Mental Health in the Schools By: Patrick Rohr MA, LPC

Goals of Presentation How to recognize the need for counseling support and who to talk to for assistance. Understand types of mental health disorders found in school settings. Learn about types of medications prescribed for common mental health disorders. Tips to maintaining confidentiality in both school and non-school settings.

Basic Facts About Childhood Mental Health Problems Approximately 1 in 5 children and youth have a mental health problem 5 Mental health problems can seriously impair children’s ability to be successful at school and in their relationships with their peers These children are not bad kids nor are their parents bad parents Mental health problems are treatable. Early prevention is important

When Should I Be Concerned? Signs that children may be struggling with mental health problems include the following 4 They exhibit behaviors or moods that are not age-appropriate Their behaviors are much more dramatic than in their peers Their behaviors continue for longer than usual

When Should I Be Concerned? Mental health is a continuum from healthy to unhealthy, and problematic behaviors are not “proof” that a student has a mental health problem 4 Frequency: how often does the student exhibit the behaviors of concern? Duration: how long do the behaviors last? Intensity: to what extent do the behaviors interfere with the child’s activities?

Next Steps What can I do? Who else should be involved? How do I know what mental health problem I’m dealing with?

Signs Your Student May Be Experiencing a Mental Health Problem Emotional/Behavioral signs 4 Overly withdrawn, quiet or doesn’t engage Low self-esteem, feelings of failure or worthlessness Increased irritability, which can appear as disobedience or aggression Feeling hopeless or overwhelmed Unstable moods, such that teachers and other students don’t know what to expect from them A short fuse and lashing out when frustrated Extreme worries or fears that interfere with friendships, schoolwork, or play Severe mood swings affecting relationships with others Drastic change in personality or behavior Extreme sadness lasting two weeks or more Refusal to go to school on a regular basis

Signs Your Student May Be Experiencing a Mental Health Problem Academic signs 4 Fidgeting, constantly moving around or seems “always on the go” Despite best efforts, poor grades poor grades in school despite trying very hard or a noticeable decline in classroom participation Poor attention to detail and careless mistakes in schoolwork Does not appear to listen when spoken to directly Does not follow instructions or finish tasks Easily distracted Forgetful in daily activities Difficulty staying focused on one thing Bores easily Loses or forgets things often Difficulty attending to individual work or class activity Dreamy or unable to pay attention Afraid to participate in class or answer questions Difficulty managing during recess and free time, while unsupervised, and in larger groups

Signs Your Student May Be Experiencing a Mental Health Problem Communication/Social Skills signs 4 Spends most of their time alone Goes on and on about a subject and takes over a conversation Acts “silly” in a group to get attention but doesn’t fi t in Plays too roughly in the playground and hurts other children Poor motor skills (e.g. can’t catch or throw a ball) Other children may feel their schoolmate is being bossy or too rough Damages toys, etc. without meaning to Speaks without thinking Barges into games

Anxiety Disorders Common types 2,7 How common are anxiety disorders? Generalized Anxiety Disorder (GAD) Panic Disorder Social Anxiety Disorder Post Traumatic Stress Disorder (PTSD) OCD How common are anxiety disorders? 6% of youth have a disorder that warrants treatment. Cost United States 42 billion dollars a year to treat.

Anxiety Disorders Causes of anxiety disorders 2,7 Multiple, complex origins What is normal and what is not? Worry vs. Anxiety

Anxiety Disorders Common signs that student may be struggling with some type of anxiety disorder 2,7 Frequent absences Refusal to join in school social activities Decline in grades or unable to work to expectations Often spends time alone, has few friends, or has great difficulty making friends Physical complaints that are not attributable to a health problem Excessive worrying about homework or grades Frequent bouts of tears Easily frustrated Fear of new situations

Anxiety Disorders Suggestions for supporting students who struggle with anxiety: Reward brave, non-anxious behavior Encourage them to take little steps toward accomplishing the feared task Learn what situations the student can handle and how you can respond when they are unable to cope Keep as much of the child’s regular schedule as possible

Anxiety Disorders: Medication Commonly prescribed medications 2,7 Antidepressants Antipsychotics Alpha-two antagonists Common side effects and impact on learning/functioning

Behavior Disorders Common Types How common are behavior disorders? Oppositional Defiant Disorder (ODD) Conduct Disorder Intermittent Explosive Disorder How common are behavior disorders? 3-16% of children and adolescents are diagnosed with ODD 1. 6-16% of children adolescents are diagnosed with conduct disorder 1.

Behavior Disorders What are the causes? 1 Biological factors Psychological Factors Social Factors What is normal opposition/behaviors and what is not? Developmentally appropriate vs exaggerated and constant.

Behavior Disorder Symptoms Children with ODD show an ongoing pattern of extreme negativity, hostility, and defiance that 1 Is constant Lasts at least 6 months Is excessive compared with what is usual for the child’s age Is disruptive to the family and the school Is usually directed toward an authority figure (parents, teachers, principal, coach) The following behavioral symptoms are associated with ODD 1 Frequent temper tantrums Excessive arguments with adults Actively refusing to comply with requests and rules Often questioning rules Deliberately annoying and upsetting others Often touchy or annoyed by others Blaming others for their mistakes Frequent outbursts of anger and resentment Spiteful attitude and revenge seeking

Behavior Disorders Suggestions for supporting students with behavior problems: Be aware of your environment Collaborative Processing Have plan in place

Behavior Disorders and Medication Is medication alone effective? High degree of comorbidity with other mental health disorders 1 ADHD Anxiety Disorders Mood Disorders (Depression, Bipolar) Learning Disorders

Mood Disorders: Depression Most common type of mood disorder: Depression How common is depression among children and teens? 10%-15% of children and teens are depressed at any give time 7,4 1 out of 4 adolescents will have an episode of major depression during high school with the average age of onset being 14 years 7,4

Mood Disorders: Depression What causes depression? 4 Painful event Family discord Poor social skills Genetics How to tell between sadness and depression: Sadness is not an every-moment-of-every-day thing Depression tends to be constant and ever present.

Mood Disorders: Depression Symptoms of depression in Children 7,4 Somatic complaints Withdrawal Antisocial behavior Boredom Irritable Prolonged sadness Low sense of self esteem Symptoms of depression in Teens 7,4 Prolonged sadness Feelings of helplessness and hopelessness Loss of appetite Loss of pleasure in activities that were once enjoyable Suicidal ideation Sleeping a lot Low sense of self esteem Problems with concentration

Mood Disorders: Depression Suggestions for supporting students with depression 7,4 Make a special contact with the student each day Children and adolescents who are depressed are more sensitive to criticism. Corrections should be accompanied by plenty of praise and support Depressed students often feel as if they have little to contribute. It is helpful to show confidence, respect, and faith in the student’s abilities Ask open-ended questions. With no clearly correct answers, these kinds of questions minimize any chances for embarrassment Check your School’s procedures for dealing with students who are expressing suicidal thoughts. Seek direction from your principal if you have questions about what to do

Depression and Medication Most common types of medication 4 SSRI’s Atypical antidepressants SNRI’s Common side effects of antidepressant medication 4 Nausea Diarrhea Insomnia Suicidal Ideation Aggression

Behavior Disorders: Bipolar Disorder What is Bipolar disorder? 3,4 Alternating episodes of mania and depression. Often confused with ADHD How common is bipolar disorder? 3,4 3% - 5% of adults have bipolar disorder. Hard to diagnose in children and teens

Behavior Disorders: Bipolar Disorder What causes Bipolar Disorder ? 3,4 Runs in families Neurochemical disorder Normal highs and lows vs problematic ones Long lasting sadness Highs go well beyond “good mood”

Behavior Disorders: Bipolar Disorder Symptoms of bipolar disorder 3,4 Rapidly changing moods lasting a few minutes to a few days Separation anxiety Crying for no apparent reason Strong and frequent cravings, often for carbohydrates and sweets Hyperactivity, agitation, and distractibility Depression Expansive or irritable mood Excessive involvement in multiple projects and activities Impaired judgment, impulsivity, racing thoughts, and pressure to keep talking Impulsive, talkative, distractible, withdrawn, unmotivated, or difficult to engage Grandiose belief in personal abilities that defy logic (ability to fly, knows more than the teacher) Explosive, lengthy, and often destructive rages Defiance of authority ‘Dare devil’ behavior

Behavior Disorders: Bipolar Disorder Suggestions for supporting students with bipolar 3,4 Allow more time to complete certain types of assignments and tasks Adjust expectations until symptoms improve Set up a procedure that allows the child to quickly and safely exit from an overwhelming situation Learning and cognitive difficulties can vary in severity from day to day Allow extra time for moving to another activity or location Encourage the child to help develop interventions.

Bipolar Disorder: Medication Types of medications prescribed 3 Mood stabilizers Atypical antipsychotics Side effects of medication 3 Dry mouth Blurred vision and constipation Dizziness or lightheadedness, Weight gain Tardive dyskinesia

Attention Deficit Hyperactivity Disorder What is Attention Deficit Hyperactivity Disorder ? 5,4 Inattentive type Hyperactive type Combined type How common is ADHD? 5,4 Approximately 11% of children 4-17 years of age (6.4 million) have been diagnosed with ADHD as of 2011 The percentage of children with an ADHD diagnosis continues to increase, from 7.8% in 2003 to 9.5% in 2007 and to 11.0% in 2011 Boys (13.2%) were more likely than girls (5.6%) to have ever been diagnosed with ADHD Using a prevalence rate of 5%, the annual societal ‘‘cost of illness’’ for ADHD is estimated to be between $36 and $52 billion, in 2005 

Attention Deficit Hyperactivity Disorder What causes ADHD? 5,4 Runs in families Pregnancy problems Neurological factors How long does ADHD last? Lifetime of coping

Attention Deficit Hyperactivity Disorder Symptoms of ADHD 5,4 Inattention Be disorganized Lack focus Have a hard time paying attention to details and a tendency to make careless mistakes. Have trouble staying on topic while talking, not listening to others, and not following social rules Be forgetful about daily activities (for example, missing appointments, forgetting to bring lunch) Be easily distracted by things like trivial noises or events that are usually ignored by others

Attention Deficit Hyperactivity Disorder Symptoms of ADHD 5,4 Hyperactivity Fidget and squirm when seated Get up frequently to walk or run around Run or climb a lot when it's not appropriate. (In teens this may seem like restlessness) Have trouble playing quietly or doing quiet hobbies Always be "on the go" Talk excessively

Attention Deficit Hyperactivity Disorder Symptoms of ADHD 5,4 Impulsivity Impatience Having a hard time waiting to talk or react Have a hard time waiting for their turn Blurt out answers before someone finishes asking them a question Frequently interrupt or intrude on others Start conversations at inappropriate times

Attention Deficit Hyperactivity Disorder Suggestions for supporting students with ADHD 5,4 Break goals/tasks down into many smaller goals/tasks Getting students to repeat back instructions Plan ahead for transition times Being firm and consistent about rules, but always staying calm and positive Providing immediate and consistent feedback regarding behavior

Attention Deficit Hyperactivity Disorder: Medications Types of medication used to treat ADHD 5,4 Stimulants Non Stimulant medications Common side effects of medication 5,4 Decreased appetite Stomach pain Sleep problems Daytime drowsiness Rebounding effects

Self-Harm Types of self-harm Definition: Deliberate attempt to harm oneself and in most cases, is done without conscious intent to commit suicide 4,6,2 Most common type of self-harm is self injury Types of self-harm Self-cutting Self-poisoning Self-burning Self-scalding Self-inflicted hitting

Self-Harm What causes self-harm? 4,6,2 Risk Factors: Getting relief from painful or distressing feelings Dealing with feelings of numbness Communicating pain or distress to others Risk Factors: Eating disorders Physical, emotional, or sexual trauma or abuse Depression, paranoia, or obsessive-compulsive disorder Low self-esteem and self-worth Bullying Feelings of shame, humiliation, and rage

Self-Harm Signs of Possible Self-Harm 4,6,2 Refusal to wear short sleeves or to remove clothing for sports Numerous unexplained scars, burns, or cuts May voice concerns that others do not listen and that they feel patronized Suggestions for supporting students struggling with self-harm: Simply being available, whenever possible, to talk to a child who self-harms can make all the difference, as feelings of isolation are often part of the problem Consult with your school counselor Make sure that they know who they can go to in your school for professional help

Confidentiality Three Confidentiality Laws: FERPA-Family Education Rights and Privacy Act IDEA-Individuals With Disabilities Education Act HIPPA-Health Insurance Portability and Accountability Act

Confidentiality Personally Identifiable Information Any personal identifier Social Security number, drivers license number, etc. List of personal characteristics that would make it possible to identify the student Physical characteristics, etc. Important concepts: “Educationally Relevant” “Legitimate Educational Interest”

Confidentiality Ask yourself these questions to protect yourself: Who is listening (or could be?) What is being discussed When is the meeting to take place Where the discussion takes place How are items discussed & documented Why the discussion took place

Questions?

References 1 American academy of child & adolescent psychiatry. (2009). Oppositional defiant disorder. In ODD: A guide for families 2 Anxiety Disorders. (2105, May). In National Institute of mental health: Mental health information. 3 Bipolar. (2015). In Child mind institute. 4 Buchanan, D., & Colton, P. (2011, September). Mental health in the class room. In Making a difference an educators’ guide to child and youth mental health problems 5 Centers for Disease Control and Prevention. Mental health surveillance among children – United States, 2005—2011. MMWR 2013;62(Suppl; May 16, 2013):1-35. 6 Diseases and conditions: Depression. (2015). In Mayo Clinic. 7 Facts & statistics. (2015). In Anxiety and depression association of America. 8 Mental health America. (2015). Conduct disorder. In Mental health 9 Mental health in schools: guidelines, models, resources, & policy considerations . (2001, May). In Policy leadership cadre for mental health in schools.