Presentation on theme: "Other Mental Health Issues that Impact Learning"— Presentation transcript:
1 Other Mental Health Issues that Impact Learning Stephanie Eken, M.D.Child and Adolescent PsychiatristDavid Causey, Ph.D.Clinical Child PsychologistSquare 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 performanceMay present with physical symptomsPoor psychosocial outcomesHigh risk for suicideHigh risk for substance abuse
5 Epidemiology of Depressive Disorders Preschool: <1%School-age: 1-2%Female-to-male ratio 1:1Adolescence: 6%Female-to-male ratio 2:1Cumulative 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 NeurobiologyDysregulation of serotonin & norepinephrine in CNSInfluence of sex hormonesPersonalityNegative cognitive styleEnvironmental factorsAbuse & neglectStressful life eventsFamily dysfunction
8 GeneticsChildren with a depressed parent are 3 times more likely to have MDDChildren 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 complaintsStomachaches & headaches most commonAnxietyIndecisionTemper tantrums & disruptive behavior
10 Depression in Adolescents Irritable or sad moodMore likely to report a sad/depressed moodIncreased sleep and appetiteIncreased suicidal ideation & attemptsIncreased impairment of functioningIncreased behavioral problemsDecreased energyRejection sensitivity
12 Psychosocial Risk Factors for Depression Family problemsConflict, maltreatment, parental loss/separation, parental mental illnessComorbid psychiatric disordersADHD, anxiety d/o’s, conduct d/o, substance abuseRecent adverse eventsSchool, relationships, loss of social supportPersonality traitsAnger, 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 stressorChildren may have transient depressed mood statesAdjustment disorders to stressorsDepression is more severe, lasts longer and impacts functioning
14 Adjustment DisorderBehavioral or emotional response to a identifiable cause or stressSymptoms occur within three months of the stressorSymptoms cause marked distress
15 Adjustment Disorder Associated with: Anxiety Mixed anxiety and depressed moodDisturbance of mood and conductDisturbance of conduct
16 Impact on Learning May change sleep or eating patterns Difficulty concentrating/focusingSocial isolationSchool behavior – fighting, argumentsAcademic difficulties can lead to changes in moodConsider an educational evaluation if treatment for depression does not resolve learning issues
17 School-based Interventions Acknowledge the student’s feelingsProvide a place for students to regroup if they feel weepy or fatiguedAllow the student to stop an activity and resume it later when calmEncourage positive self-talk and break tasks down
18 School-based Interventions Irritable MoodModel appropriate responses to replace irritable responsesAllow the student to take him/herself out of a situation (self-timeout) when irritability is starting to disrupt othersMay want to work independentlyProvide opportunities for the student to "fix" problems or inappropriate classroom behaviorsFatigueProvide class notes to the studentIdentify study partners who can support and assist with assignmentsGrade 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 factorsEarly onset depressionPsychosisMood labilitySeasonal patternFamily 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 NeurotransmittersNeuroimaging shows subtle differences in frontal lobe and amygdala volumeGeneticsOne parent with BD = 25% riskEnvironmental factorsMay potentiate genetic predispositionStressorsLow maternal warmth
23 Bipolar Disorder in Children Mood may shift rapidlyMinute-to-minuteDay-to-dayMay present as chronic irritability or explosiveness with no discernible pattern or periods of wellnessDifferent from depression by the presence of mania20% of depressed children will go on to develop bipolar disorder
24 Mania in children Excessive irritability Excessively giddy or silly Aggressive behaviorsExtended, rageful tantrumsPhysically aggressiveRestless or persistently activeAge-inappropriate sexual interestsGrandiosity
25 How does it impact school? Fluctuations in cognitive abilitiesImpaired ability to plan, organize, concentrate and use abstract reasoningHeightened sensitivity to perceived criticismsHostility or defiance with little provocationEmotions disproportionate to situation
26 School-based Interventions Develop a simple explanation that the student and staff can use with peers and teachersAccommodate tardinessAllow the student to complete schoolwork or tests in a less stimulating environmentSeat 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 periodsAllow the student to have homebound instruction during manic periodsAllow children to discreetly and frequently accommodate needs caused by medication side effects
27 Treatment for Mood Disorders Psychological interventionsIndividual therapy (CBT)Parent guidance sessionsSchool-based counselingBiological interventionsMedicationsSide effects may impact learning or behavior when starting medication
29 Anxiety DisordersMedical condition that causes people to feel persistently, uncontrollably worried over an extended period of timeLimit children’s ability to engage in a variety of activities
30 Epidemiology of Anxiety Disorders Most common emotional/behavioral disorder in childhoodIncidence 10-15% of children/adolescentsFemale-to-male ratioEqual in preadolescent childrenFemales are increasingly represented in adolescent years
31 Etiology of Anxiety Genetics Biologic Psychological Central Nervous System (brain)Abnormal neurotransmitter functioningSerotonin, norepinephrine, GABA receptorsPsychologicalInternal and external stressors overwhelm coping abilities
32 Fear Alarm and agitation Caused by expectation or realization of dangerA state of dread or apprehensionWebster’s II Dictionary, Third Ed.
33 Fear Immediate alarm reaction Basic, normal emotion Essential to alert to imminent dangerFocuses attentionPrepare to respond: Flight or FightPounding heart, rapid breathing, muscle tension, sweatingConsolidate experience to memoryTo learn appropriate response
34 Anxiety Apprehension of danger and dread Accompanied by RestlessnessTensionRapid heart rateShortness of breathUnattached to a clearly identifiable stimulus
35 When is anxiety pathologic? Intensity of anxietyOut of proportion to threatFrequency of anxietyIncrease in fear reaction and cannot be “reasoned away”Content of anxietySeemingly innocuous situation or stimulus
36 Children with Anxiety Disorders Risk for developing other types of anxiety disorders/or psychiatric disordersComorbid psychiatric disordersYoung children with GAD can also suffer from separation anxietyDepression can accompany the feeling of generalized anxietyIncreased risk for adjustment difficulties in adulthood
37 Generalized Anxiety Disorder Worry, worry, and more worryAbout – family, friends, health of others, natural disasters, school performance, etc.Somatic concernsHeadaches, feeling shaky, sweatingNot easily reassuredMay throw tantrums related to anxietyPoor concentration and attentionMay present for ADHD work-up
38 Separation AnxietyExcessive anxiety focused on separating from home or parent figureMost commonly diagnosed in prepubertal childrenMore common in 5-7 and year olds with transition into elementary and middle schoolTypically occurs following a significant change or major life event
39 Separation Anxiety Expression varies with age Prepubescent children (5-8 years)Clinging/shadowing behaviorNightmaresFear of loss of loved onesSchool refusal
40 Separation Anxiety Preadolescent (9-12 years) Emotional distress of separationStaying away from home overnightAdolescents (13-16 years)Somatic difficultiesSchool refusal
41 Social PhobiaExcessive fear in social situations where child is exposed to unfamiliar people/evaluation by othersExcessively self conscious/shyTremendous concern about social failure/embarrassment/humiliation
42 Social Phobia Exposure causes significant anxiety/panic Fear excessive and unreasonableAvoidance or endurance with extreme distressInterference in functioning
43 Selective MutismChildren 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 anxietyOften 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 escapeFeeling of doomActivation of autonomic nervous systemFight or flightDuration minutes
45 Panic Disorder Recurrent panic attacks Inter-episode worry about having a panic attackWorry about implications and consequencesChanges in behaviorMore common in adolescents
46 Anxiety at School Frequent self-doubt and criticism Seeking constant reassurance from the teacherDifficulty transitioning between home and schoolAvoidance of academic and peer activitiesPoor concentration
47 School-based interventions Accommodate late arrivalsShorter school days to transition children with separation anxietyAllow extra time for transitionsProvide alternative activities for children with somatic complaintsHave a “safe” place if child develops increased anxiety or panic attacksHave an anti-worry plan
48 Components of a Simple Anti-Worry Plan *What am I worried or afraid about?*How worried Am I? 2Not 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?
50 DefianceWhen is defiant behavior not really defiance to an authority figure….NeverWhen 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 arousalCue UtilizationAttributionsSocial Perceptions (self and others)Generating problem-solving solutionsConsidering ConsequencesImplementing SolutionsSituational Appraisals
53 Adult Issues That May Escalate an Anger Outburst The adult’s mood at that momentFeelings of helplessness in managing difficult situationsExpectations (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 outburstToo quick to say “no”Quick to anticipate a conflictQuick to raise voice or yellInterpret behavior as intentionalDon’t set limits when necessaryToo strict with limits-can’t follow throughCoercive 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 angerThe occurrence of a real or perceived threat and/or adverse eventBeing teased, bumped in the hallway, threatened by another youth, etc.Obstacles to getting or doing what they want or expectNot feeling heard or understoodDenied requests – don’t like to hear “no”Feeling unimportant and insignificant – such as being left out of somethingSome 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 offBlamed unjustlyAcademic frustrationEmbarrassed over a gradePicked on*Angry from home (“Carry Over”)
58 Purpose / Process in good anger control plans Better self-regulationEffective 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 problemsWhat’s behind the anger (feelings, issues)Ideal alternative attitudes and behaviorsBenefits to them of positive behaviors and attitudesCosts to them of negative attitudes and behaviorsHigh 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 situationThings 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 doneWays the adult can help with high-risk timesReinforcements and consequences if anyRegular time to review how things are goingDiscussion of problem possibilitiesCompletion of problem-solving sheet
61 Mistakes adults sometimes make Setting too many goals at one timeSetting 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” situationsFeelings when this happensAngry thoughts that worsen my anger:What to do:Identify the problemUse good self talkCoping strategiesWhat others can do to helpEvaluate the process or how it could turn out
65 Talking with ParentsNeed to involved parents when the student experiences significant academic, social or emotional difficulties that interfere with learningDevelop a shared understanding of child/adolescentAsk parents if they see concerning emotional or behavioral problems at homeParents may have effective strategies they use at home that can be implemented in the classroom
66 When to refer for further evaluation Impact on learningEffecting social interactionsSafety concernsSuicidal statementsThreats toward othersConcern for abuse/neglectTypical interventions do not work
67 Choosing Initial Treatment PsychotherapyIndividualFamily – parental educationsPsychopharmacologic InterventionPatients unable to participate in therapy due to severity of symptomsComorbidity with other psychiatric illnessesSymptoms that do not respond to therapy
68 Goals of Treatment Safety Build alliance & instill hope Clarify diagnosisAssess comorbidity (substance abuse, medical illness, other psych d/o’s)Assess motivation for treatmentAvailability 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 illnessAddress family, school, peer issuesPsychotherapy for mild to moderate mood disorders (CBT, IPT, family therapy, psychodynamic)Consider medications
71 Antidepressants Mechanism of Action Indications Modulation of neurotransmittersIncrease serotonin at 5-HT receptorAtypical antidepressants may modulate serotonin, norepinephrine and dopamineIndicationsDepression (unipolar/bipolar)Anxiety disordersObsessive Compulsive DisorderPanic DisorderPTSDBulimia Nervosa
72 SSRIs No evidence that one SSRI is superior to another First-line medication for depressive and anxiety disordersNo evidence that one SSRI is superior to anotherSSRIs take 4-6 weeks to determine efficacy of doseFewer side effects than older antidepressants
73 SSRIs FDA approved in children & adolescents FluoxetineDepression (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 populationOff label useParoxetine (Paxil)Citalopram (Celexa)Escitalopram (Lexapro)
75 SSRI Side Effects that May Impact Learning CommonGastrointestinal – dyspepsia, diarrheaCNS – headache, anxiety, insomniaIncreased sweatingUncommonAkasthisia (inner feeling of restlessness)AgitationMania (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 USATo apply to ALL antidepressants for children and adolescents < 25 yrs oldExplicit about the increased risk of suicide especially during the early phase of txNo completed suicides in studies reviewedReview of studies showed increased suicidal thoughts (2% to 4%) through adverse event reporting
78 Antidepressant Black Box Children and adolescents must be monitored closelySchool officials should notify parent if student’s work reflects suicidal themes
80 Other Antidepressants SNRIsModulate serotonin and norepinephrine transmissionAtypical AntidepressantsMay modulate serotonin, norepinephrine, and dopamineCan be used as single agent or as augmentation strategy with SSRI or other psychotropicFewer studies in children & adolescentsNo FDA approved SNRIs in pediatric OCD
81 Side Effects SNRIs Atypical Antidepressants Venlafaxine (Effexor) Elevated B/P - diastolicDuloxetine (Cymbalta)Blurred vision, mydriasis (dilated pupils – can affect vision)Atypical AntidepressantsMirtazapine (Remeron)SedationWeight gainNo sexual side effects
82 Mood Stabilizers Indications Mechanism of Action Early-onset bipolar AnxietyOCDExplosive aggressionMechanism of ActionMultipleEnhance GABABlock glutamateSecond messengers
84 Side Effects that may Impact School Weight gain or lossChange in appetiteStomachachesSedationCognitive impairmentEspecially Topamax (processing speed)
85 Atypical Antipsychotics Mechanism of action5HT2A/D2 receptor antagonismLess TD and EPS symptoms than 1st generationIndicationsPsychosis/psychotic depressionMood stabilization – bipolar, mood dysregulationAggressive behaviors – autism, MR, DDAugmenting agent for OCDConduct problemsSevere tic disorders
86 Atypical Antipsychotics FDA approvedRisperidone (Risperdal)Treatment of irritability associated with autism in children 5 years of age and olderSchizophrenia (13 years and older) and bipolar disorder in children (10 years and older)Off label useQuetiapine (Seroquel)Aripiprazole (Abilify)Ziprasidone (Geodon)Olanzapine (Zyprexa)Paliperidone (Invega)
87 Side Effects of Anti-psychotics Weight gainSedationDyspepsiaImpaired glucose toleranceDyslipidemia – elevated cholesterolHyperprolactinemia – gynecomastia, menstrual irregularitiesLong-term effects to CNS in children?
88 Serious Side Effects Acute Dystonia Extrapyramidal symptoms Spastic contraction of discrete muscle groupsMost common – neck, tongue, eyesRisk factors – young, male, medication initiation or dose increaseExtrapyramidal symptomsRelated to dopamine blockade in nigrostriatal pathwayAkathisia & parkinsonism
89 School Role with Medication Part of treatment teamObservations of student during school invaluableDispense medicationMedication or side effects may impact behavior or learningImpact on parent attitude toward medication
90 Internet ResourcesAmerican Academy of Child and Adolescent Psychiatry (aacap.org)“Facts for Families” handouts on many topicsLatest news on hot topicsParentsMedGuide.orgQuestion and answer material about depression, suicide and black box warningLinks for parents and physiciansUp-to-date, well-organized, English-Spanish
91 Internet ResourcesMassachusetts General Hospital School Psychiatry Program
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