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Other Mental Health Issues that Impact Learning Stephanie Eken, M.D. Child and Adolescent Psychiatrist David Causey, Ph.D. Clinical Child Psychologist.

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Presentation on theme: "Other Mental Health Issues that Impact Learning Stephanie Eken, M.D. Child and Adolescent Psychiatrist David Causey, Ph.D. Clinical Child Psychologist."— Presentation transcript:

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 Parent20% End of a relationship12% Financial problems10% 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 stressors15%

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/os, 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 students 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 childrens 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 Websters 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 childs 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 Anti - Worry Plan *What am I worried or afraid about? *How worried Am I? 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 its 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 adults mood at that moment Feelings of helplessness in managing difficult situations Expectations (or judgments) about the youth are already determined and influence the adults response to the current situation. Not being well prepared for managing the situations.

54 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 Dont set limits when necessary Too strict with limits-cant 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 – dont 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 didnt do or didnt 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 Whats 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 cant 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 isnt working because the youngster isnt trying or doesnt 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/os) 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 –Antidepressants SSRIs Atypical antidepressants TCAs Bipolar Disorder/Mood dysregulation –Mood stabilizers –Antidepressants

71 Antidepressants Mechanism of Action 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 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 students 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 –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 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 5HT 2A /D 2 receptor antagonism Less TD and EPS symptoms than 1 st 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 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 ( Facts for Families handouts on many topics Latest news on hot topics 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

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