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How Mental Health Effects Us and Our Students Larry Scott

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1 How Mental Health Effects Us and Our Students Larry Scott

2 I. Current State of Mental Health II. General Characteristics of Anxiety & Depression III. Depression IV. Anxiety V. Self-Harm & Suicide VI. Addiction VII. Mental Health Treatment/Intervention

3  North of NYC (over a 5 year period) 47% of people killed by police suffered from a mental illness or were emotionally disturbed  56% of NYS prison population have a “mental health problem” including substance abuse (5x the rate of general public)  8,000 inmates are cared for by NYS Office of Mental Health  About 17% of U.S. prison population have mental illness (3x the rate of the general public)

4  Mentally ill are more likely to be victims of crime, than criminals, and they are more likely to be harmed by police, than harm police  Law enforcement have become primary providers for those with serious mental illness  Cuts, consolidations, and closings in mental health continue  In 1955 the U.S. had 558,000 beds for mentally ill; today we have about 40,000

5  The number of poor in the entire Buffalo Niagara metropolitan area grew from 120,861 in 1970 to 162,917 in 2011  52 percent of this area’s poor reside in the suburbs  Mobile Safety-Net Team (John R. Oishei Foundation):  Free/reduced lunch in Ken-Ton (#1):  27% in March of 2001 compared to 41% in March of 2013  Ken-Ton School District is the largest human service of 38 agencies

6  Question #4  CDC (2012): About 20% of American youth (aged 3 – 17) suffer from a mental health disorder (ADHD, anxiety, depression, and conduct problems)  ADHD= 6.8%  Conduct Problems= 3.5%  Anxiety= 3%  Depression= 2.1%  Autism Spectrum Disorder= 1.1%  ADHD diagnosis has jumped 53% in past decade  Chronic health problems (i.e. asthma & diabetes) are associated with mental illness in adulthood  Question #3  $247 Billion is spent per year for mental health services from medical bills, special education, and juvenile justice  Question #2  Suicide has become the 2 nd leading cause of death among youth (aged 12-17) behind accidents

7  Everyone experiences varying emotion and mood, including symptoms of anxiety and depression  “Emotion is the weather, mood is the climate.” (C. Smith)  Mood : sustained emotional state which impacts how we respond on a regular basis; becomes more of an internal state, independent of external circumstances  Emotion : short-term and more influenced by external factors  Mood exists across species; the more developed the species the more intensely mood exists independent of external events  Some manage the interaction of mood, personality, and stress well, while it becomes problematic for others

8  Anxiety & Depression often co-exist and influence each  Share a single set of genes, which are also involved in alcoholism  Depression: a response to loss; Anxiety : a response to future loss  Intervention is needed when anxiety and/or depression interferes with a life function (i.e. work, school, family relationships/functioning….).

9 Genetics Environmental Neuropsychological Personality

10 Sherri (13) whose mother has untreated depression and father has untreated bipolar disorder, is having meltdowns in school and failing many subject areas. Sherri lives in a duplex in a poverty stricken and violent neighborhood. Sherri was born premature and was separated from her mother several times until the age of two, due to hospitalizations for medical issues. Last summer, a friend of Sherri’s was shot and killed in her neighborhood. Sherri exhibits high irritability and often perceives others as untrustworthy and guilty of mistreating her. A social-emotional assessment indicates that she perceives limited internal control over events in her life. Blood work indicates high levels of the stress hormone, cortisol, which is associated with depression and cognitive deficits.

11  Brain Plasticity  Between approximately 10 to 18 months of age is a critical period of plasticity and shaping of the brain (right frontal lobe) for attachments & emotional regulation  Neglect/trauma during this period can negatively shape “wiring” for attachments & emotional regulation, which can continue into adulthood  Limbic System ( amygdala, hypothalamus, hippocampus, & thalamus) is involved in emotional regulation Limbic System


13  About 19 million Americans suffer chronic depression (over 2 million are children)  About 15% will commit suicide  2.3 million suffer from Bipolar Disorder  Could be leading cause of death when considering its influence on suicide, substance abuse, heart disease, and other health issues  Anger & violence may be symptoms of depression, particularly in males (destructive, but short-term remedy)

14  Females are 2x more likely to suffer depression, a ratio consistent throughout Western societies  Rate of depression is about the same among working and non-working married females  Males synthesize serotonin 50% more rapidly than females  Males are more likely to have ADHD, autism, and alcoholism  Closeted people and single people have a higher rate of depression

15  Question #5  Leading cause of disability in U.S. for those over the age of 5 and leading cause worldwide (WHO); costs tens of billions yearly in lost productivity  Question #6  Women who are pregnant or have just given birth are more likely than anyone else to suffer depression, but least likely to commit suicide  Question #7  Poverty & parent depression are highest predictors of child depression  Question #8  GLBT are at increased risk for depression and anxiety problems. Suicide is the number 1 cause of death for this group  Question #9  Those in poverty represent the highest rate of depression compared to any other class in U.S.  Question #10  85 – 95% of those with serious mental illness are unemployed

16  Fewer social skills and close relationships  Fewer social interactions  Limited interest in activities  Limited motivation and academic achievement  Irritability  Limited energy  Limited affect  Worsened with the presence of learning weaknesses  Most challenging during adolescence

17  There are particular genes involved in serotonin regulation which predispose depression, but whether one suffers depression is dependent on life events/experiences  There are three possible gene combinations, one from each parent: short/short, short/long, and long/long  A short/short combination with multiple uncontrollable bad life events makes it about twice as likely to suffer from depression than long/long combination

18 Short/Short High Predisposition Multiple Uncontrollable Events 2x more likely to suffer Depression than Long/Long

19  Significant episodes of depression alter brain chemistry (i.e. decrease Serotonin receptors) and structure (i.e. hippocampus)  With each episode of depression there is an increased 10% risk depression will become chronic and inescapable  Early childhood trauma causes major changes to the brain’s hippocampus, shrinking it & inhibiting new, long-term memories  Depression, high stress, and childhood trauma all cause the release of stress hormone (glucocorticoid) - kills cells in the hippocampus  The longer someone is seriously depressed or under high stress the smaller their hippocampus.  Antidepressants have been found to increase stem cells that become new neurons in the hippocampus  It takes about 3-6 weeks on an antidepressant for new neurons to mature and connect with other neurons

20  Many studies show that socioeconomic status is the number one predictor of depression  Depression is so common in poor communities awareness that an internal problem exists is lacking; perceived the problems are only due to uncontrollable external factors  Poverty is highly associated with a learned helplessness & passivity  Rate among welfare recipients is about 3x higher

21  Quality mental health care is lacking most among the poor  Investment in addressing mental health needs may be worthwhile, financially and socially  The cost of not treating mental illness, may far outweigh the cost of adequately treating it

22  Depressed mothers greatly influence the likelihood that a child will suffer depression or other emotional / behavioral issues  Having a depressed mother is often more detrimental than a schizophrenic mother  With a depressed mother, signs of depression can be seen in infants, as early as 3 months: weepy, angry, & aggressive  If mother’s depression is treated early, children show improvement, reversal becomes more challenging with age

23  Five potential impacts on child’s emotional / behavioral development (Sameroff, A.): 1. Genetics 2. Empathetic mirroring: repeating back what they experience 3. Learned helplessness : giving up on connecting due to lack of parent approval for emotional outreach 4. Role-playing : taking on the illness role to avoid unpleasant things as observed by parent 5. Withdrawal: consequence of seeing no pleasure/meaning in communication with unhappy parent

24  Anaclitic depression: occurs in second half of the child’s first year when separated too much from their mother  May develop in “failure to thrive” starting at age four or five; limited affect & don’t bond  At age five to six show extreme crankiness, irritability, poor sleeping, and poor eating  Low self-esteem, high anxiety, and bed-wetting become common problems

25  Depressed children usually go on to be depressed adults  Occurs in many before puberty, but peaks in adolescence  The earlier the onset the more resistance to treatment  Early/preventative intervention is critical

26  Four possible theories: 1. Served an important purpose in pre-human times 2. The stresses of modern life are incompatible with the brains we have evolved. 3. It serves a useful function. 4. It is a secondary result of other characteristics.

27  Self-Consciousness: high awareness of self, meta- cognition, and awareness of competing cognitive functions (i.e. rational and emotional thinking) makes us unlike any other species  Humans have the slowest brain maturation and are most plastic at older ages  Humans exhibit significant capacity to regulate emotions  Linguistic-Evolutionary Model (Crow, Timothy) mental illness is on a continuous spectrum and is determined by difference in intensity of symptoms

28 Low Intensity Moderate Intensity High Intensity

29  Out of the Shadows Out of the Shadows

30  10 – 20% Americans suffer from Anxiety Disorder  About ½ of those with true anxiety disorders develop major depression within 5 years  Worsens with time if untreated  Anxiety is often overlooked, misdiagnosed as ADHD, left untreated, and sometimes worsened when misdiagnosed  Anxiety is difficult to detect- internal, not easily observed  Children and self-awareness  Medication

31  When doing something new  When uncertain about plans  When there “what ifs”  When you have to perform  When doing something scary

32  The opposite of peace and feeling safe  “Curse” of sensitivity & empathy: a capacity for feeling deeply, including emotional pain, which both can be helpful and hindering.  Often obsessive thinkers without compulsive tendencies  Anticipatory anxiety

33  Strong episodes of anxiousness and panicky feelings  Feelings of bewilderment and unreality  Feelings of depression and hopelessness  Restless feelings, insomnia, sleeping too much  Picking at self or objects  Uncontrollable bouts of anger/crying  Obsessive-compulsive tendencies  Withdrawing  Frightening, gruesome thoughts (diversion from conflict)

34  Temperament: inborn, biological ways of responding emotionally/behaviorally in infancy and early childhood  Personality: outcome of an interaction of biological traits with social and personal experiences S. Cain (2013): Quiet

35  Longitudinal study by Jerome Kagan, 1989 (500 infants):  Exposed 4 month-olds to novel experiences: strange visuals, loud noise, and odd smells  20% were “high reactive” cried vigorously, pumped arms and legs and had higher activity in amygdala, higher heart rate, more eye dilation, more cortisol in saliva  Many in this group developed to be introverted, sensitive, deep processors, and highly attentive to others / environment / experiences  Sensitive to sensory stimuli and challenges, such as marital tension, death of a parent, and abuse S. Cain (2013): Quiet

36  Prone to be shy and experience anxiety and depression  Usually very empathetic, caring, and cooperative, while easily upset with injustice, cruelty, and irresponsibility  Amygdales remained more reactive to novel stimuli  With good parenting and stable home life they often have fewer emotional problems and more social skills S. Cain (2013): Quiet

37  Experiencing severe panic attacks can be debilitating  Often develop from life events where there is a loss of security or perceived loss of security  Most difficult factor- it is not volitional, feelings occur for absolutely no reason  About 1/3 of panic attacks related to depression occur during deep, dreamless sleep

38 Cognitive Symptoms:  “I’m going to have a heart attack.”  “I’m about to die.”  “I can’t breathe properly. I’m going to suffocate.”  “I’m about to pass out.”  “I’m going to lose control and go crazy.”

39 Hot / cold flashes Numbness / tingling Chest pain / tightness Trembling Tight, tense muscles Pounding heart Shortness of breath Nausea / dizzy Feeling unreal or detached

40  What is the difference between fear and danger?  When is it smart and useful to be scared?

41  Anxiety is one of the most basic emotions found in almost all animal species  Is a response to danger or threat- perceived or real  It’s primary purpose is to protect us, not harm us  “Fight/Flight/Freeze” response  Sympathetic nervous system releases energy to respond to threat  Parasympathetic nervous system restores the body to normal function


43 Control Anxiety Anxiety Control

44  People with high anxiety lock onto worry and can’t let go  Their brains are haunted with horrific scenarios that present as quite real and can’t be ignored  Norepinephrine and serotonin are neurotransmitters which play a role in anxiety  Locus coeruleus controls norepinephrine production & the lower bowel Locus coeruleus

45  Obsessive-Compulsive Disorder (OCD) can be most severe with frequent worrying about harm to self and/or loved ones  Excessive fear of health is common- with frequent scanning of body for symptoms & doctor visits  OCD often worsens with time, slowly shaping brain structures/functioning  Certain thoughts continue even when it is known that they are meaningless

46  The brain of OCD does not move or transition easily. It becomes “locked.”  3 major areas are hyperactive in those who suffer from OCD: 1. Orbital frontal cortex: the more obsessive the more activity in this area 2. Cingulate gyrus: seems to play a role in triggering the sense of impending dread which then activates physiological responses (pain in stomach, pounding heart, etc…) 3. Caudate nucleus: plays a role in transitioning our thoughts  OCD can be inherited, but infections can swell the caudate nucleus leading to OCD symptoms

47 Brain chemistry changes = feeing unpleasant Do something to feel better: avoid, seek reassurance ask a lot of questions, etc… Perceive threat/fear Dr. K. Morrow


49  Dr. Jeffery Schwartz ( Brain Lock ) and his research have discovered much about the brain’s role in OCD  Uses a form of psychotherapy to restructure the brain with a success rate of about 80% when combined with an antidepressant medication  The 3 major parts of the brain which are hyperactive & “locked” begin to function normally and separately, relieving the brain lock  Uses 2 major methods: 1. Identify & accept that an obsessive worry is a symptom of OCD & not something else (i.e. chronic disease) 2. Focus on something desirable & pleasurable (about 30 minute intervals) when faced with the obsessive thoughts

50  With obsessions & compulsions the more you do it, the more desire to do it; the less you do it, the less you desire to do it  Intensive therapy which compels patients to think or do something pleasurable triggers dopamine release, rewarding new brain activity and growth of healthy neural circuitry and connections  One needs to be distracted and “change the channel” for a period of time when experiencing obsessions & compulsions  Anxious feelings will remain for some time (may initially increase) but by changing behavior & how one responds, brain restructuring can occur & with time anxiety will reduce

51  Depression is not always the primary reason or only reason; often committed after coming out of a depression or long after recovery  Suicide is more a response to anxiety and a tortured mind, rather than a solution to depression and purposeless mind  Question #12  Prior attempt to commit suicide is highest predictor of suicide  Although suicide can coincide with depression, it should be viewed independently just like substance abuse  Many unknowns  There is a significant difference between wanting to die and wanting to kill yourself

52  Statistics:  Most often on Mondays, between late morning & noon, and spring  Evidence suggests that the best-intentioned prevention programs introduce the idea to a vulnerable population & increase the rate  Suicide rate for age group of 10 – 14 increased by 120% between the early 80’s to the mid-90’s; 85% use aggressive means (guns, hanging, and poisoning)  Question #13  U.S. is the only country where guns are the primary means of suicide; more Americans kill themselves with guns than murder others with guns, yearly  10 states with lax gun-control laws have a suicide rate 2x that of states with the strongest gun-control laws

53  Deliberate Self-Harm (DSH) has been on rise since 1980’s  Question #11  Average age of onset is about 13  Eating disorder & substance abuse are commonly associated  Females are 3x more likely than males  Reasons from an Inpatient Population:  To stop bad feelings  To feel something even if it was pain  To relieve feeling numb or empty  To punish themselves  To get help or attention out of desperation

54  Stereotypic Harm : includes behaviors like head- banging/hitting self associated with mental retardation and severe autism  Major mutilation: involves a great deal of tissue damage associated with psychosis  Superficial/moderate mutilation : most common and usually includes skin cutting & burning

55  Self-harm: intentional, non-life threatening bodily harm or disfigurement while in a state of distress  Suicidal behavior: act of self-inflicted, self-intended cessation of life  Question #14  Less than 1% kill selves from cutting  Self-harm is usually life sustaining act associated with the following:  Impulsive- thought about for less than an hour  Relieve inexpressible feelings  Body alienation  “Life preserver” rather than exit strategy  May become angry if described as suicidal

56  Substance abuse  Eating disorder  Physical risk taking  High risk sexual behavior  Unauthorized discontinuation of medication

57 4 Broad Types of Suicide: 1. Impulsive : sudden act triggered by specific external event without much thought 2. Revenge: poor awareness that death is the end 3. Faulty logic : death is the only escape from unbearable problems 4. Reasonable/logical: as a result of physical illness, mental instability, or change in life circumstances- do not wish to experience pain of life which outweighs remaining pleasure

58  Low levels of serotonin in brain areas associated with inhibition and freedom to act impulsively on emotion (similar to impulsive murders/arsonists)  Excessive number of serotonin receptors (possible brain compensating)  Stress reduces serotonin making the combination of stressful events and depression high risk for suicide

59  A cognitive-behavioral treatment empirically supported to treat self-harm in patients with Borderline Personality Disorder  Views self-harm behavior as a combination of dysfunction in emotional regulation in the brain & invalidating social environment, causing confusion of self, impulsivity, emotional instability, & interpersonal problems  Provides a comprehensive structure for treatment providers in dealing with a complex behavior

60 Mental Illness Substance Abuse

61  Alcohol is appealing for reducing anxiety short-term, but often worsens depression  Alcohol decreases serotonin  Self-medication is common with alcohol and marijuana  Long-term use can alter brain structure and chemistry  Dopamine plays a role in addiction, requiring the need for more  It is typically thought that addiction should be addressed first, then the mental illness, but role of mental illness should not be ignored

62  Regular marijuana use mimics symptoms of depression  Marijuana may have short-term relief of anxiety and agitated- depression  Cocaine: 15% of those who try it become addicted, but for those 15% it is highly addictive and associated high risk of depression  Cocaine produces immediate gratification, acting on multiple neurotransmitters (serotonin, dopamine, and norepinephrine)  48-72 hours after cocaine use usually elicits an intense depression; depression can become the baseline with long-term use when not high

63  Two Broad Treatment Methods: 1. Medical (medication and/or electroshock) 2. Therapy (counseling)  Medication & therapy should be complimentary, not competitive; used together or separately depending on the situation and individual  Large study by NIMH (2004) on moderately to severely depressed youth (aged 12 – 17):  CBT: 69% success  Prozac: 65%  A combination of Prozac and CBT: 85%

64  U.S. use of psychiatric medications is far higher than any other country  Question #15  Anti-depressants have become the most used drug in U.S. (about 10% of adults)  About 28 Million Americans are on SSRIs (Selective Serotonin Reuptake Inhibitors)  About 16% of females, compared to 6% of males  About 5% of adolescents (aged 12 – 19) take an antidepressant  White adolescents are 5x more likely to use antidepressants than black adolescents and 2x more than Latino  1996 – 2005: 40% drop in those receiving therapy

65  Selective Serotonin & Norepinephrine Reuptake Inhibitors (SSRI’s & SNRI’s) act on serotonin and some also act on norepinephrine  Are useful in treating chronic anxiety  Are relatively safe drugs, but do have side effects and unpleasant withdrawal symptoms (sometimes dangerous)  Efficacy in children has not been conducted  Only Prozac has been approved for children by the FDA, but others under generic labels can be prescribed

66  Benzodiazepine (tranquilizers) are intended for short-term use, and not regarded as safe drugs for long-term treatment of anxiety  Physical tolerance and dependence requiring the need for more of the medication can lead to addiction and abuse  Dangerous when mixed with alcohol  Withdrawal symptoms can be very unpleasant and dangerous

67  In isolation, does not address a psychological understanding of anxiety and depression  Limited research and education on long-term use and effectiveness  Weaning off medication can be a challenge and withdrawal can be unpleasant  Suicide risk in adolescents (FDA found a 4% increase in suicidal thoughts and behavior)  Side effects, stigma, and uncertainties make medication a challenging decision for parents

68  Question #16  1997: FDA permitted drug companies to advertise prescription drugs directly to the public  1997 – 2004: Money on advertising quadrupled to $4.35 Billion  2000: Every dollar spent on advertising translated to an additional $4.20 in sales  Profiting off of benefit and not just need  Most funding for mental health research comes from pharmaceutical companies  Few psychiatrists provide therapy, just prescribe medication  Payments from drug companies to doctors sways prescription patterns  Perpetual increase in “ polypharmacy ”

69  Research shows strong evidence that talk therapy can be effective  About 75% report improvement: diminished symptoms and greater length of time between episodes  Two most critical predictors of success: 1. Rapport 2. Trust in framework being used by patient & therapist

70  Cognitive-Behavioral Therapy  Based on theory that negative thinking and habits drive anxiety/depression  Alter thinking, self-beliefs, and behavior  Limited focus on emotion  Youth anxiety  Psychodynamic Therapy  Builds self-awareness and understanding of hidden/unresolved conflict & denied feelings to elicit change  Deeper understanding of emotion and it’s meaning  Less intensive than psychoanalysis  Interpersonal Therapy  Communication  Relationships  Family Therapy

71  Keeping secrets may be unhealthy for the brain  Study- when subjects shared intimate secrets- health improved, doctor visits and stress hormones decreased  Competing operations (telling and withholding) may influence stress/inner tension  May explain the need for some to vent to strangers and the appeal of prayer/confession amongst religions  Venting a secret to an open ear (human or human-like) is the intervention and advice is not intended/needed

72  Fosters positive therapeutic relationship  Reduces self-blame & guilt  Instills hope  Increases motivation  Reduces anxiety  Promotes self help & reliance

73  Primary objective is stop avoiding and face fears (negative reinforcement)  Gradual or sudden exposure to fear  Cognitive Exposure  Reality Exposure  With youth it should be done gradually and not be forced

74  Challenge to get all involved on the same page  Varying agendas and sense of urgency  Respect youth’s pace/comfort level  Communication and clear plan is needed for gradual exposure

75  Adjusted school schedule  Staff support person  Lunch support group or social skills group  Time away in safe place  In-school counseling  Test accommodations/program modifications through 504 Plan/IEP  In severe cases: Home Instruction (short-term with plan for reintegration, only part-time if possible)  Special education programming

76  Yoga / Meditation  Deep Breathing  Progressive Muscle Relaxation  Pleasant Imagery  Visualization

77  Children & most adolescents don’t seek help on there own  Therapy cannot begin to be successful until a patient willingly accepts help  Alternative therapies (i.e. play therapy) can be helpful with young children  Asking a child to provide wishes or things they wish they had the power to change can provide much insight into a child’s view of self, life, and others  Parent anxiety and resistance

78 Exercise Diet Sleep

79 ThoughtsBehaviors Physical (Body) Symptoms Emotions

80  The way we think effects the way we feel, behave, and how our bodies operate.  The opposite is also true- if we are physical ill or in pain it effects how we think, feel, behave.  Neurotransmitters:  chemicals in our bodies that play a role in our thoughts, feelings, and behaviors

81 The most successful people I know have gotten there by choosing to underact to stressful conditions and keep moving forward. Lucinda Bassett

82  What is it?  Our response to external conditions (stressors) which effect our thoughts, feelings, and bodies  Stressors:  Adrenaline & Cortisol: chemicals that are released in our bodies when we experience stress

83  Nervousness  Irritability  Crying  Anxiety  Lack of motivation or excitement  Angry outbursts  Feeling powerless  Easily upset  Loneliness

84  Trouble thinking clearly  Forgetfulness  Lack of creativity  Memory loss  Inability to make decisions  Constant thoughts of worry  Racing thoughts or mind going blank  Lack of sense of humor

85  Bossiness  Compulsive tendencies- repeating something over & over (eating, chewing gum, playing video games…..)  Critical attitude of others  Grinding teeth  Not able to complete important tasks  Smoking or abusing alcohol and drugs

86  Headaches  Stomach aches and indigestion  Sweaty palms  Difficulty sleeping  Dizziness  Back pain  Tight neck and shoulders  Feeling nauseous  Hot & Cold Flashes  Numbness or strange aches/pains  Chest pain  Racing heart  Restlessness  Tiredness  Frequent illness

87  Change the way we think about certain situations or events  Eat healthy and get good SLEEP  Physical activity: exercise, sports, walking, weightlifting, etc…  Relaxed breathing techniques  Meditation  Yoga / Tai Chi  Talk to a trusted person  Listening to or playing music  Reading, drawing, & writing  Spending time having fun with self or others

88  Doidge, N. (2007), The Brain that Changes Itself.  Eagleman, D. (2011), Incognito: The Secret Lives of the Brain.  Pearrow, M. (2013), Students who Self-Injure: School-based Strategies Based on DBT, NASP Convention, Seattle, WA, Februay 15, 2013.  Solomon, A. (2001), The Noonday Demon  Burns, D. (2006) When Panic Attacks  Bassett, L. (1995), From Panic to Power  (2013), One in five U.S. kids has a mental disorder; ADHD the most common: CDC, May 17, 2013  The Buffalo News (2013), Today’s Mental Health Squad: The Police, May 19, 2013.  The Buffalo News (2013), Does Training Prepare Cops for the Mentally Ill, August 4, 2013.  The Buffalo News (2013), Suburban Poverty on the Rise, June 8, 2013.  Sharpe, K. (2012), Coming of Age on Zoloft: How Antidepressants Cheered Us Up, Let Us Down, and Changed Who We Are.  Rapee, R., Craske, M., & Barlow, D. The Causes of Anxiety and Panic Attacks,  Pratt, D. (2012), Anxiety Disorders in Children & Adolescents (power point)

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