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. Symptoms, Treatment, & Impact on Learning
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 %
Family Problems %
Academic problems 5%
Substance abuse %
Homosexuality %
Recent abuse %
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 Risk factors
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 Genetics Environmental factors
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 Psychological
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 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 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
*What am I worried or afraid about?
*How worried Am I? 2
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?
*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)

51. Two Types of Aggression
Proactive Aggression – aggression that is more organized and less impulsive, not necessarily emotional driven, and may be goal oriented.
Reactive Aggression – more impulsive and resulting from overwhelming affect; quickly reaches threshold for inability to cope with the demands of the situation.

52. Cognitive Distortions in Angry Youth
Appraisal of internal arousal
Cue Utilization
Attributions
Social Perceptions (self and others)
Generating problem-solving solutions
Considering Consequences
Implementing Solutions
Situational Appraisals

53. Adult Issues That May Escalate an Anger Outburst
The adult’s mood at that moment
Feelings of helplessness in managing difficult situations
Expectations (or judgments) about the youth are already determined and influence the adult’s response to the current situation.
Not being well prepared for managing the situations.

54. Quick to anticipate a conflict Quick to raise voice or yell
Specific adult behaviors that may increase the likelihood of an anger outburst
Too quick to say “no”
Quick to anticipate a conflict
Quick to raise voice or yell
Interpret behavior as intentional
Don’t set limits when necessary
Too strict with limits-can’t follow through
Coercive Process

55. Situational Factors (Possible Anger Triggers):
“Antecedents” refers to those factors that precede and trigger a conflict or anger outburst.
“Situation Specificity” refers to specific situations that are likely to raise frustration levels, lower coping thresholds, and make the youngster more vulnerable to the impact of an antecedent.

56. Specific student issues that may increase the likelihood of an anger outburst
Experiencing frustration and worry – interpret anger
The occurrence of a real or perceived threat and/or adverse event
Being teased, bumped in the hallway, threatened by another youth, etc.
Obstacles to getting or doing what they want or expect
Not feeling heard or understood
Denied requests – don’t like to hear “no”
Feeling unimportant and insignificant – such as being left out of something
Some injustice occurs – e.g., the youth gets into trouble for something they didn’t do or didn’t initiate.

57. Other “High Risk” Situations
Medications wear off
Blamed unjustly
Academic frustration
Embarrassed over a grade
Picked on
*Angry from home (“Carry Over”)

58. Purpose / Process in good anger control plans
Better self-regulation
Effective use of language
“Interactive Coping” – working with the student while maintaining authority
“Firm Flexibility” – adult must be firm, clear, and consistent while ALSO being flexible, supportive, and collaborative with the student when appropriate.

59. Things to consider, explore, or examine when developing an anger plan
Clarification of the concerns or problems
What’s behind the anger (feelings, issues)
Ideal alternative attitudes and behaviors
Benefits to them of positive behaviors and attitudes
Costs to them of negative attitudes and behaviors
High risk situations, antecedents (people, places, times, etc.)

60. Things to consider, explore, or examine when developing an anger plan
Things that can be done to prevent frustration when entering a high risk situation
Things that can be done when frustration is present and/or escalating (i.e., 3-7)
Calm down actions or de-escalation strategies that can and can’t be done
Ways the adult can help with high-risk times
Reinforcements and consequences if any
Regular time to review how things are going
Discussion of problem possibilities
Completion of problem-solving sheet

61. Mistakes adults sometimes make
Setting too many goals at one time
Setting goals that are too lofty; it is sometimes better to begin with smaller more attainable goals, than to start with the obvious problem that needs to be eliminated.
Measuring success by an absence of the problem, rather than recognizing a reduction in the problem.
Scrapping a plan because “its not working”.
Assuming the plan isn’t working because the youngster isn’t trying or doesn’t care about doing better.

62. Key Parts to a Problem-Solving Plan
“High risk” situations
Feelings when this happens
Angry thoughts that worsen my anger:
What to do:
Identify the problem
Use good self talk
Coping strategies
What others can do to help
Evaluate the process or how it could turn out

63. Positive Attention Things
PATs

64. Treatment of Mood & Anxiety Disorders

65. Talking with Parents
Need to involved parents when the student experiences significant academic, social or emotional difficulties that interfere with learning
Develop a shared understanding of child/adolescent
Ask parents if they see concerning emotional or behavioral problems at home
Parents may have effective strategies they use at home that can be implemented in the classroom

66. When to refer for further evaluation
Impact on learning
Effecting social interactions
Safety concerns
Suicidal statements
Threats toward others
Concern for abuse/neglect
Typical interventions do not work

67. Choosing Initial Treatment
Psychotherapy
Individual
Family – parental educations
Psychopharmacologic Intervention
Patients unable to participate in therapy due to severity of symptoms
Comorbidity with other psychiatric illnesses
Symptoms that do not respond to therapy

68. Goals of Treatment Safety Build alliance & instill hope
Clarify diagnosis
Assess comorbidity (substance abuse, medical illness, other psych d/o’s)
Assess motivation for treatment
Availability of resources (e.g., partial hospital, day tx programs, outpt. tx)

69. Treatment Treatment is multimodal
Pharmacotherapy alone not effective due to psychosocial context of illness
Address family, school, peer issues
Psychotherapy for mild to moderate mood disorders (CBT, IPT, family therapy, psychodynamic)
Consider medications

70. Medications Depression/Anxiety Bipolar Disorder/Mood dysregulation
Antidepressants
SSRIs
Atypical antidepressants
TCAs
Bipolar Disorder/Mood dysregulation
Mood stabilizers

71. Antidepressants Mechanism of Action Indications
Modulation of neurotransmitters
Increase serotonin at 5-HT receptor
Atypical antidepressants may modulate serotonin, norepinephrine and dopamine
Indications
Depression (unipolar/bipolar)
Anxiety disorders
Obsessive Compulsive Disorder
Panic Disorder
PTSD
Bulimia Nervosa

72. SSRIs No evidence that one SSRI is superior to another
First-line medication for depressive and anxiety disorders
No evidence that one SSRI is superior to another
SSRIs take 4-6 weeks to determine efficacy of dose
Fewer side effects than older antidepressants

73. SSRIs FDA approved in children & adolescents
Fluoxetine
Depression (age 8 and over)
OCD (age 7 and over)
Sertraline (Zoloft) – OCD (age 6 & over)
Fluvoxamine (Luvox) – OCD (age 8 & over)
Significant portion of psychiatric medications are prescribed “off-label” for use in pediatric population
Off label use
Paroxetine (Paxil)
Citalopram (Celexa)
Escitalopram (Lexapro)

75. SSRI Side Effects that May Impact Learning
Common
Gastrointestinal – dyspepsia, diarrhea
CNS – headache, anxiety, insomnia
Increased sweating
Uncommon
Akasthisia (inner feeling of restlessness)
Agitation
Mania (may occur in children with BD)
May need to add additional agent to manage side effects

77. Antidepressant Black Box
The most serious warning possible on drug packaging in the USA
To apply to ALL antidepressants for children and adolescents < 25 yrs old
Explicit about the increased risk of suicide especially during the early phase of tx
No completed suicides in studies reviewed
Review of studies showed increased suicidal thoughts (2% to 4%) through adverse event reporting

78. Antidepressant Black Box
Children and adolescents must be monitored closely
School officials should notify parent if student’s work reflects suicidal themes

80. Other Antidepressants
SNRIs
Modulate serotonin and norepinephrine transmission
Atypical Antidepressants
May modulate serotonin, norepinephrine, and dopamine
Can be used as single agent or as augmentation strategy with SSRI or other psychotropic
Fewer studies in children & adolescents
No FDA approved SNRIs in pediatric OCD

81. Side Effects SNRIs Atypical Antidepressants Venlafaxine (Effexor)
Elevated B/P - diastolic
Duloxetine (Cymbalta)
Blurred vision, mydriasis (dilated pupils – can affect vision)
Atypical Antidepressants
Mirtazapine (Remeron)
Sedation
Weight gain
No sexual side effects

82. Mood Stabilizers Indications Mechanism of Action Early-onset bipolar
Anxiety
OCD
Explosive aggression
Mechanism of Action
Multiple
Enhance GABA
Block glutamate
Second messengers

83. Mood Stabilizers Depakote Lithium Oxcarbazepine (Trileptal)
Gabapentin (Neurontin)
Topirimate (Topamax)
Migraine prophylaxis
Psychiatric indications
Mood stabilization
Augmenting agent for treatment resistant OCD

84. Side Effects that may Impact School
Weight gain or loss
Change in appetite
Stomachaches
Sedation
Cognitive impairment
Especially Topamax (processing speed)

85. Atypical Antipsychotics
Mechanism of action
5HT2A/D2 receptor antagonism
Less TD and EPS symptoms than 1st generation
Indications
Psychosis/psychotic depression
Mood stabilization – bipolar, mood dysregulation
Aggressive behaviors – autism, MR, DD
Augmenting agent for OCD
Conduct problems
Severe tic disorders

86. Atypical Antipsychotics
FDA approved
Risperidone (Risperdal)
Treatment of irritability associated with autism in children 5 years of age and older
Schizophrenia (13 years and older) and bipolar disorder in children (10 years and older)
Off label use
Quetiapine (Seroquel)
Aripiprazole (Abilify)
Ziprasidone (Geodon)
Olanzapine (Zyprexa)
Paliperidone (Invega)

87. Side Effects of Anti-psychotics
Weight gain
Sedation
Dyspepsia
Impaired glucose tolerance
Dyslipidemia – elevated cholesterol
Hyperprolactinemia – gynecomastia, menstrual irregularities
Long-term effects to CNS in children?

88. Serious Side Effects Acute Dystonia Extrapyramidal symptoms
Spastic contraction of discrete muscle groups
Most common – neck, tongue, eyes
Risk factors – young, male, medication initiation or dose increase
Extrapyramidal symptoms
Related to dopamine blockade in nigrostriatal pathway
Akathisia & parkinsonism

89. School Role with Medication
Part of treatment team
Observations of student during school invaluable
Dispense medication
Medication or side effects may impact behavior or learning
Impact on parent attitude toward medication

90. Internet Resources
American Academy of Child and Adolescent Psychiatry (aacap.org)
“Facts for Families” handouts on many topics
Latest news on hot topics
ParentsMedGuide.org
Question and answer material about depression, suicide and black box warning
Links for parents and physicians
Up-to-date, well-organized, English-Spanish

91. Internet Resources
Massachusetts General Hospital School Psychiatry Program

92. Books
One Mind at a Time by Mel Levine