Other Mental Health Issues that Impact Learning

1. Other Mental Health Issues that Impact Learning Stephanie Eken, M.D. Child and Adolescent Psychiatrist David Causey, Ph.D. Clinical Child Psychologist Square One: Specialists in Child and Adolescent Development

2. Mood Disorders: Symptoms, Treatment, & Impact on Learning

4. Why Should We Care? • Mood disorders are prevalent and recurrent • May impact school performance • May present with physical symptoms • Poor psychosocial outcomes • High risk for suicide • High risk for substance abuse

5. Epidemiology of Depressive Disorders • Preschool: <1% • School-age: 1-2% • Female-to-male ratio 1:1 • Adolescence: 6% • Female-to-male ratio 2:1 • Cumulative incidence by 18 yrs: 20% • Hospitalized children: 20% • Hospitalized adolescents: 40%

6. Most common stressors leading to youth suicide in Kentucky Fight with Parent 20% End of a relationship 12% Financial problems 10% Fight with a significant other 8% Recent move, social isolation 7% Legal problems 6% Family Problems 6% Academic problems 5% Substance abuse 4% Homosexuality 3% Recent abuse 4% Other stressors 15%

7. Etiology of Depression • Neurobiology • Dysregulation of serotonin & norepinephrine in CNS • Influence of sex hormones • Personality • Negative cognitive style • Environmental factors • Abuse & neglect • Stressful life events • Family dysfunction

8. Genetics • Children with a depressed parent are 3 times more likely to have MDD • Children at high genetic risk may be more sensitive to adverse environmental experiences

9. Depression in Children • Irritability (more common than depressed mood) • Boredom (anhedonia) • Somatic complaints • Stomachaches & headaches most common • Anxiety • Indecision • Temper tantrums & disruptive behavior

10. Depression in Adolescents • Irritable or sad mood • More likely to report a sad/depressed mood • Increased sleep and appetite • Increased suicidal ideation & attempts • Increased impairment of functioning • Increased behavioral problems • Decreased energy • Rejection sensitivity

12. Psychosocial Risk Factors for Depression • Family problems • Conflict, maltreatment, parental loss/separation, parental mental illness • Comorbid psychiatric disorders • ADHD, anxiety d/o’s, conduct d/o, substance abuse • Recent adverse events • School, relationships, loss of social support • Personality traits • Anger, dependence, difficulty regulating affect

13. Is he sad or depressed? • Feeling sad or “blue” • Temporary period in which a child feels sad in response to a major stressor • Children may have transient depressed mood states • Adjustment disorders to stressors • Depression is more severe, lasts longer and impacts functioning

14. Adjustment Disorder • Behavioral or emotional response to a identifiable cause or stress • Symptoms occur within three months of the stressor • Symptoms cause marked distress

15. Adjustment Disorder • Associated with: • Anxiety • Mixed anxiety and depressed mood • Disturbance of mood and conduct • Disturbance of conduct

16. Impact on Learning • May change sleep or eating patterns • Difficulty concentrating/focusing • Social isolation • School behavior – fighting, arguments • Academic difficulties can lead to changes in mood • Consider an educational evaluation if treatment for depression does not resolve learning issues

17. School-based Interventions • Acknowledge the student’s feelings • Provide a place for students to regroup if they feel weepy or fatigued • Allow the student to stop an activity and resume it later when calm • Encourage positive self-talk and break tasks down

18. School-based Interventions • Irritable Mood • Model appropriate responses to replace irritable responses • Allow the student to take him/herself out of a situation (self-timeout) when irritability is starting to disrupt others • May want to work independently • Provide opportunities for the student to "fix" problems or inappropriate classroom behaviors • Fatigue • Provide class notes to the student • Identify study partners who can support and assist with assignments • Grade the student based on work completed or attempted (rather than work assigned)

19. Bipolar Disorder • Increasingly diagnosed in children • Lifetime prevalence = 1% • Risk factors • Early onset depression • Psychosis • Mood lability • Seasonal pattern • Family history of BD

20. Bipolar Disorder • Increasingly diagnosed in children • Genetics • If untreated, children/adolescents are at risk for substance abuse, school failure, accidents, incarceration and suicide

21. Bipolar Disorder • Neurobiology • Neurotransmitters • Neuroimaging shows subtle differences in frontal lobe and amygdala volume • Genetics • One parent with BD = 25% risk • Environmental factors • May potentiate genetic predisposition • Stressors • Low maternal warmth

23. Bipolar Disorder in Children • Mood may shift rapidly • Minute-to-minute • Day-to-day • May present as chronic irritability or explosiveness with no discernible pattern or periods of wellness • Different from depression by the presence of mania • 20% of depressed children will go on to develop bipolar disorder

24. Mania in children • Excessive irritability • Excessively giddy or silly • Aggressive behaviors • Extended, rageful tantrums • Physically aggressive • Restless or persistently active • Age-inappropriate sexual interests • Grandiosity

25. How does it impact school? • Fluctuations in cognitive abilities • Impaired ability to plan, organize, concentrate and use abstract reasoning • Heightened sensitivity to perceived criticisms • Hostility or defiance with little provocation • Emotions disproportionate to situation

26. School-based Interventions • Develop a simple explanation that the student and staff can use with peers and teachers • Accommodate tardiness • Allow the student to complete schoolwork or tests in a less stimulating environment • Seat the student where the teacher can monitor, but not where the student is the focal "center of attention" • Limit homework to a feasible amount during manic periods • Allow the student to have homebound instruction during manic periods • Allow children to discreetly and frequently accommodate needs caused by medication side effects

27. Treatment for Mood Disorders • Psychological interventions • Individual therapy (CBT) • Parent guidance sessions • School-based counseling • Biological interventions • Medications • Side effects may impact learning or behavior when starting medication

28. Childhood Anxiety Disorders

29. Anxiety Disorders • Medical condition that causes people to feel persistently, uncontrollably worried over an extended period of time • Limit children’s ability to engage in a variety of activities

30. Epidemiology of Anxiety Disorders • Most common emotional/behavioral disorder in childhood • Incidence 10-15% of children/adolescents • Female-to-male ratio • Equal in preadolescent children • Females are increasingly represented in adolescent years

31. Etiology of Anxiety • Genetics • Biologic • Central Nervous System (brain) • Abnormal neurotransmitter functioning • Serotonin, norepinephrine, GABA receptors • Psychological • Internal and external stressors overwhelm coping abilities

32. Fear • Alarm and agitation • Caused by expectation or realization of danger • A state of dread or apprehension Webster’s II Dictionary, Third Ed.

33. Fear • Immediate alarm reaction • Basic, normal emotion • Essential to alert to imminent danger • Focuses attention • Prepare to respond: Flight or Fight • Pounding heart, rapid breathing, muscle tension, sweating • Consolidate experience to memory • To learn appropriate response

34. Anxiety • Apprehension of danger and dread • Accompanied by • Restlessness • Tension • Rapid heart rate • Shortness of breath • Unattached to a clearly identifiable stimulus

35. When is anxiety pathologic? • Intensity of anxiety • Out of proportion to threat • Frequency of anxiety • Increase in fear reaction and cannot be “reasoned away” • Content of anxiety • Seemingly innocuous situation or stimulus

36. Children with Anxiety Disorders • Risk for developing other types of anxiety disorders/or psychiatric disorders • Comorbid psychiatric disorders • Young children with GAD can also suffer from separation anxiety • Depression can accompany the feeling of generalized anxiety • Increased risk for adjustment difficulties in adulthood

37. Generalized Anxiety Disorder • Worry, worry, and more worry • About – family, friends, health of others, natural disasters, school performance, etc. • Somatic concerns • Headaches, feeling shaky, sweating • Not easily reassured • May throw tantrums related to anxiety • Poor concentration and attention • May present for ADHD work-up

38. Separation Anxiety • Excessive anxiety focused on separating from home or parent figure • Most commonly diagnosed in prepubertal children • More common in 5-7 and 11-12 year olds with transition into elementary and middle school • Typically occurs following a significant change or major life event

39. Separation Anxiety • Expression varies with age • Prepubescent children (5-8 years) • Clinging/shadowing behavior • Nightmares • Fear of loss of loved ones • School refusal

40. Separation Anxiety • Preadolescent (9-12 years) • Emotional distress of separation • Staying away from home overnight • Adolescents (13-16 years) • Somatic difficulties • School refusal

41. Social Phobia • Excessive fear in social situations where child is exposed to unfamiliar people/evaluation by others • Excessively self conscious/shy • Tremendous concern about social failure/embarrassment/humiliation

42. Social Phobia • Exposure causes significant anxiety/panic • Fear excessive and unreasonable • Avoidance or endurance with extreme distress • Interference in functioning

43. Selective Mutism • Children either talk minimally or not at all in certain settings or situations that are part of their daily lives (e.g., school) • Reflects underlying problems with anxiety • Often inadvertently reinforced by other individuals (i.e., parents, friends) in the child’s daily life (e.g., speaking for the child, permitting the use of nonverbal communication, etc.). • Considered an extreme form of social phobia

44. Panic Attacks • Sudden, discrete episodes of intense fear • Intense desire to escape • Feeling of doom • Activation of autonomic nervous system • Fight or flight • Duration 20-30 minutes

45. Panic Disorder • Recurrent panic attacks • Inter-episode worry about having a panic attack • Worry about implications and consequences • Changes in behavior • More common in adolescents

46. Anxiety at School • Frequent self-doubt and criticism • Seeking constant reassurance from the teacher • Difficulty transitioning between home and school • Avoidance of academic and peer activities • Poor concentration

47. School-based interventions • Accommodate late arrivals • Shorter school days to transition children with separation anxiety • Allow extra time for transitions • Provide alternative activities for children with somatic complaints • Have a “safe” place if child develops increased anxiety or panic attacks • Have an anti-worry plan

48. Components of a Simple Anti-Worry Plan • Anti - Worry Plan • *What am I worried or afraid about? • *How worried Am I? 2 • 0 1 2 3 Not at all A little worried A lot • *How do we know that things will be OK? • *What can I do to help myself not worry so much? • *What can I do to help myself not worry so much? • *Is this something that I should worry about?

49. Defiance & Aggression

50. Defiance • When is defiant behavior not really defiance to an authority figure….Never • When is defiant behavior a result of something other than a defiant attitude?...When it’s a coping response to an underlying vulnerability, frustration, or disappointment (“solution” versus problem)