Identifying Emotionally Troubled Students

1. Identifying Emotionally Troubled Students Maria Bartolomeo-Maida, Ph.D. Coordinator of Counseling Counseling Resource Center Kingsborough Community College

2. Goals Of This Presentation: 1. To provide a context that offers insight as to why problems may arise. 2. To differentiate between normal adolescent developmental issues & more serious psychological problems among college students. 3. To provide basic education about symptom patterns & warning signs of emotional problems. 4. To inform staff about how to assist & refer troubled students.

3. How Do We Define “Emotionally Troubled” ? • Post Virginia Tech- large focus on campus safety & the ability to identify violent behavior. • Perception by counseling staff- increase in severe pathology on campus (but is this actually true?). 85% ofcounselingcenter directors have reported seeing students with more serious mental health problems in recent years (Gallagher, Gill & Sysco, 2000). • Methodology in many studies have limitations. • Helpful to have an operational definition of what “severe psychopathology” is.

4. Normal Developmental Issues Facing College Students(Kadison & DiGeronimo, 2004) • Identity Development(Who am I?, Where do I fit in?). • Relationships and Sexuality(anxiety about sexual freedom, STDs, peer pressure, body image, intimacy & gender differences). • Interpersonal Issues(conflict resolution, acceptance of different cultures, etc.)

5. Typical Challenges Among College Students (Kadison & DiGeronimo, 2004) • Academic pressure to succeed • Balancing extracurricular activities • Parental expectations • Racial and cultural problems • Financial worries • Social fears (terrorism, campus safety, sexual assault) • Pressure to find work

6. More On Financial Worries… • College Tuition is expensive-between 1981 and 1994 costs increased 153 percent at public universities & over 200 percent at private universities. • Students from divorced families have increased financial stress- student must gather tax forms from both parents, sometimes a parent becomes estranged. • Academic progress gets strained with a part time job that student feels necessary to have. • Loans are not always an option students want to take due to being indebted. • Uncertain economic times (Recession, gas prices, etc.) (Kadison & DiGeronimo, 2004)

7. More On Social Fears… • Social climate in which we live creates uncertainty for students. This includes: 1. Increase in campus violence in recent years 2. Post 9/11, bombing of trains in Madrid 3. For women, the fear of being raped is a crime more feared than being murdered.

8. Challenges Facing International Students in Particular • 1995 survey of students at CUNY reported that 51% of students attending the 6 community colleges were born outside of the U.S. (Brilliant, 2000) • Issues of acculturation. • International students might view counseling as a sign of weakness, it is stigmatized in their country. • Students might feel depression and mourning with the realization of the struggle of immigration (typically after the 1st yr. in new country). (Brilliant, 2000)/ language barriers, homesickness, etc.

9. International Student Challenges Continued… • Somatic complaints, family problems, the loss of loved ones, adjustment to food and climate, finances, culture shock (In Grayson & Stowe, 2005) • Non-support at times from their ethnic counterparts- “acting white” or the opposite-these students are first in family to attend college and there is significant pressure to excel. • Different learning styles- (i.e. in Asian countries, students are not allowed to challenge or disagree with the instructor but very different in the U.S.) • Legal issues- temporary student visas, etc. • Effects of Terrorism- i.e. students of Muslim countries (Kadison & DiGeronimo, 2004)

10. Other Challenges/ Possible Causes of Problem Behavior… • Students are lacking role models at home. • Students may become very sensitive to perceived criticism (reminder of earlier trauma). • Many students may feel embarrassed, powerless or invalidated if smallest thing goes wrong. • Anger in particular can be fueled by a loss or conflict in their personal lives. • Important to think about students’ environmental and cultural background when trying to understand behavior. (Hernandez & Fister, 2001)

11. Differences in College Students Today • Students are more isolated-they rely more on peers than on family, cultural norms, etc. Isolation from web & other technology leaves students w/poor social skills. • Students have blurry perceptions of boundaries between themselves & faculty and staff (seen as peers). • Decrease in students attending college for intrinsic, moral value. Seen only as a means for employment. (Hernandez & Fister, 2001)

12. Differences Continued… • A more diverse cross section of our society is attending college more than any other time in history (Gilbert, 1992) • Students are more nontraditional- age, socioeconomic status, mental illness, etc. (Benton & Benton, 2006) • There are more veterans returning to college than ever before.

13. Common Disruptions in Classrooms Are these typical adolescent issues or something we should worry about?? • Leaving class frequently • Copying work/ plagiarism or lying • Refusal to participate • Continued tardiness • Disruptions from electronic devices/ from food • Sleeping in class • Off topic conversations • Any others??? (Amada, 1999)

14. Common Psychological Problems Among College Students • Depression • Sleep Disorders • Substance Abuse • Anxiety Disorders • Eating Disorders • Impulsive Behaviors (cutting) • Suicide (Kadison & DiGeronimo, 2004)

15. Some Alarming Statistics • 25% of college students are now being prescribed medications compared to 7% 14 years ago. • 17% of students engage in self injurious behavior on college campuses compared to 12% national average. • In the most recent ACHA survey, almost 20% of students indicated that during past year, they had become so concerned about a friend that it interfered with their academics.

16. Statistics Continued… • In research conducted over 13 year span (1988-2001) at Kansas State University, researchers found that anxiety disorders doubled and depression as well as suicidal ideation and intent tripled (Benton et al., 2003). • Of 16,000 students in 2002 by the ACHA, 54.6% reported feeling hopeless in the past year, 37.6% reported feeling so depressed 3 or more times in past year that they could not function, 9.5% reported seriously considering suicide, 1.4% made an attempt (Benton & Benton, 2006).

17. Statistics, p 3. • A 10 yr study on suicides at Midwestern University Campuses shows that students ages 25 & over were at greater risk for committing suicide (Silverman, 1997). • Overall, however, the student suicide rate is one half of the national rate (Silverman, 1997). • Studies suggest that 80% of students who commit suicide have not visited their campus counseling center (Hanover Research Council, 2008).

18. Demographic Information • Onset period for mental disorders = 20 yrs old for schizophrenia (males), mood disorders, and substance abuse, 30 years old for schizophrenia (females). • Depression is more prevalent in females. Eating disorders are more prevalent in females though there is an increase in males (athletes) and transgendered students in recent years. • 80% of mental illness in men occurs between ages 20-27. • Onset for eating disorders = bulemia during college years, anorexia develops somewhat earlier.

19. Suicide In Particular • Suicide is the 2nd leading cause of death on college campuses. • The odds that a student will commit suicide are 1,000 to 1 (Pavela, 2007) • 7.5/100,000 college students commit suicide/ National Average is 15 per 100,000 (Silverman et al., 1997) • Males are 4x more likely to commit suicide/ Caucasians are more likely to commit suicide.

20. Depression 5 or more of the following symptoms are present over a two week period: - depressed mood most of day -diminished interest in almost all activities - significant weight loss, weight gain - insomnia or increased sleeping - restlessness - fatigue/ loss of energy - reduced concentration/ indecisiveness - feelings of worthlessness/ excessive guilt - recurrent thoughts of suicide

21. Bipolar Disorder • Students experiencing a manic episode may exhibit the following: - poor judgment -reckless behavior - impulsivity - sexual promiscuity - grandiosity - rapid speech This is often followed by period of depression and withdrawal. There is a strong genetic component.

22. Anxiety • According to the NIMH, anxiety affects approximately 19 million adults and 9.1% of college students. • Anxiety disorders include: panic disorder, OCD, PTSD, Phobias, and GAD. • Symptoms can range from exaggerated worries, fear of humiliation and embarrassment, to many physical complaints such as headache, nausea, shortness of breath, etc.

23. PTSD Symptom criteria according to the DSM-IV: • The traumatic event is persistently reexperienced. • There is persistent avoidance of stimuli associated w/ the trauma and emotional numbing. • Persistent symptoms of increased arousal (not present before the trauma)- i.e. hypervigilance, difficulty falling asleep, irritability, etc.

24. Substance Use • 1400 college students between 18-24 die each year from alcohol related injuries (MVA). • 31% of college students met criteria for alcohol abuse in the past 12 months. • Alcohol problems are highest among young adults ages 18-29. (National Advisory Council of the National Institute on Alcohol Abuse and Alcoholism, 2002)

25. Substance Abuse Diagnosis • Criteria for substance abuse, according to the DSM-IV, is at least 1 or more of the following during 12 mth pd.= recurrent use resulting in failure to fulfill major obligations at work, school, etc., recurrent use in situations in which it is physically hazardous, recurrent substance related legal problems, continued use despite having persistent social or interpersonal problems.

26. Other Substance Problems Are we seeing the impact of being on drugs such as Adderrall & Ritalin?-these drugs keep you awake longer & have the following negative side effects: lack of appetite, paranoia, dry mouth, aggression, sleep deprivation (Kadison & DiGeronimo, 2004). Are we seeing alcohol withdrawal?- the following may develop w/in several hours to a few days: insomnia, anxiety, nausea, hallucinations, autonomic hperactivity (DSM-IV, 2000).

27. Sleep Difficulties • The most common physical complaint of college students. • Sleep problems often become self-fulfilling prophecies. • The costs of sleep deprivation: cognitive difficulties, anxiety, depression, reduced physical health, irritability, etc. • 80% of depressed people have sleep disorders- which one comes first? (Kadison & DiGeronimo, 2004)

28. Asperger’s Syndrome On the autism spectrum of development disorders. Symptoms may include any of the following: • Impairment in the use of nonverbal behavior(body posture, eye to eye gaze, etc.) • Failure to develop peer relationships • Lack of social reciprocity • Inflexible adherence to specific routines, rituals • Repetitive motor mannerisms (hand flapping, etc.)

29. Psychosis • 50% of individuals who are psychotic do not think they are. • Individuals may be exhibiting delusions or hallucinations: Delusion- firmly held false beliefs (most common are being controlled by someone else, being persecuted by someone else) Hallucination- perceiving things that do not actually exist (can be auditory and visual)

30. Schizophrenia • Refers to a class of disorders in which severe distortion of reality occurs. • According to the DSM-IV, 2 or more of the following are present during a 1 month period: - delusions -hallucinations - disorganized speech (incoherence) -disorganized behavior -negative symptoms (flat affect, alogia, avolition)

31. Personality Disorders Enduring patterns of behavior/ personality characteristics that are inflexible and pervasive across a broad range of personal/ social situations. DSM –IV defines 10 distinct ones. Paranoid PD- distrust and suspiciousness of others Schizoid PD- detachment from social relationships, restricted range of expression/ emotion Borderline PD- instability of self image, interpersonal relationships, impulsivity

32. Organic/ Neurological Problems • Frontal Lobe Brain problems (tumor, injury, stroke): impulsivity, poor judgment, reduced reasoning ability. • Medical issues such as Hyperthyroidism • Mental Retardation • Tic Disorders/ Tourettes

33. How do these psychological disabilities manifest? In class or during advisement sessions, students may: - show signs of cognitive and processing difficulties. - have trouble following directions and processing information. - seem socially awkward or unfriendly. - uninterested or dazed/ confused - have difficulty remembering something - seem hostile or defensive/ easily agitated and argumentative

34. Warning Signs Of Violence • Loss of temper • Frequent physical fighting or other current violent behavior • Increase in use of drugs or alcohol • Increase in risk taking behavior • Has access to weapons • Has detailed plans to commit acts of violence • Announcing threats or plans of hurting others • Psychiatric history

35. More on Violence… • For the period from 1995-2002, colleges students ages 18-24 experienced violence at average annual rates lower than those for non-students in same age group (East Tennessee State University Memorandum to Faculty, 2008). • Overall, violence is difficult to predict. • The best predictor of violence is prior violence. • Violence risk increases with use of alcohol. • School violence in recent years are often shooting sprees for which perpetrator commits suicide. • Recent research has shown that the vast majority of people who are violent do not suffer from mental illness (American Psychiatric Association, 1994).

36. Americans with Disabilities • Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990, prohibit universities from discriminating against individuals with disabilities (including mental disabilities). • Discrimination is prohibited against “otherwise qualified individuals”- one who with or without reasonable modifications meets the essential eligibility requirements. • “Disability” includes a mental impairment that substantially limits a major life activity. • Under these acts, universities can take disciplinary action when behaviors are disruptive but they can not take disciplinary action when the person is ill and the behavior is not disruptive. (Benton & Benton, 2006)

37. Specific Cultural Issues Not To Be Overlooked When Determining a Behavior “Troubled” • According to the DSM-IV, there are culture bound syndromes that denote locality specific patterns of troubling experience that may or may not be linked to a particular DSM-IV category. • According to the DSM-IV, many of these patterns are indigenously considered to be “illnesses”.

38. Why Might Staff Be Reluctant To Intervene? • Literature seems to focus on faculty in particular vs. other staff. • Some faculty feel they could handle situations on their own. • Faculty might feel embarrassed that there are problems in their classroom. • Might feel fear of harming the psychologically fragile student. • Might feel fear of student retaliation • Might remain silent for fear of receiving inadequate administrative support. (Amada, 1999)

39. How To Assist Students • 3 R’s = Recognize, Respond, Refer (Benton & Benton, 2006) • It is appropriate to approach students anytime you have concerns. • Many students may feel relieved that someone cares. • Waiting to intervene may complicate the situation. • Helpful to document behavior as you see it happening.

40. The Importance of Making a Referral! • Research has shown that students who reported having significant emotional problems over the previous year and had more functional relationships with their advisors were more likely to use mental health services (Hanover Research Council, 2008)

41. In The Case of Suicide… • Not helpful to tell students, “look on the bright side” or “you’ll get over it”. • Many students cry out for help through writing assignments, poetry, etc. • We should always take this seriously. • Remain with the student and walk them to counseling if possible. • Contact public safety even if the student does not comply.

42. Language To Use When Making a Referral: • “I’ve noticed that you’ve appeared sad and withdrawn during our last few meetings…” • “I’m aware that you have fallen asleep in class more often during the past few weeks…” • “I’m concerned about your tendency to come late to every appointment we have had so far and I want to make sure you are okay…” • Be direct, supportive, and nonjudgmental. • Provide empathy vs. trying to fix or gloss over problem (i.e. “you’ll do just fine on the exam”)

43. Other Considerations When Making a Referral • Helpful to know about the counseling center & services offered on your campus. • Find out if students have resources at home, etc. • Find out if they have ever used counseling services in the past. • If calling counseling directly, it’s best if you tell the student that you are referring them. • Helpful to escort student.

44. And More Considerations… • Ask for clarification if necessary (i.e. “I am not sure what you mean”) • Invite the student to speak in a private area. Might be helpful to see where the student is comfortable meeting. • If the student refuses or is reluctant to talk, indicate that your door is open and that the student can return at a later time. (Hernandez & Fister, 2001)

45. Managing Other Specific Situations • Angry student- try not to personalize their agitation, try to remain calm & model calm behavior, avoid challenging body language. • Paranoid student- try to understand that most attempts you make at communicating with student might be fraught with defensiveness and feelings of personal attack by student. • Disorganized student- do not pretend to understand them. Try to get them to a safe place (Counseling, Health Services, etc.) • Withdrawn students- we must be creative in trying to engage them, sometimes this takes time and trust needs to be established.