Mental Health and the Schools

1. Mental Health and the Schools John Yasenchak, Ed.D. Husson University

2. What is Mental Health?

3. When people here the term “mental health”, it is equated with “mental illness” and defined as “the absence of problems” But the facts are: • Most behavior, learning, and emotional problems of children stem from sociocultural/economic factors and not pathology • Problems can often be dealt with through promotion of social and emotional development and prevention (Adelman $ Taylor, 2010)

4. DSM Definition of Mental Disorder “….a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., painful symptoms) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering, death, pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example the death of a loved one. Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior (e.g., political, religious, or sexual) not conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual….”

5. However….. • Tendency to “view” everyday problems as “symptoms” and diagnosis as disorders • The cause is always internal pathology • Tendency to misdiagnosis and problems with differential diagnosis • Narrow focus limits discussions of cause and intervention strategies • Classification of Child and Adolescent Mental Diagnoses in Primary Care (DSM-PC) looks at: • 1. Developmental Variation 2. Presence of a Problem 3. Diagnosis of a disorder.

6. Mental Health is the sum total of how kids think, feel, and behave. It influences: • How kids deal with stress • How kids relate to teaches and peers • How kids make decisions • How they grieve losses • How they seem themselves and others • How they process information • How they learn

7. Positive Mental Health allows kids to: • Think clearly • Learn more effectively • Develop appropriate social skills • Develop coping skills • Learn to express emotions constructively • Learn to “hold” uncomfortable emotions • Feel good about themselves!

8. Positive Mental Health in kids results from: • Success at developmental markers • Development of interpersonal coping skills • Feeling like they matter • Living in a nurturing “holding” environment

9. Why Should Schools Be Concerned with Mental Health?

10. Mental health issues may act as barriers to learning in the classroom • Students with mental health problems may be truant allot or fall behind • Students with mental health problems are at greater risk for substance abuse and involvement with law enforcement and the juvenile justice system • Schools are “the Front line”; the one “last Place” • Productivity, safety, and quality of life are all impacted • Others?

11. Individuals With Disabilities Education Act • Students with an MH diagnosis do not automatically qualified for special education • IEP Teams (Individualized Education Program) cannot diagnose and physicians cannot identify special education needs under IDEA • As a result, schools may provide services in the regular education program through 504 plan or IDEA

12. StatisticsSurgeon General’s Report and the President’s New Freedom Commission • 21% of children between ages 9-17 have a diagnosable mental or addictive disorder. • 11% of those have significant functional impairment and 5% have extreme impairment • Children of depressed parents are >3 times more likely to experience depression • Parental depression increases a child’s risk of anxiety disorders, conduct disorders, and addition problems. • 74% of 21 year olds with MH diagnoses had prior problems when children

13. Primary Care • Half of physicians surveyed in a recent study regularly screen adolescents for mental health disorders • Only 46% feel capable of identifying depression • 19 % feel confident about schizophrenia • 16% about bi-polar disorder • Annenberg Public Policy Center • www.annenbergpublicpolicycenter.org

14. IDEA of 2005Individuals with Disabilities Education Act Calls for: • Early Intervention Services – Districts are to use up to 15% of funding received under Part B to develop early intervention services. This may include k-12 students not necessarily special education • Response to Intervention Logic • Universal Screening • Progress Monitoring • Data-based decision making http://www.rti4success.org/

15. Risk Factors

16. Genetic predisposition for illness • Biological problems related to illness • Exposure to toxins • Prenatal damage • Poverty • Poor nutrition • Deprivation • Others?

17. Parental mental health problems • Parental addiction • Abuse, neglect, trauma, family violence • Poor caregiving and parenting • Stressful life events (family criminality, maladaptive sibling relationships, discord, dysfunctions family life) • Lack of a loving relationship with at least one parent or significant caregiver.

18. Warning Signs that a Child or Adolescent may Need Mental Health Services National Mental Health Information Center www.mentalhealth.samhsa.gov National Mental Health Association www.nmha.org

19. Feelings • Sadness or hopelessness for no reason • Crying or overreaction • Excessive worry or guilt • Extreme fearlessness • Extreme anger most of the time • Excessive concern with physical problems or appearance • Fear of being out of control • Unable to move through a loss • Suicidal ideation – feel like life is worthless or too much

20. Noticeable Change • Decline in school performance • Loss of interest in enjoyment • Avoidance of people and isolation • Daydreaming too much • Not finishing tasks • Hearing voices that cannot be explained • Repeated refusal to go to school or take part in normal activities • Changes in eating and sleeping habits

21. Experiences • Hyperactivity and excessive fidgeting • Persistent nightmares • Difficult concentrating and making decisions • Racing thoughts • Persistent disobedience or aggression • Excessive worry about something “bad” happening • Need to wash or perform certain routines many times a day

22. Behaviors • Alcohol and drug use • Binging and purging; using laxatives • Setting fires • Excessive dieting or exercising • Torturing or killing animals • Behaving without regard for other people • Breaking the law • Life threatening behavior

23. School-Based Mental Health School-Linked Mental Health UCLA School Mental Health

24. How would you define “mental health services” in the School?

25. The promotion of positive mental, social, emotional, and physical development • Identifying and addressing mental health problems that present as “barriers to learning” • Provide resources and links to community services • The provision of mental health/substance abuse services delivered in the school or linked to the school in some way.

26. What are some of the resources that your school has for meeting student mental health needs?

27. Primary vs. Secondary Prevention • Parental involvement • Transition support • Conflict resolution • Health Classes • Alcohol and Drug Education • Others?

28. Early Intervention • Dropout Prevention • Violence Prevention • Pregnancy Prevention • School-age Parent Programs • Work Programs • Accommodations for learning and behavior issues • Alcohol and Drug Counseling • Others?

29. Severe and Chronic Problems • Special Education • Family Involvement and Communication • Coordination with community Providers • Language barriers • Crisis Intervention – is there a plan? • Information, problem-solving, restoring calm • Safety for the student – away from being a victim • Immediate support • Care for the caregivers • Aftermath • Bereavement • How kids Grieve • How the school handles grief

30. How Do We Differentiate Between Mental Health Problems and Learned Behaviors?

31. Learn about the symptoms of an illness and how it manifests • How is the problem related to development? • Talk to the Parents • Do a fictional analysis of the problem and a behavioral plan • Does the behavior go beyond what might be expected of the illness? What might be the learned part! • Difficult to separate the behavior from an illness.

32. A Brief Summary of Some DSM IV-TR Diagnoses in Children and Adolescents

33. Anxiety Disorders • The feeling that one is in danger • Some anxiety is normal for younger children • There is a developmental range for anxiety between ages 6-13, from concrete fears to more abstract. • But 1 in 10 children/adolescents may have an anxiety disorder – precipitants include high stress situations • About ½ of those will have a second mental health issue: anxiety or depression • Social phobias may start early with physical complaints of tummy ache or headache • If untreated, they can be a significant barrier to learning.

34. Types of Anxiety Disorders • Phobias • Social Anxiety Disorder • Generalized Anxiety Disorder • Panic Disorder with/without Agoraphobia • Post Traumatic Stress Disorder • Acute Stress Disorder.

35. Teaching Coping Skills (COPE) • Calming – learn relaxation skills, calming, grounding, self-control • Originate – create an imaginative plan based on insight into the anxiety • Persist – keep going in the face of failure and obstacles • Evaluate – adjust the plan as needed Dacey, J.S., & Fiore, Lisa. B (2000). Your anxious child:How parents and teachers can relieve anxiety in children. New York: Jossey-Bass.

36. Mood Disorders (Depression) • Not just “feeling blue” • NIMH – 2.5% of children and up to 8.3% adolescents suffer from depression • Although recovery rates are good, relapse rates are high (70%) • Kids may have a hard time “talking” about it • Risk for suicide • First choice is CBT or interpersonal therapy. • There is little research regarding effectiveness of medications alone.

37. Signs and Symptoms • Frequent crying • Hopeless, bored, low • Decreased interest • Inability to concentrate • Rejected by peers • Overly sensitive; negative self-talk • Guilt • Anger • Decreased appetite, sleep • Internalizing behaviors • Running away • Reckless; drugs, alcohol • Difficulty concentrating • Somber • Self-destructive • Decrease school performance • Suicidal thoughts, threats • Tantrums, restlessness, angry outbursts

38. Most Common Mood Disorders Major Depression Dysthymia Bipolar Disorder

39. Bi-Polar Disorder • Building Blocks • Depressive episode – two week symptom duration • Manic episode – lasting at least one week • Hypomanic episode – lasts at least 4 days • Types • Bipolar I – a combination of depressive episodes and manic/or manic episodes • Bipolar II – a combination of depressive episodes and hypomanic episodes • With or without cycling

40. There is some debate about ADHD versus early onset of pediatric bipolar disorder • It is believed that 80% of diagnosed children have family members with the diagnosis or family histories of substance abuse • It is believed that up to 1/3 of children diagnosed with depression may have early onset bipolar disorder • But it is not really known how common it is in children

41. Treatment for Bipolar Disorder • Although there is little research on the use of mood stabilizers on children, treatment is often based on medication such as: • Lithium, depakote, tegretol, SSRI’s, etc • Side effects may include: headaches, thirst, dizziness, gastro-intestinal upset, frequent urination, weight-gain, short-term memory loss, acne, etc.

42. Disruptive Behavior Disorders

43. Correlates Tendency to wreak havoc often overshadows individual needs: • Co-morbid mental health problems (e.g.., 55% with anxiety disorders) • Peer relationships • Rejection serves to validate negative world view • Affiliation with negative peer models • Negative thinking patterns “world is a battlefield”…”adults are out to control them”

44. Antecedent Risk Factors • Genetic and biological • Frontal lobe regulation, executive functioning • Parental characteristics • Substance abuse, anti-social personality • Parent-child relationship • Minimal warmth, harsh, lack of monitoring, negative • Life experiences • Victimization, assault victims, sexual abuse.`

45. Youth Decision-Making Process Research identifies two processes: • Response validation – “Is my behavior morally and socially acceptable?” • Outcome expectancy – “ Will my behavior bring about a positive outcome?” Students with DBD’s are more likely to think that aggression is ok and that it pays off. (Auger, 2011)

46. Triggers in the School • Sick, tired, hungry • Distress over events • Difficult academic task • Request denied • Criticism in public • Verbally challenged • Impress high-status peers • Lack of supervision • Bored • Under the influence • Activities that emotionally threaten • Talked to in an authoritative manner • Rejection by peers • Domination of low-status peers • Being laughed at • (Auger, 2011)

47. Maintenance Variables • Feeling of power and control • Freedom and escape • Adhering to a personal code (no one will hurt me) • Avoidance of classroom situations that are threatening • Peer attention and approval • Tangible rewards (from thefts) • Reduction of physical and emotional tension • Removal from classroom situations • Teacher attention. • Others? • (Auger, 2011)

48. Oppositional Defiant Behavior Disorder • On-going pattern of destructive, uncooperative, and hostile behavior • Onset around age 8 and not later than adolescence • Believed that 5% of school age children have ODD • 40-65% comorbidity rate with ADHD • More common in boys before puberty • Power and control issues; rarely sorry

49. Causes and Treatment of ODD • Causes not clearly known; possible brain chemistry, temperament, and environment. • “Concerning Behaviors” – what to target, what to live with, and what to ignore • Therapy and medication for co-morbid issues: • Sometimes atypical antipsychotics (Zyprexa, Rispeidal) are used as well as mood stabilizers. • Consistent responses re the most important factor! • Persistent ODD becomes Anti-Social Personality Disorder at age 18! • Riley, A.R. (1997). The defiant child: A parent’s guide to oppositional defiant behavior disorder.

50. ODD DSM-IV TR Criteria • Behavior pattern lasting at least six months with four of the following present: • Often loses temper • Often argues with adults • Often actively defies or refuses to comply with adults • Often deliberately annoys people • Often blames others • Touchy or easily annoyed • Often angry and resentful • Often spiteful or vindictive • Clinically significant impairment and not psychosis or mood disorder