Mental Health 101 for Non-Mental Health Providers

1. Mental Health 101 for Non-Mental Health Providers Developed by Faculty and Staff of the University of Maryland & Prince Georges County Public School System Support provided in part from grant 1R01MH71015-01A1 from the National Institute of Mental Health and Project # U45 MC00174 from the Office of Adolescent Health, Maternal, and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services

2. Erik Erickson’s Stages of Development

3. Overview • Developmental Stages; Review of Normal versus Abnormal Child Development • Why Schools? • DSM-IV TR • Common Mental Health Issues, Review of Symptoms and Practice Skills • Putting it All Together-Case Examples • Developing Healthy School Environments • Q and A

4. Mental Health Issue or Not? Red Flags or Not? • If a child falls asleep every afternoon in class during the lesson? • If a child is late for school often? • If a child has frequent suspensions for not following directions in class? • If a child has a temper tantrum? • If a child is unkempt?

5. Lets Visit Ages 6 to 12 Think about your experiences in 3rd Grade • Where did you live? • Who was your best friend? • What games did you like to play? • Where did you go to school? Who was your teacher? What expression did he or she have on his or her face in greeting you each day? • What game or technology was the newest thing? • What was your favorite thing to eat at school? • Was there a particular smell that you can remember to your school? (pine sol? Mystery meat?....)

6. Developmental Goals (6 to 12) • Ages 6 to 12 • To develop industry • Begins to learn the capacity to work • Develops imagination and creativity • Learns self-care skills • Develops a conscience • Learns to cooperate, play fairly, and follow social rules

7. Normal Difficult Behavior Ages 6 to 12 • Arguments/Fights with Siblings and/or Peers • Curiosity about Body Parts of males and females • Testing Limits • Limited Attention Span • Worries about being accepted • Lying • Not Taking Responsibility for Behavior

8. Cries for Help/More Serious IssuesAges 6-12 • Excessive Aggressiveness • Serious Injury to Self or Others • Excessive Fears • School Refusal/Phobia • Fire Fixation/Setting • Frequent Excessive or Extended Emotional Reactions • Inability to Focus on Activity even for Five Minutes • Patterns of Delinquent behaviors

9. Adolescence

10. Let’s Visit Ages 13-18 Think about your experiences in 10th grade • Who was your favorite teacher? • Were you dating or not dating? • Who was your best friend? • How would you have described your parent/caregiver? • What did you do for fun? • What was the latest and greatest technology? • What was your favorite movie, song, or tv show?

11. Developmental Goals • Developing Identity-the child develops self-identity and the capacity for intimacy • Continue mastery of skills • Accepting responsibility for behavior • Able to develop friendships • Able to follow social rules

14. Normal Difficult Behavior • Moodiness! • Less attention and affection towards parents • Extremely self involved • Peer conflicts • Worries and stress about relationships • Testing limits • Identity Searching/Exploring • Substance use experimentation • Preoccupation with sex

15. Cries for Help- Ages 13-18 • Sexual promiscuity • Suicidal/homicidal ideation • Self-mutilation • Frequent displays of temper • Withdrawal from usual activities • Significant change in grades, attitude, hygiene, functioning, sleeping, and/or eating habits • Delinquency • Excessive fighting and/or aggression (physical/verbal) • Inability to cope with day to day activities • Lots of somatic complaints (frequent flyers)

16. Discussion • How do you make the distinction between normal versus abnormal development? • How can you tell?

17. Why Schools?

18. “Could someone help me with these? I’m late for math class.”

20. Schools: The Most Universal Natural Setting • Over 55 million youth attend 114,700 schools (K-12) in the U.S. • 6.8 million adults work in schools • Combining students and staff, approximately 20% of the U.S. population can be found in schools during the work week.

21. Overview of Children’s Mental Health Needs • Between 20% to 38% of youth in the U.S. have diagnosable mental health disorders • Between 9% to 13% of youth have serious disturbances that impact their daily functioning • Between one-sixth to one-third of youth with diagnosable disorders receive any treatment • Schools provide a natural, universal setting for providing a full continuum of mental health care

22. Workforce Issues • 15% of teachers leave after year 1 • 30% of teachers leave within 3 years • 40-50% of teachers leave within 5 years (Smith and Ingersoll, 2003)

23. Opportunities in Schools • Can do observations of children in a natural setting • Can outreach to youth with internalizing disorders • Can provide three tiers of service (universal, selective, and indicated) • Can be part of a multidisciplinary team involving school staff, families, and youth

24. Activity-Brainstorming • What is the mental health issue that you find the most challenging in schools?

25. What is the DSM-IV-TR? • A reference guide for diagnosing mental health concerns • Published by the American Psychiatric Association in May 2000 • For each Diagnosis provides specific criteria that needs to be met • Next update (DSM-V) will be published in 2011 or later

27. Depressive Disorders • Major Depressive Disorder • Dysthymic Disorder • Depressive Disorder Not Otherwise Specified (NOS)

28. Depression Epidemiology • 2.5% of children, up to 5% of adolescents • Prepubertal-1:1/F:M; adolescence-4:1/F:M • Average length of untreated Major Depressive Disorder – 7.2 months • Recurrence rates-40% within 2 years • Heredity • Most important risk factor for the development of depressive illness is having at least one affectively ill parent

29. Major Depressive Disorder I. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning. At least one symptom is either (1) depressed mood or (2) loss of interest or pleasure. • Depressed mood most of the day, nearly every day, as indicated by subjective report or based on the observations of others. In children and adolescents, this is often presented as irritability. • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day • Significant weight loss when not dieting or weight gain (change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day • Insomnia or hypersomnia nearly every day • Psychomotor agitation or retardation nearly every day (observable by others) • Fatigue or loss of energy nearly every day • Feelings of worthlessness or inappropriate guilt nearly every day • Diminished ability to think, concentrate, make a decision nearly every day

30. Major Depressive Disorder II. Symptoms cause clinically significant distress or impairment in social or academic functioning III. Symptoms are not due to the direct physiological effects of a substance (drugs or medication) or a general medical condition Although there is a different diagnostic category for individuals who suffer from Bereavement, many of the symptoms are the same and counseling techniques may overlap.

31. Dysthymic Disorder • Major difference between a diagnosis of Major Depressive Disorder and Dysthymia is the intensity of the feelings of depression and the duration of symptoms. • Dysthymia is an overarching feeling of depression most of the day, more days than not, that does not meet criteria for a Major Depressive Episode. • Impairs functioning and lasts for at least one year in children and adolescents, two in adults.

32. Depression Modifications in DSM- IV for children: • irritable mood (vs. depressive mood) • observed apathy and pervasive boredom (vs. anhedonia) • failure to make expected weight gains (rather than significant weight loss) • somatic complaints • social withdrawal • declining school performance

33. What depression may look like: • Negative thinking – “I can’t, I won’t” • Social withdrawal • Irritability • Poor school performance (not just grades) • Lack of interest in peer activities • Muscle aches or lack of energy • Reports of feeling helpless a lot of the time. • Lowering their confidence-level about intelligence, friends, future, body, etc. • Getting into trouble because of boredom.

34. What Works for Depression • Psychoeducation • Cognitive/Coping • Problem Solving • Activity Scheduling • Skill-building/Behavioral Rehearsal • Social Skills Training • Communication Skills

35. Cognitive/Coping • Change cognitive distortions • Increase positive self talk • Identify the type of event that will trigger the irrational thought. • Help students become aware of their thoughts • Recognize and get rid of negative self talk • Counter negative thoughts with realistic positive self talk • Believe the positive self talk!

36. Cognitive Distortions • Exaggerating - Making self-critical or other critical statements that include terms like never, nothing, everything or always. • Filtering - Ignoring positive things that occur to and around self but focusing on and inflating the negative. • Labeling - Calling self or others a bad name when displeased with a behavior Adapted from: Walker, P.H. & Martinez, R. (Eds.) (2001) Excellence in Mental Health: A school Health Curriculum - A Training Manual for Practicing School Nurses and Educators. Funded by HRSA, Division of Nursing, printed by the University of Colorado School of Nursing.

37. Cognitive Distortions • Discounting - Rejecting positive experiences as not important or meaningful. • Catastrophizing - Blowing expected consequences out of proportion in a negative direction. • Self-blaming - Holding self responsible for an outcome that was not completely under one's control. Adapted from: Walker, P.H. & Martinez, R. (Eds.) (2001) Excellence in Mental Health: A school Health Curriculum - A Training Manual for Practicing School Nurses and Educators. Funded by HRSA, Division of Nursing, printed by the University of Colorado School of Nursing.

38. Anxiety • Panic Disorder • Obsessive Compulsive Disorder • Specific Phobias • Separation Anxiety Disorder • Posttraumatic Stress Disorder • Generalized Anxiety Disorder

39. Anxiety - Prevalence • 13% of youth ages 9 to 17 will have an anxiety disorder in any given year • Girls are affected more than boys • ~1/2 of children and adolescents with anxiety disorders have a 2nd anxiety disorder or other co-occurring disorder, such as depression

40. Panic Disorder - Diagnostic Criteria I. Recurrent unexpected Panic Attacks Criteria for Panic Attack: A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: (1) Palpitations, pounding heart, or accelerated heart rate (2) Sweating (3) Trembling or shaking (4) Sensations of shortness of breath or smothering (5) Feeling of choking (6) Chest pain or discomfort (7) Nausea or abdominal distress (8) Feeling dizzy, unsteady, lightheaded, or faint (9) Derealization (feelings of unreality) or depersonalization (being detached from oneself) (10) Fear of losing control or going crazy (11) Fear of dying (12) Paresthesias (numbness or tingling sensations) (13) Chills or hot flushes

41. Specific Phobias • Marked and persistent fear of a specific object or situation with exposure causing an immediate anxiety response that is excessive or unreasonable • In children, anxiety may be expressed as crying, tantrums, freezing, or clinging. • Animal phobias most common childhood phobia. • Also frequently afraid of the dark and imaginary creatures • In older children and adolescents, fears are more focused on health, social and school problems • Adults recognize that their fear is excessive. Children may not. • Causes significant interference in life, or significant distress. • Under 18 years of age – symptoms must be > 6 months

42. Separation Anxiety Disorder Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following: • Recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated • Persistent and excessive worry about losing, or about possible harm befalling, major attachment figures • Persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped) • Persistent reluctance or refusal to go to school or elsewhere because of fear of separation

43. Separation Anxiety Disorder • Persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings • Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home • Repeated nightmares involving the theme of separation • Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated • Duration of at least 4 weeks • Causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning

44. Generalized Anxiety Disorder • Excessive anxiety and worry for at least 6 months, more days than not • Worry about performance at school, sports, etc. • DSM IV criteria less stringent for children (Need only one criteria instead of three of six): • Restlessness or feeling keyed up or on edge • Being easily fatigued • Difficulty concentrating or mind going blank • Irritability • Muscle tension • Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

45. Obsessive Compulsive Disorder • Presence of Obsessions (thoughts) and/or Compulsions (behaviors) • Although adults may have insight, kids may not • Interferes with life or causes distress • One third to one half of all adult patients report onset in childhood or adolescence

46. Post-traumatic Stress Disorder (PTSD) The person has been exposed to a traumatic event in which both of the following were present: • (1) The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others • (2) The person's response involved intense fear, helplessness, or horror. (Note: In children, this may be expressed instead by disorganized or agitated behavior.)

47. Persistent Re-experiencing of event (1 or more) • Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. (Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.) • Recurrent distressing dreams of the event. (Note: In children, there may be frightening dreams without recognizable content.) • Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). (Note: In young children, trauma-specific reenactment may occur.) • Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

48. Avoidance and Numbing (3 or more) • Efforts to avoid thoughts, feelings, or conversations associated with the trauma • Efforts to avoid activities, places, or people that arouse recollections of the trauma • Inability to recall an important aspect of the trauma • Markedly diminished interest or participation in significant activities • Feeling of detachment or estrangement from others • Restricted range of affect (e.g., unable to have loving feelings) • Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

49. Increased Arousal (2 or more) • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response

50. Posttraumatic Stress Disorder (PTSD) • At least one month duration. • Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning • Many students with PTSD meet criteria for another Axis I Disorder (e.g., major depression, Panic Disorder) – both should be diagnosed • Prevalence in adolescents • 4% of boys and 6% of girls • 75% of those with PTSD have additional mental health problem (Breslau et al., 1991; Kilpatrick 2003, Horowitz, Weine & Jekel, 1995 )