Our Clients

Childhood and adolescence are rich developmental stages that come with milestones to reach and challenges to overcome. Every child, no matter how good-natured, has behavioral outbursts that can be challenging, even for the most patient caregiver. Although these outbursts are common at all stages, the frequency and intensity of a child’s behaviors might indicate the presence of an underlying clinical condition.

By adulthood, most “formal” clinical conditions of childhood are well known to the family. However, as the supportive school environments and “childhood services” fade, many families struggle even more with finding effective supports for their adult children with special needs.

At Pivot Point, we believe that any family struggling to manage those “conditions of childhood” – whether in a child, teen, or adult – should have access to supports that help them to be at their best. As such, Pivot Point programs are suitable for a full range of families, from parents with minor concerns and questions about parenting, to families who are clearly struggling and suspect underlying challenges, to families with children or adults with mild to severe clinical conditions such as those listed on this page.

Select “Read more >>” if you suspect, or want to learn more about any of the following complex childhood conditions:

Autism Spectrum Disorder (including Asperger Syndrome)

Autism Spectrum Disorder (ASD)

Definition at a glance:

Autism is a pervasive developmental disorder defined by the presence of abnormal and/or impaired development that is manifest before the age of 3 years, and by the characteristic type of abnormal functioning in all three areas of social interaction, communication, and restricted, repetitive behaviour. The disorder occurs in boys three to four times more often than in girls.

The condition is also characterized by restricted, repetitive, and stereotyped patterns of behaviour, interests, and activities. These take the form of a tendency to impose rigidity and routine on a wide range of aspects of day-to day functioning; this usually applies to novel activities as well as to familiar habits and play patterns. In early childhood particularly, there may be specific attachment to unusual, typically non-soft objects. The children may insist on the performance of particular routines in rituals of a nonfunctional character; there may be stereotyped preoccupations with interests such as dates, routes or timetables; often there are motor stereotypies; a specific interest in nonfunctional elements of objects (such as their smell or feel) is common; and there may be a resistance to changes in routine or in details of the personal environment (such as the movement of ornaments or furniture in the family home).

In addition to these specific diagnostic features, it is frequent for children with autism to show a range of other nonspecific problems such as fear/phobias, sleeping and eating disturbances, temper tantrums, and aggression. Self-injury (e.g. by wrist-biting) is fairly common, especially when there is associated severe mental retardation. Most individuals with autism lack spontaneity, initiative, and creativity in the organization of their leisure time and have difficulty applying conceptualizations in decision-making in work (even when the tasks themselves are well within their capacity). The specific manifestation of deficits characteristic of autism change as the children grow older, but the deficits continue into and through adult life with a broadly similar pattern of problems in socialization, communication, and interest patterns.

Diagnostic Criteria Include:

The latest Diagnostic and Statistical Manual of the American Psychological Association (DSM IV — text revised) offers the following diagnostic criteria for the assessment of Autism:

A. 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 behaviours 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 gesture 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 behaviour, interests, and activities, as manifested by at least one of the following:

a)	encompassing preoccupation with one or more stereotyped and restricted 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.

Anxiety and Depressive Disorders

Attention Deficit / Hyperactivity Disorder (ADHD)

Attention Deficit hyperactivity Disorder (ADHD)

Definition at a glance:

This group of disorders is characterized by: early onset; a combination of overactive, poorly modulated behaviour with marked inattention and lack of persistent task involvement; and the pervasiveness of these behavioural characteristics over situations and time.

ADHD disorders always arise early in development (usually in the first 5 years of life). Their chief characteristics are lack of persistence in activities that require cognitive involvement, and a tendency to move from one activity to another without completing any one, together with disorganized, ill-regulated, and excessive activity. These problems usually persist through school years and even into adult life, but many affected individuals show a gradual improvement in activity and attention.

Several other abnormalities may be associated with these disorders. ADHD children are often reckless and impulsive, prone to accidents, and find themselves in disciplinary trouble because of unthinking (rather than deliberately defiant) breaches of rules. Their relationships with adults are often socially disinhibited, with a lack of normal caution and reserve; they are unpopular with other children and may become isolated. Cognitive impairment is common, and specific delays in motor and language development are disproportionately frequent. Associated reading difficulties (and/or other scholastic problems) are common.

ADHD disorders are several times more frequent in boys than in girls.

Diagnostic Criteria include:

A. Either (1) or (2):

1. Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

a)	Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
b)	Often has difficulty sustaining attention in tasks or play activities
c)	Often does not seem to listen when spoken to directly
d)	Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
e)	Often has difficulty organizing tasks and activities
f)	Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
g)	Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
h)	Is often easily distracted by extraneous stimuli
i)	Is often forgetful in daily activities

2. Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity

a)	Often fidgets with hands or feet or squirms in seat
b)	Often leaves seat in classroom or in other situations in which remaining seated is expected
c)	Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
d)	Often has difficulty playing or engaging in leisure activities quietly
e)	Is often “on the go” or often acts as if “driven by a motor”
f)	Often talks excessively

Impulsivity

g)	Often blurts out answers before questions have been completed
h)	Is often “on the go” or often acts as if “driven by a motor”
i)	Often has difficulty awaiting turn
j)	Is often “on the go” or often acts as if “driven by a motor”
k)	Often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.

C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Conduct Disorder (CD)

Definition at a glance:

Conduct disorders are characterized by a repetitive and persistent pattern (more than 6 months) of dissocial, aggressive, or defiant conduct. Such behaviour, when at its most extreme for the individual, typically amounts to major violations of age-appropriate social expectations, and is therefore more severe than ordinary childish mischief or adolescent rebelliousness. Isolated dissocial or criminal acts are not in themselves grounds for the diagnosis, which implies an enduring pattern of behaviour.

Conduct disorder is frequently associated with adverse psychosocial environments, including unsatisfactory family relationships and failure at school, and is more commonly noted in boys. Its distinction from emotional disorder is well validated; its separation from hyperactivity is less clear and there is often overlap.

Examples of the behaviours on which the diagnosis is based include the following: excessive levels of fighting or bullying; cruelty to animals or other people; severe destructiveness to property; firesetting; stealing; repeated lying; truancy from school and running away from home; unusually frequent and severe temper tantrums; defiant provocative behaviour; and persistent severe disobedience. Any one of these categories, if marked, is sufficient for the diagnosis, but isolated dissocial acts are not.

Diagnostic Criteria Include:

A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:

Aggression to people and animals

1.	often bullies, threatens, or intimidates others
2.	often initiates physical fights
3.	has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
4.	has been physically cruel to people
5.	has been physically cruel to animals
6.	has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
7.	has forced someone into sexual activity

Destruction of property

8.	has deliberately engaged in fire setting with the intention of causing serious damage
9.	has deliberately destroyed others’ property (other than by fire setting)

Deceitfulness or theft

10.	has broken into someone else’s house, building, or car
11.	often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others)
12.	has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)

Serious violations of rules

13.	often stays out at night despite parental prohibitions, beginning before age 13 years
14.	has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
15.	is often truant from school, beginning before age 13 years

Down Syndrome

Down Syndrome (DS)

Definition at a glance:

Down Syndrome is a genetic condition caused by having extra genes on the 21st chromosome. The extra genetic material causes certain characteristics (biological and psychological) that are know as Down Syndrome, in addition to the inherited individual features from their parents. Down syndrome is the single most common cause of mental handicap, and is one of the most frequently occurring chromosomal abnormalities found in humans, occurring once in approximately every 800 to 1,000 live births. In the United States, approximately 350,000 families are affected by Down syndrome. Approximately 5,000 children with Down syndrome are born each year.

Although the risk of Down Syndrome increases with age, a child with Down Syndrome can be born to a mother at any age. Although only 5-8% of pregnancies occur in women over the age of 35, they account for 20% of Down Syndrome births. Therefore, 80% of children with Down Syndrome are born to women who are less than 35 years of age.

Diagnostic Criteria Include:

Normally, the nucleus of each cell contains 23 pairs of chromosomes, half of which are inherited from each parent, making 46 in total. However, in Down syndrome the cells usually contain 47 chromosomes; with the extra chromosome being at number 21. This excess genetic material, in the form of additional genes along the 21st chromosome, results in Down syndrome.

There are many physical characteristics which form the basis for suspecting an infant has Down syndrome. Many of these characteristics are found, to some extent, in the general population of individuals who do not have Down syndrome. Hence, if Down syndrome is suspected, a karyotype will be performed to ascertain the diagnosis. Some infants with Down syndrome have only a few of these traits, while others have many. Among the most common traits are:

Muscle hypotonia, low muscle tone
Flat facial profile, a somewhat depressed nasal bridge and a small nose
Oblique palpebral fissures, an upward slant to the eyes
Dysplastic ear, an abnormal shape of the ear
Simian crease, a single deep crease across the center of the palm
Hyperflexibility, an excessive ability to extend the joints
Dysplastic middle phalanx of the fifth finger, fifth finger has one flexion furrow instead of two
Epicanthal folds, small skin folds on the inner corner of the eyes
Excessive space between large and second toe
Enlargement of tongue in relationship to size of mouth

Fetal Alcohol Spectrum Disorders

Fragile X Syndrome

Oppositional / Defiant Disorder (ODD)

Oppositional / Defiant Disorder (O.D.D.)

Definition at a glance:

Oppositional / Defiant Disorder (ODD) is a persistent pattern of behaviour and relational interaction that appears negativistic, hostile, disobedient, and defiant. ODD occurs in children or teen, and does not include serious violations of the basic rights of others (otherwise it would be called “Conduct Disorder”).

The symptoms of ODD include many behaviours common to all children, just much more frequently and more severe than expected for that age group. For example, ODD children frequently lose their temper; argue with adults; defy adults or refuse adult requests or rules; blame others for their own mistakes or misbehavior; appear to deliberately annoy others; they can be touchy and easily annoyed; are often angry and resentful; spiteful or vindictive; they may swear or use obscene language; and have a low opinion of themselves. Many children with ODD seem overly moody and easily frustrated, and may be depressed and have low self-esteem. Through late childhood and teens, many may abuse drugs and/or alcohol to help numb, or bring a sense of balance to, their worlds.

ODD is the most common psychiatric problem in children
Estimates range from 2-16% of children meet the diagnostic criteria
ODD appears in 16-22% of school-aged children

Comorbidity, or co-occurrence, is the tendency of one disorder to appear in conjunction with or along-side another diagnosable condition. For children with ODD, 60-70 % of them also have ADHD. These disorders often look the same — defiant, consistently questioning authority, argumentative, refusal to do school work or to attend school. Yet ODD on its own does not include problems with impulse control or with distractibility (as in ADHD).

15-20% of children with ODD have problems with depression, anxiety, and mood regulation. Since the aggression and defiance can be so antagonistic for parents, evoking strong emotional reactions in nearly all caregivers, the depression of ODD children often goes unnoticed. Many times, the intensity of a child’s emotional struggles are not even considered until the child attempts suicide or runs away.

Ross Greene, Ph.D. proposes in his book, The Explosive Child, that children with ODD have significant impairments in their ability to be flexible, and in how they manage or process frustration. More specifically, ODD children have a low threshold for frustration (little things upset them) AND a low tolerance for frustration (they can only handle a small amount before they become overwhelmed). These features are consistent with the cognitive deficits often attributed to children with ADHD, namely difficulty shifting from one mind-set to another, difficulty organizing a coherent plan of action to deal with problems, difficulty separating emotion from the thinking they need to do to solve problems, and a tendency to become overwhelmed with emotion — which short-circuits the brain’s ability to think and plan rationally.

Diagnostic Criteria Include: (From the DSM — IV tr)

A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:

1.	Often loses temper
2.	Often argues with adults
3.	Often actively defies or refuses to comply with adults’ requests or rules
4.	Often deliberately annoys people
5.	Often blames others for his or her mistakes or misbehavior
6.	Is often touchy or easily annoyed by others
7.	Is often angry and resentful
8.	Is often spiteful or vindictive

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.

D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.

Our Clients

Autism Spectrum Disorder (including Asperger Syndrome)

Autism Spectrum Disorder (ASD)

Diagnostic Criteria Include:

Anxiety and Depressive Disorders

Attention Deficit / Hyperactivity Disorder (ADHD)

Attention Deficit hyperactivity Disorder (ADHD)

Diagnostic Criteria include:

Conduct Disorder (CD)

Conduct Disorder (CD)

Diagnostic Criteria Include:

Down Syndrome

Down Syndrome (DS)

Diagnostic Criteria Include:

Fetal Alcohol Spectrum Disorders

Fragile X Syndrome

Oppositional / Defiant Disorder (ODD)

Oppositional / Defiant Disorder (O.D.D.)

Diagnostic Criteria Include: (From the DSM — IV tr)

Tourette’s Disorder

Tourette Syndrome (TS)

Diagnostic Criteria Include:

A.	Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently.
B.	The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.
C.	The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning.
D.	The onset is before age 18 years.
E.	The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington’s disease or postviral encephalitis).