly emotionally reactive to situations or having trouble tolerating frustration
• Parenting issues — a child who experiences abuse or neglect, harsh or inconsistent discipline, or a lack of parental supervision
• Other family issues — a child who lives with parent or family discord or has a parent with a mental health or substance use disorder
• Environment — oppositional and defiant behaviors can be strengthened and reinforced through attention from peers and inconsistent discipline from other authority figures, such as teachers

Complications

Children and teenagers with oppositional defiant disorder may have trouble at home with parents and siblings, in school with teachers, and at work with supervisors and other authority figures. Children with ODD may struggle to make and keep friends and relationships.

ODD may lead to problems such as:

• Poor school and work performance
• Antisocial behavior
• Impulse control problems
• Substance use disorder
• Suicide

Many children and teens with ODD also have other mental health disorders, such as:

• Attention-deficit/hyperactivity disorder (ADHD)
• Conduct disorder
• Depression
• Anxiety
• Learning and communication disorders

Treating these other mental health disorders may help improve ODD symptoms. And it may be difficult to treat ODD if these other disorders are not evaluated and treated appropriately.

Prevention

There's no guaranteed way to prevent oppositional defiant disorder. However, positive parenting and early treatment can help improve behavior and prevent the situation from getting worse. The earlier that ODD can be managed, the better.

Treatment can help restore your child's self-esteem and rebuild a positive relationship between you and your child. Your child's relationships with other important adults in his or her life — such as teachers and care providers — also will benefit from early treatment.

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Posttraumatic Stress Disorder (PTSD)

​Posttraumatic stress disorder is a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, rape or other violent personal assault. PTSD affects approximately 3.5 percent of U.S. adults or 8 million American adults, and an estimated one in 11 people will be diagnosed PTSD in their lifetime. Researchers estimate that as many as 40% of children and adolescents will experience at least one traumatic event in their lifetime. Women are twice as likely as men to have PTSD. There is evidence that it may run in families.

PTSD can occur in all people, in people of any ethnicity, nationality or culture, and any age. People with PTSD have intense, disturbing thoughts and feelings related to their experience that last long after the traumatic event has ended. They may relive the event through flashbacks or nightmares; they may feel sadness, fear or anger; and they may feel detached or estranged from other people. People with PTSD may avoid situations or people that remind them of the traumatic event, and they may have strong negative reactions to something as ordinary as a loud noise or an accidental touch.

Whether a child or teen develops PTSD depends on many factors, including the severity of the trauma, how frequently it occurs, and how family members react to the event. A child or adolescent with PTSD feels that they are unable to escape the impact of the trauma. They try to avoid people or situations that remind them of the event. Sometimes they will experience memories or “flashbacks” of the event, or they may have nightmares about it that feel very real. These constant reminders make living day-to-day life a real challenge, especially for young people who might struggle to express what they’re feeling and experiencing.

A diagnosis of PTSD requires exposure to an upsetting traumatic event. However, exposure could be indirect rather than first hand. For example, PTSD could occur in an individual learning about the violent death of a close family. It can also occur as a result of repeated exposure to horrible details of trauma such as police officers exposed to details of child abuse cases. For people with PTSD the symptoms cause significant distress or problems functioning. PTSD often occurs with other related conditions, such as depression, substance use, memory problems and other physical and mental health problems. For a person to be diagnosed with PTSD, however, symptoms last for more than a month and often persist for months and sometimes years. Many individuals develop symptoms within three months of the trauma, but symptoms may appear later.

Symptoms

• Common PTSD Symptoms in Children and Teens
• Avoiding situations that make them recall the traumatic event
• Experiencing nightmares or flashbacks about the trauma
• Playing in a way that repeats or recalls the trauma
• Acting impulsively or aggressively
• Feeling nervous or anxious frequently
• Experiencing emotional numbness
• Having trouble focusing at school

Adult Symptoms of PTSD fall into four categories and specific symptoms can vary in severity.

1. Intrusive thoughts such as repeated, involuntary memories; distressing dreams; or flashbacks of the traumatic event. Flashbacks may be so vivid that people feel they are re-living the traumatic experience or seeing it before their eyes.
2. Avoiding reminders of the traumatic event may include avoiding people, places, activities, objects and situations that bring on distressing memories. People may try to avoid remembering or thinking about the traumatic event. They may resist talking about what happened or how they feel about it.
3. Negative thoughts and feelings may include ongoing and distorted beliefs about oneself or others (e.g., “I am bad,” “No one can be trusted”); ongoing fear, horror, anger, guilt or shame; much less interest in activities previously enjoyed; or feeling detached or estranged from others.
4. Arousal and reactive symptoms may include being irritable and having angry outbursts; behaving recklessly or in a self-destructive way; being easily startled; or having problems concentrating or sleeping.

Diagnosis criteria that apply to adults, adolescents, and children older than six include those below. 

Exposure to actual or threatened death, serious injury, or sexual violation:

• directly experiencing the traumatic events 
• witnessing, in person, the traumatic events
• learning that the traumatic events occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental
• experiencing repeated or extreme exposure to aversive details of the traumatic events (Examples are first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless exposure is work-related.

The presence of one or more of the following:

• spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic events (Note: In children repetitive play may occur in which themes or aspects of the traumatic events are expressed.)
• recurrent distressing dreams in which the content or affect (i.e. feeling) of the dream is related to the events (Note: In children there may be frightening dreams without recognizable content.)
• flashbacks or other dissociative reactions in which the individual feels or acts as if the traumatic events are recurring (Note: In children trauma-specific reenactment may occur in play.)
• intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic events
• physiological reactions to reminders of the traumatic events

Two or more of the following:

• inability to remember an important aspect of the traumatic events (not due to head injury, alcohol, or drugs)
• persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” "The world is completely dangerous"). 
• persistent, distorted blame of self or others about the cause or consequences of the traumatic events
• persistent fear, horror, anger, guilt, or shame
• markedly diminished interest or participation in significant activities
• feelings of detachment or estrangement from others
• persistent inability to experience positive emotions

Two or more of the following marked changes in arousal and reactivity:

• irritable or aggressive behavior
• reckless or self-destructive behavior
• hypervigilance
• exaggerated startle response
• problems with concentration
• difficulty falling or staying asleep or restless sleep

Causes

The cause of PTSD is unknown, but psychological, genetic, physical, and social factors are involved. PTSD changes the body's response to stress. It affects the stress hormones and chemicals that carry information between the nerves. People who have suffered childhood abuse or other previous traumatic experiences are likely to develop the disorder, sometimes months or years after the trauma. Temperamental variables such as externalizing behaviors or other anxiety issues may also increase risk. Other environmental risk factors include family dysfunction, childhood adversity, cultural variables, and family history of psychiatric illness. The greater the magnitude of the trauma, the greater the risk for PTSD—witnessing atrocities, severe personal injury, perpetrating violence. Inappropriate coping mechanisms, lack of social support, family instability, or financial stress may further worsen the outcome.

Resilience factors can help reduce the risk of the disorder. Some resilience factors are present before the trauma and others become important during and after a traumatic event. The resilience factors may reduce the risk of PTSD and include seeking out support from other people, such as mental health professionals, friends and family, finding a support group after a traumatic event, feeling good about one’s own actions in the face of danger, having a coping strategy, and being able to act and respond effectively despite feeling fear.

Treatment

Treating PTSD in Children and Teens

It’s important to remember that if your child does exhibit trauma symptoms, chances are they will decrease and disappear within a few months. This does not mean, however, that you should not consult with a mental health professional for an assessment and to discuss treatment options when symptoms occur. PTSD is treatable, so never hesitate to ask for help and see what works best. Here are some common treatment options for children with Post-traumatic stress disorder.

Cognitive behavioral therapy – CBT is one of the most common forms of “talk therapy,” and therapists can use a trauma-focused style of the therapy to work with children and adults. A trauma-focused CBT therapist helps a child identity and correct irrational or illogical thoughts they might have about the trauma itself or people and situations they encounter in everyday life. CBT also typically includes psychoeducation about relaxation and coping techniques for stress.

Play therapy – This type of therapy can work especially well for younger children who struggle to communicate their reactions to the trauma and understanding of what happened. Play therapists use art therapy, games, and other interventions to help a child process a trauma and cope resiliently with life.

Eye moment desensitization and reprocessing – EMDR is a technique that is increasingly in popularity among mental health professionals. The therapy incorporates guided eye movement exercises while a child recalls the traumatic event and works through cognitions and emotional responses they have about it.

Medication – There is no medication that “cures” PTSD, but sometimes antidepressants and anti-anxiety medication can help relieve symptoms in some children while they are also seeing a therapist.

PTSD symptoms frequently co-occur with other types of mental illness or lead to other issues with children and teens, including substance use, risky behaviors, and self-injury. These issues may need to be addressed in treatment as well to protect your child and help them achieve a full recovery.

As a parent, you want nothing but the best for your child. So watching them be “held hostage” by trauma symptoms can make you feel powerless and clueless about where you should begin. The best place to begin is by listening to your child and choosing not to ignore their symptoms and struggles. Ally yourself with friends, family, and professionals who support both you and your child. Search for resources at your child’s school, the doctor’s office, or your local community center that can get you pointed in the right direction. Help your child learn to accept trauma and recover from it.

Remember, PTSD is treatable, and your child can have a healthy body and mind, free of symptoms and fully in control of their own destiny.

Complementary Health Approaches

Recently, many health care professionals have begun to include complementary and alternative methods into treatment regimens.

Some methods that have been used for PTSD include:

• Yoga
• Aqua therapy
• Acupuncture
• Mindfulness and meditation strategies and practices

Service dogs are another option for non-traditional therapy for people experiencing PTSD. A service dog is by a person’s side 24 hours a day to help navigate daily stressors. Most animals come to the person pre-trained with a set of commands. The owner can rely upon the dog for help and as a reality grounding tool, which can help prevent a re-experience or other symptoms. These animals can also serve as a social buffer, an incentive to exercise and a de-escalation tool during times of stress.

Other strategies for treatment include:

• Educating trauma survivors and their families about risks related to PTSD, how PTSD affects survivors and their loved ones, and other problems commonly associated with PTSD symptoms. Understanding that PTSD is a medically recognized disorder is essential for effective treatment.
• Exposure to the event via imagery allows the survivor to re-experience the event in a safe, controlled environment. A professional can carefully examine reactions and beliefs in relation to that event.
• Examining and resolving strong feelings such as shame, anger, or guilt, which are common among survivors of trauma.
• Teaching the survivor to cope with post-traumatic memories, reminders, reactions, and feelings without avoiding them or becoming overwhelmed or emotionally numb. Trauma memories usually do not go away entirely as a result of therapy, but new coping skills can make them more manageable.

Related Conditions

Acute stress disorder occurs in reaction to a traumatic event, just as PTSD does, and the symptoms are similar. However, the symptoms occur between three days and one month after the event. People with acute stress disorder may relive the trauma, have flashbacks or nightmares and may feel numb or detached from themselves.  These symptoms cause major distress and cause problems in their daily lives. About half of people with acute stress disorder go on to have PTSD. An estimated 13 to 21 percent of survivors of car accidents develop acute stress disorder and between 20 and 50 percent of survivors of assault, rape or mass shootings develop it.

Psychotherapy, including cognitive behavior therapy can help control symptoms and help prevent them from getting worse and developing into PTSD.  Medication, such as SSRI antidepressants can help ease the symptoms.

Adjustment disorder occurs in response to a stressful life event (or events). The emotional or behavioral symptoms a person experiences in response to the stressor are generally more severe or more intense than what would be reasonably expected for the type of event that occurred.

Symptoms can include feeling tense, sad or hopeless; withdrawing from other people; acting defiantly or showing impulsive behavior; or physical manifestations like tremors, palpitations, and headaches. The symptoms cause significant distress or problems functioning in important areas of someone’s life, for example, at work, school or in social interactions. Symptoms of adjustment disorders begin within three months of a stressful event and last no longer than six months after the stressor or its consequences have ended.

The stressor may be a single event (such as a romantic breakup), or there may be more than one event with a cumulative effect. Stressors may be recurring or continuous (such as an ongoing painful illness with increasing disability). Stressors may affect a single individual, an entire family, or a larger group or community (for example, in the case of a natural disaster).

An estimated 5% to 20% of individuals in outpatient mental health treatment have a principal diagnosis of adjustment disorder. A recent study found that more than 15% of adults with cancer had adjustment disorder. It is typically treated with psychotherapy.     

Disinhibited social engagement disorder occurs in children who have experienced severe social neglect or deprivation before the age of 2. Similar to reactive attachment disorder, it can occur when children lack the basic emotional needs for comfort, stimulation and affection, or when repeated changes in caregivers (such as frequent foster care changes) prevent them from forming stable attachments.

Disinhibited social engagement disorder involves a child engaging in overly familiar or culturally inappropriate behavior with unfamiliar adults. For example, the child may be willing to go off with an unfamiliar adult with minimal or no hesitation. These behaviors cause problems in the child’s ability to relate to adults and peers. Moving the child to a normal caregiving environment improves the symptoms. However, even after placement in a positive environment, some children continue to have symptoms through adolescence. Developmental delays, especially cognitive and language delays, may co-occur along with the disorder. The prevalence of disinhibited social engagement disorder is unknown, but it is thought to be rare. Most severely neglected children do not develop the disorder. Treatment involves the child and family working with a therapist to strengthen their relationship.   

Reactive attachment disorder occurs in children who have experienced severe social neglect or deprivation during their first years of life. It can occur when children lack the basic emotional needs for comfort, stimulation and affection, or when repeated changes in caregivers (such as frequent foster care changes) prevent them from forming stable attachments. Children with reactive attachment disorder are emotionally withdrawn from their adult caregivers. They rarely turn to caregivers for comfort, support or protection or do not respond to comforting when they are distressed. During routine interactions with caregivers, they show little positive emotion and may show unexplained fear or sadness. The problems appear before age 5. Developmental delays, especially cognitive and language delays, often occur along with the disorder. Reactive attachment disorder is uncommon, even in severely neglected children. Treatment involves the child and family working with a therapist to strengthen their relationship.

Suicide

Suicide causes immeasurable pain, suffering, and loss to individuals, families, and communities nationwide. On average, 132 Americans die by suicide each day and this is the tenth leading cause of death. In 2020, 1.4 million Americans attempted suicide and 48,344 Americans died by suicide. Suicide is the second leading cause of death for ages 10-34 and fourth leading cause of death for ages 35-54. Ninety percent of those who died by suicide had a diagnosable mental health condition at the time of their death.

Know the Risk Factors

Risk factors are characteristics that make it more likely that someone will consider, attempt, or die by suicide. The risk factors can't cause or predict a suicide attempt, but they are important to be aware of.

• Co-occuring mental and alcohol or substance abuse disorders
• Hopelessness
• Impulsive and/or aggressive tendencies
• History of trauma, physical or sexual abuse
• Major physical illnesses
• Previous suicide attempt(s)
• Family history of suicide
• Job or financial loss
• Stigma associated with asking for help
• Same-sex sexual orientation (only shown for suicidal behavior, not suicide)
• Impaired parent-child relationships
• Life stressors
• Lack of involvement in school and/or work ("drifting")
• Lack of healthcare, especially mental health and substance abuse treatment
• Relationship loss
• Easy access to lethal means

Self-injury/Self-Harm (Cutting)

Self-injury is the act of deliberately harming your own body, such as cutting or burning yourself. This type of self-injury is not typically meant as a suicide attempt, is a harmful way to cope with emotional pain, intense anger, and frustration.

Self-injury may bring a momentary sense of calm and release tension, it’s often followed by guilt and share and the return of painful emotions. Life-threatening injuries are not intended, but it comes with the possibility of more-serious and even fatal self-aggressive actions. Research indicates that self-injury occurs in as many as 4% of adults in the US. Rates are higher among adolescents with teens reporting approximately 15% of some form of self-injury. Studies show a higher risk among college students, with rates ranging from 17-35%.

Symptoms

• Signs and symptoms of self-injury may include:
• Scars, usually patterns
• Fresh cuts, scratches, bruises, bite marks or other wounds
• Wearing long sleeves or long pants, even in warmer weather
• Difficulties in interpersonal relationships
• Keeping sharp objects on hand
• Excessive rubbing of an area to create a burn
• Statements of helplessness, hopelessness or worthlessness
• Frequent reports of accidental injury

Warning signs

Signs that someone may be injuring themselves include:

• Unexplained frequent injuries including cuts and burns
• Low self-esteem
• Difficulty handling feelings
• Poor functioning at work, school, or home
• Relationship problems or avoidance of relationships

Those who self-injure attempt to conceal their marks and you may notice them wearing inappropriate clothing. A person who self-injures may often make excuses as to how an injury happened.

Forms of self-injury

This usually occurs in private and is done in a controlled or ritualistic manner that often leaves patterns on the skin. Examples of self-harm include:

• Skin cutting (70-90%)
• Self-hitting, punching or head banging (21-44%)
• Burning, with lit matches, cigarettes or heated, sharp objects (15-35%)
• Scratching
• Carving words or symbols on the skin
• Inserting objects under the skin
• Piercing the skin with sharp objections

Typically, the arms, legs and front of the torso are the targets of self-injury but any area of the body may be used. Those that self-injure may use more than one method to harm themselves.

When to see a professional

The person should reach out for help if they are injuring themselves or if they have thoughts of harming themselves. Any form of self-injury is a sign of bigger issues that need and should be addressed.

Talking to someone you trust who can help you take the first steps to successful treatment. You can find supportive, caring and nonjudgmental help even if you feel ashamed and embarrassed about your behavior.

When a friend or loved one self-injures

If you have a friend of loved one who is self-injuring, you may be shocked and scared. Take all talk of self-injury seriously. Self-injury is a big problem and should not be ignored or left to deal with it alone even if you feel that you’d be betraying their confidence.

Here are some ways you can help your child: Start by consulting your pediatrician or other health care providers who can provide an initial evaluation or a referral to a mental health professional. Do not yell or make threats or accusations to your child, but express your concern.

• Preteen or teenage friend – Suggest that your friend or teen reaches out to parents, a teacher, a school
• counselor or another trusted adult.
• Adult – Express your concern and encourage the person to seek medical and mental health treatment.

When to seek emergency help

If you’ve injured yourself severely or believe your injury may be life-threatening or you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately.

Consider these options if you’re considering suicide or have suicidal thoughts:

• Call your mental health professional (if you have or are seeing one)
• Call a suicide hotline. The National Suicidal Prevention Lifeline can be reached by different methods:
• 1-800-273-TALK (1-800-273-8255)
• Webchat at https://suicidepreventionlifeline.org/chat/
• Seek help from your school counselor, nurse, teacher, doctor or other health care professional
• Reach out to a loved one or close friend
• Contact a spiritual leaders of someone in your faith community

Causes

There are different reasons why people harm themselves. Self-injury may result from:

Poor coping skills – nonsuicidal self-injury is usually the result of an inability to cope with psychological pain in a healthy way.

Difficulty managing emotions – The person has a difficult time regulating, expressing or understanding emotions. The mix of emotions that triggers self-injury is complex and there may be feelings of worthlessness, loneliness, panic, guilt, anger, rejection, self-hatred or confused sexuality

They harm themselves to try to:

• Make themselves feel something, when they feel empty or numb inside
• Block upsetting memories
• Show that they need help
• Release strong feelings that overwhelm them, such as anger, loneliness, or hopelessness
• Punish themselves
• Feel a sense of control

Risk factors

Most who self-injure are teenagers and younger adults, although those in other age groups also self-injure. Often self-injury starts in the preteen or early teen years when their emotions are more volatile and face increased peer pressure, loneliness, and conflicts with authority figures or with parents. Some factors may increase the risk of self-injury, such as:

• Having friends who self-injure
• Life issues
• Mental health issues (depression, eating disorders, post-traumatic stress disorder)
• Alcohol or drug use
• Low self-esteem
• Trauma or abused as a child

Complications from self-injury

• A variety of complications include:
• Infection, either from wounds or from sharing tools
• Severe, possibly fatal injury
• Worsening of underlying issues and disorders (if not treated)
• Worsening feelings of shame, guilt or low self-esteem

Prevention

There is no sure way to prevent one’s self-injury, but reducing the risk includes strategies that involve both individuals and communities. Parents, family members, teachers, coaches, counselors and nurses can help.

Identify someone at risk and offer to help

• Encourage expansion of social networks
• Raise awareness
• Encourage peers to seek help
• Talk about media influence

Other Resources

• The Mighty’s Guide to Understanding Self-Harm https://themighty.com/2019/06/what-is-self-harm/
• S.A.F.E. Alternatives (Self-Abuse Finally Ends)
  Information Hotline: 1-800-DON’T-CUT (1-800-366-8288)
  Email: info@selfinjury.com
  www.selfinjury.com